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medication harm reduction

Unintended errors in the prescription, administration and reconciliation of high risk medicines account for a significant proportion of harm caused to patients within the healthcare environment. High risk medicines are medicines that are most likely to cause significant harm to the patient, even when used as intended. The Institute for Safe Medication Practices (ISMP) reports that incident rates with these medicines may not necessarily be higher than with other medicines, but when incidents occur the impact on the patient can be significant (serious).

The fourth report from the Patient Safety Observatory reported that 60,000 medication incidents were reported to the NPSA via the National Reporting and Learning System (NRLS) between January 2005 and June 2006. The report reviews 92 of these incidents in detail, 38 of which resulted in death.

The Patient Safety First campaign (first launched in 2008) – ‘How to Guide’ for Reducing Harm from High Risk Medicines, highlighted actions that can reduce harm from high risk medicines based on approaches to developing safer systems: identification, prevention and mitigation.

By following a number of simple steps the risk of unintended harm to patients can be minimised.

The aim of the ‘Reduction in High Risk Medication Harm’ project is to reduce the number of incidents involving high risk medicines across the East Midlands by prevention, identification and mitigation of risks.

Its objectives are:

  • To identify how designated leads provide board assurance in relation to the tracking and reduction of high risk medicines (Anticoagulants, Sedatives, Opiates & Insulin). Identify and share best practice.

 

  • To identify and share best practice of measurement tools used by organisations to measure improvement.

 

  • To identify and share best practice of current medication risk assessment tools used on admission being used within the acute / community and mental health care settings throughout the East Midlands.

What are High Risk Medicines?

Anticoagulants                                                                                                                                                                                                                     

The management of Warfarin therapy spans across primary and secondary care and this can make the pathways complex. Whilst management takes place mainly in the outpatient setting, problems frequently occur when patients are transferring between the community and hospital setting. This can be due to issues around medicine reconciliation or failure to stop or start therapy appropriately when patients are admitted for surgical procedures.

Harm events with Warfarin and heparin have been associated with a lack of dosing guidelines and appropriate monitoring. Studies have shown that strategies to improve prescribing and monitoring have the potential to reduce adverse events such as bleeding or thromboembolic events.

In March 2007 the NPSA produced ‘Patient Safety Alert: Actions that can make anticoagulant therapy safer’

Opiates

Opiate overdose or underdose may be associated with respiratory depression or pain control. As with other medicines, differing strength medicines in similar packaging can increase the likelihood of human error. Delays in administering a reversal agent in cases of overdose may lead to more serious harm.

Sedatives

Up to April 2008, the NPSA received 242 ‘wrong dose’ patient safety incidents concerning midazolam injections where the dose was prescribed and/or administered to the patient was inappropriate. Other sedatives present similar risks, particularly when administered to elderly patients.

NPSA guidance is available

Insulin

The introduction of new insulin formulations has resulted in potential risks in the care of diabetic patients. Errors may also occur from inadequate monitoring. Patients may not have blood glucose monitored at the correct frequency or before administration of insulin.

NPSA guidance is available