Electronic systems needed to prevent medication errors
12/12/2018 9:03:28 a.m.

Wednesday, 12 December 2018

Electronic systems needed to prevent medication errors

The Health and Disability Commissioner is calling for the nationwide roll-out of electronic systems to reduce the significant harm caused by medication errors.

Health and Disability Commissioner Anthony Hill today released a report analysing complaints to HDC where a medication error had occurred.

“There is a person and whānau at the centre of every error and it is important to take every opportunity to learn and reduce harm,” Anthony Hill said.

“Human error happens so it is important that organisations have systems with defences built into them to prevent those errors from reaching a patient.

“I am concerned by the lack of progress in rolling out electronic medicine management systems, such as electronic prescribing, across the health sector. Having a good system in place, that was fit for purpose, would have helped prevent a number of these errors from occurring in the first place.

“Having an electronic health record that allows a patient’s medication information to follow them as they move through the health sector would also avoid mistakes that occur during transfers of care.”

Anthony Hill said it was important to understand the trends and patterns in complaints to help identify common issues and possible solutions.

“Medication is the most common healthcare intervention and most of the time the care provided in regards to medicine is very good. However, medication errors have the potential to cause significant harm and it is vital lessons are learnt.”

In addition to having robust electronic systems in place, Anthony Hill said that it was important that health professionals ensured that they were doing the basics well every time and that organisations fostered a culture that supported them to do their jobs well.

“It is incumbent on prescribers, dispensers, and those administering medication to think critically each time they deliver a medication — considering the drug, the patient, and the context in which the medication is being delivered — to ensure that the medication is being delivered safely.”

Anthony Hill noted that failing to follow basic procedures contributed to a number of the errors studied in the report.

“Some cases point to a culture of tolerance, where not following policies had become normalised. Organisational leaders must be alert to such issues, and ensure that staff are supported to do what is required of them, and foster a culture where adhering to policies is the way we do things around here.

“I encourage all health professionals, when reading this report, to consider, could this happen at my place? and, if so, what changes could be made to prevent it?”

The report is the latest in a series using HDC complaints data to identify trends and patterns in a particular area and highlight opportunity for improvement.

The full report is available on the HDC website [report link].


Background on HDC Medication Errors Report

The data
The Medication Errors Report analyses HDC complaints data to identify patterns in the factors that contribute to medication error.

The report also gathers the lessons learnt from our findings and from the case examples detailed in the report, to help providers and organisations recognise and address the factors that can lead to medication errors.

This report presents an analysis of complaints closed by the Health and Disability Commissioner between 2009 and 2016 where a medication error was found to have occurred.

Multiple medication errors are sometimes involved in a single complaint. A separate analysis was undertaken for each medication error complained about. Therefore, although there were 310 complaints about medication errors, 338 medication errors were analysed.

Medication is an extremely high volume area of healthcare activity and these cases represent a very small part of that overall number. Nonetheless across the 338 examples of error and harm assessed by HDC, some common themes and lessons are evident.

The medication process
The medication process can be broken down into three stages of: prescribing, dispensing and administration. Each stage was responsible for roughly a third of the errors complained about. Types of errors and contributing factors differed by the stage of the medication process involved.

Prescribing errors
The most common prescribing errors were prescribing an inappropriate medication (prescribing a contraindicated medication or a medication to which the consumer was allergic/had had a previous adverse reaction), or the wrong dose of medication.

Dispensing errors
The most common dispensing errors were dispensing the wrong medication, followed by the wrong dose.

Administering errors
The most common administering errors were giving the wrong dose, followed by failure to administer a medication and giving the medication to the wrong patient.

Common reasons for medication errors
The factors which contributed to a medication error differed depending on what stage of the medication process the error happened (i.e. prescribing, dispensing, administering).

The majority of errors were due to a complex mix of human and organisational factors and many were inadvertent slips or lapses.

Across the data some common themes emerged including:

• Failure to follow policies and procedures
• Inadequate communication between providers and inadequate documentation contributing to errors during transfer of care
• Failure to do the basic checks – is this the right drug, for the right patient, for the right reasons, in the right dose, at the right time?
• Lack of communication with the consumer

Key lessons

In the report the Health and Disability Commissioner identified a number of matters where additional focus would help to reduce medication errors, including that:

• Priority be placed on completing the nationwide rollout of electronic systems including an appropriate electronic prescribing system and electronic health record.
• Organisational leaders foster cultures that support staff to do what is required of them, encourage staff to follow policies and procedures and avoid a culture of tolerance.
• Individuals ensure they are doing the basics well – reading the notes, talking to the patient, asking the questions, and undertaking the necessary checking procedures