Nearly 6,000 people harmed by prescribing errors in the NHS last year | NHS


A pregnant woman who died after being given the wrong dose of medicine was one of almost 6,000 people injured and 29 killed as a result of prescription errors in the NHS in England last year.

Figures from NHS England show that 98 hospital trusts saw an increase in the number of prescribing errors reported in 2021, including cases where patients received the wrong medicine, the wrong dosage or did not receive medicine at all. if needed. During this time, the number of errors fell to 105 trusts.

The Leeds Community Healthcare Trust saw a six-fold increase in prescribing errors – with 111 errors, up from just 17 in 2020. At the Royal National Orthopedic Hospital, errors rose from 60 to 193, while the University of Herefordshire recorded 55 errors, down from 20 in 2020.

The NHS said almost one in six trusts still do not have a fully funded plan to introduce e-prescribing, meaning it is still managed at least partially using paper notes.

Peter Walsh, chief executive of Medical Accident Action, said: ‘These are very disappointing statistics and behind each there is a story of personal suffering or tragedy. What’s particularly frustrating is that prescription errors are probably easier to avoid than a lot of things that go wrong in healthcare.

“The fact that nearly one in six trusts do not have a funded plan to reduce these errors is quite shocking. Even with those who do, having a plan is not enough.

“We are particularly concerned about vulnerable people such as the elderly or disabled in nursing homes, who may be at greater risk because they may be less able to check for themselves and because they tend to get less personalized service than the average patient.”

The vast majority of prescribing incidents – 86% – were recorded as causing no harm to the patient, and in total the number of prescribing errors recorded on the National Reporting and Learning System (NRLS) is increased from 44,928 in 2020 to 43,452 in 2021.

However, 5,349 were recorded as causing a low level of harm, meaning they required further observation or minor treatment. Another 520 incidents caused a moderate degree of harm, which may lead to further treatment, potential surgery, cancellation of treatment, or transfer to another area.

There were 49 incidents that caused serious harm, while in 29 cases incidents were recorded as resulting in patient deaths.

In one case, a patient was seen in an anticoagulant clinic. She informed them that she was pregnant, which meant that her anti-blood clot medication Warfarin was stopped (it is considered unsafe during pregnancy). Following a series of miscommunications, the patient was prescribed twice as much dalteparin as she should have been – and later died of a brain haemorrhage. The incident was not discovered until 10 months later when the coroner requested a doctor’s report.

NHS England said that while the NRLS was intended to record the actual degree of harm suffered by the patient, the large number of organizations reporting to the system meant that cases were not always coded accurately.

The NHS is moving to a new system for recording patient safety incidents.

An NHS spokesperson said: ‘Patient safety is paramount, and although rare in the context of the millions of patients who receive hospital care each year, it is vital that any prescription errors are promptly reported. and that measures are taken to avoid future errors.

“As part of this action, over the past three years the NHS has invested £75 million in electronic prescribing systems, which can reduce prescribing errors by almost a third, and more than five out of six trusts now have a fully funded plan to introduce electronics. prescribe”.

Steph Lawrence, Executive Director of Nursing and Allied Health Professionals at Leeds Community Healthcare, said: “Leeds Community Healthcare NHS Trust recognizes that a good safety culture is built on incidents reported by staff as they occur. occur. We are proud of the safety culture within the organization.

“Thirty-seven percent of all medication incidents reported by LCH staff occur in another part of the health and social care system. Our staff play a key role at the interfaces of care between hospitals and GPs, identifying and resolving issues which may include problems with prescribed medications, and this is reflected in the figures reported to the NRLS.

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