Industry bodies aim to reduce risk of medication errors

Scientists are embarking on a new approach to overhaul the system for safe research and use of medicines which will help tackle medication errors

The Chartered Institute of Ergonomics and Human Factors has set up a group which includes scientists, members of the the pharmaceutical sector and healthcare professionals to examine how society can improve the system for safe and effective medicine.  

In a review of incidents reported to the National Reporting and Learning System (NRLS) over six years between 2005 to 2010 there were 86,821 of medication incidents reporting actual patient harm, with 822 (0.9%) resulting in death or severe harm. *  

“We know that errors and adverse reactions from medicines can cause distressing symptoms, loss of function and loss of income. This can cause profound distress to patients and their carers, and contribute to the financial burden for the NHS,” said Dr Brian Edwards from NDA Regulatory Science.  

The NHS has established a Never Events list of serious incidents that should be wholly preventable such as (preventable) low blood sugar following an unintentional overdose of insulin. Traditionally investigations of how to reduce harm from unsafe use of medicines have focussed on healthcare professionals within the NHS and not how the broader pharmaceutical system has been working.  

Speaking at the British Pharmacological Society’s annual meeting, Dr Brian Edwards, an expert in safety of medicines, explained that there is no agreed systematic approach involving all parties including the NHS, the pharmaceutical sector, patient groups, lawyers and others, about how we should optimise the way medicines are used to contain the risk of errors at many levels.  

This systematic approach begins early in drug development with drug design and continues through product naming, packaging and labelling. Some of the names of medicines are similar and therefore it is easier to make mistakes. Drug labelling describes the drug and proper storage, preparation, dispensing, administration and tracing throughout the supply chain. However, it is not known whether this happens consistently and safely.  

“We have evidence to demonstrate how humans can perform more effectively in complex systems, but this is not being applied systematically for medicines with so many people and professions being involved who work in their own silos,” he said.  

The newly-formed Pharmaceutical Human Factors and Ergonomics Group will examine all aspects that influence human behaviour throughout the pharmaceutical system that ultimately impact prescribing and administering medications, for example, leadership and decision-making, the work situation, communications and personality.  

Although strategies exist for evaluating a process and assessing the relative impact of different failures, they do not cover all groups collectively associated with medication errors and, in particular, Never Events. “One day we’ll have one joined up system for healthcare and research,” said Dr Edwards, a consultant in pharmacovigilance and drug safety.  

The Pharmaceutical Human Factors and Ergonomics Group will stimulate debate and eliminate blame-culture, providing an impartial forum for open discussion on these critical issues. They will determine what needs to be done to effectively tackle medical errors.  

Pharmacology is the study of how medicines and other drugs work and are processed by the body. Addressing delegates, Dr Edwards advised, “It is very important for up-and-coming pharmacologists to understand how human and organisational factors contribute to how the knowledge and evidence they create needs to be translated into processes for safe and effective treatments.”  

* Improving medication error incident reporting and learning MHRA and NHS England, March 2014 www.england.nhs.uk/wp-content/uploads/2014/03/psa-sup-info-med-error.pdf