Medication Errors and Patient Safety
February 2008
In Horton v Evans [2007] EWCH 315 (QB) Mrs Horton succeeded in her claim against a pharmacist who had not questioned the correctness of a prescription and she was awarded nearly £1.5 million in compensation.
Mrs Horton’s GP had mistakenly written a prescription for eight times her usual dose of dexamethasone. Mrs Horton also brought a claim against her GP but this was settled prior to trial.
An important point in the Horton case is that Mrs Horton travelled to the USA and showed the pharmacist’s label of her tablet bottle to a doctor whom she consulted there. The doctor relied on the information written on the label, together with Mrs Horton’s belief that it was her usual prescription, and re-prescribed dexamethasone at the same dose. Mrs Horton suffered an adverse reaction to the medication and became very unwell. At trial the Court held that the pharmacist should have foreseen that the label on the bottle of tablets might be relied upon by a physician, other than the patient’s usual GP, to identify what the prescription was. It is clear to see that one mistake, whether it is in a patient’s clinical notes or in a prescription, can set off a chain of events where others rely on that incorrect information resulting in harm to the patient and significant financial implications. It is no defence to such a mistake that another doctor relied on the incorrect information without checking it, even if he or she was negligent in not doing so.
Medication or prescribing errors occur most commonly on transfer between care settings and particularly at the time of admission to hospital. The National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA) issued guidance in December 2007 on how to reduce the risk of prescribing errors at the time of an adult patient admission or discharge from hospital. The guidance refers to two recent literature reviews which report surprisingly high levels of unintentional variances between the medications patients were taking before admission and their prescriptions on admission at between 30% and 70%. Further, and according to the NPSA, there were 7070 prescribing errors involving patients being admitted or discharged from hospital between November 2003 and March 2007. These errors resulted in 30 serious incidents and sadly in the death of two patients.
Errors can occur at a number of stages during a patients’ admission, or transfer, including when:
The NICE and NPSA guidance recommends that healthcare organisations, including mental health units, should consider new policies for medicines reconciliation on admission to ensure that medicines prescribed to the patient in hospital correspond to, and are compliant with, those they were taking before admission.
The National Prescribing Centre defines medicines reconciliation as:
Sheffield University conducted a study, as part of the NICE Patient Safety Pilot, into the effectiveness of a number of methods to try and reduce medication errors on patient admission. The methods included medicine reconciliation interventions, transfer of information by fax from a GP to the admitting ward and involvement of the clinical pharmacist. Pharmacist led intervention at the time of the patient’s admission inevitably involved greater input from the pharmacy department, with the associated rescourcing issues, but the Sheffield study predicted this step was most likely to prevent medication errors.
Following the Sheffield study the December 2007 NICE and NPSA guidance, in addition to specifying standardised systems for collecting and documenting information about current medications, recommended that pharmacists should be involved in medicines reconciliation as soon as possible after the patient’s admission.
As always, if you have any queries, your NHSLA contact will help you, or feel free to contact one of the Medical Law and Personal Injury team at Bevan Brittan.
Mrs Horton’s GP had mistakenly written a prescription for eight times her usual dose of dexamethasone. Mrs Horton also brought a claim against her GP but this was settled prior to trial.
An important point in the Horton case is that Mrs Horton travelled to the USA and showed the pharmacist’s label of her tablet bottle to a doctor whom she consulted there. The doctor relied on the information written on the label, together with Mrs Horton’s belief that it was her usual prescription, and re-prescribed dexamethasone at the same dose. Mrs Horton suffered an adverse reaction to the medication and became very unwell. At trial the Court held that the pharmacist should have foreseen that the label on the bottle of tablets might be relied upon by a physician, other than the patient’s usual GP, to identify what the prescription was. It is clear to see that one mistake, whether it is in a patient’s clinical notes or in a prescription, can set off a chain of events where others rely on that incorrect information resulting in harm to the patient and significant financial implications. It is no defence to such a mistake that another doctor relied on the incorrect information without checking it, even if he or she was negligent in not doing so.
Medication or prescribing errors occur most commonly on transfer between care settings and particularly at the time of admission to hospital. The National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA) issued guidance in December 2007 on how to reduce the risk of prescribing errors at the time of an adult patient admission or discharge from hospital. The guidance refers to two recent literature reviews which report surprisingly high levels of unintentional variances between the medications patients were taking before admission and their prescriptions on admission at between 30% and 70%. Further, and according to the NPSA, there were 7070 prescribing errors involving patients being admitted or discharged from hospital between November 2003 and March 2007. These errors resulted in 30 serious incidents and sadly in the death of two patients.
Errors can occur at a number of stages during a patients’ admission, or transfer, including when:
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Establishing what medication the patient is currently taking | |
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Transcribing details of the patient’s medication to the clinical notes | |
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Prescribing medication after admission |
The NICE and NPSA guidance recommends that healthcare organisations, including mental health units, should consider new policies for medicines reconciliation on admission to ensure that medicines prescribed to the patient in hospital correspond to, and are compliant with, those they were taking before admission.
The National Prescribing Centre defines medicines reconciliation as:
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Collecting information on the patient’s medication history before admission using the most recent and accurate sources to create a full and current list, this may include obtaining a GP repeat prescribing record and information from the patient and any carer and | |
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Checking the list against the current hospital prescription chart and ensuring any discrepancies are accounted for and | |
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Communicating through appropriate documentation any changes, omissions and discrepancies. |
Sheffield University conducted a study, as part of the NICE Patient Safety Pilot, into the effectiveness of a number of methods to try and reduce medication errors on patient admission. The methods included medicine reconciliation interventions, transfer of information by fax from a GP to the admitting ward and involvement of the clinical pharmacist. Pharmacist led intervention at the time of the patient’s admission inevitably involved greater input from the pharmacy department, with the associated rescourcing issues, but the Sheffield study predicted this step was most likely to prevent medication errors.
Following the Sheffield study the December 2007 NICE and NPSA guidance, in addition to specifying standardised systems for collecting and documenting information about current medications, recommended that pharmacists should be involved in medicines reconciliation as soon as possible after the patient’s admission.
As always, if you have any queries, your NHSLA contact will help you, or feel free to contact one of the Medical Law and Personal Injury team at Bevan Brittan.
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