Identifying risk

Identifying risk

Incident-reporting systems

Risks with medicines are usually identified through incident-reporting systems.

All NHS organisations are required to have incident-reporting systems in place to capture patient safety information, including information on adverse events with medicines.  Review of reports submitted to local incident-reporting systems is essential to gain an understanding of the medicines and processes which are prone to error or introduce risk in individual organisations. Incident reporting is voluntary and relies on recognition of an adverse event, understanding the need to report, knowing how and what to report and willingness to report. Because of these and other factors, such as fear of blame and disciplinary action, there is underreporting to local incident-reporting schemes. Information collected through such schemes is limited but it does provide valuable qualitative information about medication error types. Voluntary reporting schemes cannot be used for quantitative analysis of error frequency or as a measure of the safety of medicine use systems.

Medication errors that have a noticeable clinical impact on a patient and can be attributed to a particular medicine are most likely to be reported as an adverse incident. Investigation of these incidents is usually carried out locally within the organisation by a multidisciplinary team to identify root causes and predisposing factors. Steps can then be taken to raise awareness of risks or make changes to eliminate risks.

Because incident reports are completed and submitted by individuals the amount of information they contain varies widely and descriptions may lack sufficient detail to understand fully exactly what events led to the incident. Electronic reporting systems set mandatory fields to be completed but accur-ate supplementary information is essential to the usefulness of reports. Because of this and other limitations of voluntary incident-reporting systems, proactive methods of identifying risks are useful.

The NPSA and the National Reporting and Learning System aggregate incident reports from NHS organisations in England and Wales to identify themes and trends. Centralisation of data increases the opportunity for the NHS to recognise recurring themes and identify rare but serious untoward events and issue guidance to NHS organisations to take action to prevent patient harm.

The NPSA issues patient safety alerts, rapid response reports and signals to NHS organisations detailing these actions and giving deadlines before which recommendations should be implemented.

Trigger tools

Triggers are used as a proactive tool for identifying adverse drug events. Triggers can be changes in a patient’s clinical condition, an abnormal labora-tory test or a prescription for a drug which might prompt investigation into a medicine-related cause of the event. Medicines which might be triggers for adverse drug events include vitamin K to reverse overanticoagulation in patients receiving warfarin, glucagon for insulin-induced hypoglycaemia, naloxone for opioid toxicity and flumazenil for oversedation with benzodi-azepines. Pharmacists should be prompted to investigate the reason why trigger drugs are prescribed and report any adverse drug reactions or medi-cation errors identified. Similarly, abnormal laboratory results may indicate medication-related problems. Elevated serum potassium levels may indicate inappropriate use of potassium-sparing diuretics and rapid falls in haemoglo-bin may indicate gastrointestinal bleeding in a patient receiving non-steroidal anti-inflammatory medicines. Pharmacists can use triggers to identify risks with medicines proactively, prevent patient harm by contributing to changes in medication regimens and report adverse incidents.

Triggers are used in the Patient Safety First campaign to measure the incidence of patient safety incidents, including medication incidents.