Medication errors and adverse drug reaction reporting

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Chapter: Hospital pharmacy : Clinical pharmacy

Despite the important role of clinical pharmacy services, patients receiving drug therapy may still experience unintended harm or injury as a result of medication errors or from ADRs.

Medication errors and adverse drug reaction reporting


Despite the important role of clinical pharmacy services, patients receiving drug therapy may still experience unintended harm or injury as a result of medication errors or from ADRs. Adverse events (from any cause) occur in around 10% of all hospital admissions and medication errors account for one-quarter of all the incidents that threaten patient safety. A study commis-sioned by the General Medical Council identified a mean prescribing error rate of 8.9 per 100 medication orders.


Contributing to the avoidance or resolution of adverse medication events is an important part of any hospital pharmacist’s clinical duties. This requires a multisystem approach, often incorporated into a hospital’s clinical risk management strategy. Important lessons can be learned from analysis of medication-related incidents and from near-misses (that is, those that do not develop sufficiently to result in patient harm or are detected prior to patient harm). Chapter 12 considers these issues in fur-ther detail.


Even when the prescribed and administered treatment is correct and no errors have occurred, a small proportion of patients can still suffer from ADRs. Clinical pharmacists have an important role to play in the detection and management of ADRs and, more recently, directly reporting ADRs to the Committee on Safety of Medicines via the Yellow Card scheme. Their involvement can help to increase the number of ADR reports made, particu-larly those involving serious reaction. However, even in hospitals with formal ADR schemes, gross underreporting of reactions still remains a major problem.


Medication history-taking and medicines reconciliation


Taking a medication history from patients and prescribing on admission have traditionally been done by junior doctors, but published work suggests that pharmacists are able to take more accurate medication histories than medical staff. The crucial role of clinical pharmacists in undertaking medicines reconciliation for patients on admission to hospital has been endorsed by the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency. The guidance recognised the increased risk of morbidity, mortality and economic burden to health services caused by medication errors and noted that errors occur most commonly on transfer between care settings, particularly at the time of admission, with unintentional variances of up to 70%. It recommended that pharmacists should be involved in medicines reconciliation as soon as possible after hospital admission, noting this is a cost-effective interven-tion. Reconciliation was defined as:


·      collecting information on medication history (prior to admission) using the most recent and accurate sources of information to create a full and current list of medicines

·      checking or verifying this list against the current prescription chart in the hospital, ensuring any discrepancies are accounted for and acted on appropriately

·      communicating through appropriate documentation any changes, omissions or discrepancies.


With the increasing use of information technology, access to patients’ sum-mary care record from their general practitioner surgery offers a timely and accurate method for obtaining this important information. The pharmacist can also question patients on concordance with prescribed treatment, check their own medicines to ensure suitability for reuse in hospital of POD and self-medication schemes and help to identify whether or not an admission is due to prescribing errors or ADRs. Pharmacy technicians are increasingly involved in supporting these roles. This is discussed further later in the chapter.


A report commissioned by NICE included economic evaluation modelling of several different methods of medicines reconciliation and stated that: ‘in terms of effectiveness, the pharmacist-led reconciliation intervention is pre-dicted to prevent the most medication errors. This reduction is shown to reduce costs associated with errors by £3002 [per 1000 prescription orders] compared to the baseline scenario’.


For planned admissions to hospital (for example, elective surgery), the medication history-taking role can be moved to an earlier stage in the patient care process. Preadmission clinics have traditionally been used to assess patients’ suitability for surgery, but are also increasingly used to make other preparations for admission. Clinical pharmacists can work alongside medical and nursing staff, to help ensure that full and accurate details of medication are recorded and that either patients bring their own medication with them on admission or that medicines not routinely stocked by the hospital pharmacy can be ordered in advance. For patients on clearly defined treatment pathways, early discharge planning and advance preparation of discharge medication can also help to reduce delayed dis-charges and this can also involve pharmacists prescribing the discharge medication.


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