Factors contributing to medication errors
Medication errors can occur at any stage of the medicine journey, and involve a range of errors from ordering, prescribing, dispensing, administration and monitoring. According to the Care Quality Commission’s Insight 14, an estimated 237 million medication errors occur in the NHS in England every year.
Several factors can influence why things go wrong and contribute to medication errors. It is useful to understand the relationship between humans and the systems they work, known as human factors or ergonomics. This can help within your workplace to design systems, processes and equipment to minimise errors.
Several factors can contribute to a single medication error as discussed below.
Medicine factors
The appearance or nature of the medicine itself may contribute to errors. “Look alike, sound alike” (LASA) medicines may increase the chance of mis-selection, and unclear or misleading labelling may lead to errors.
Complex dose calculations or handling requirements may mean errors are more likely for certain medicines.
Environmental factors
Inadequate lighting, poorly laid out storage, cramped working areas and intrusive uncontrolled noise are just a few of the physical environmental factors which can increase the risk of an error occurring.
People factors
The knowledge and skills of healthcare professionals, including their understanding of medicines errors and error prevention, are important in minimising risks to patients. Individuals who do not adhere to established safe working practices, for whatever reason, are more likely to cause errors with medicines.
System and process factors
Poorly designed systems, gaps in processes and impractical working practices contribute to medication errors. Lack of clarity about actions to be taken, or responsibilities for taking the actions, leaves room for errors to occur.
Minimising risk of errors
Organisations should take a systematic approach to minimise risks. Organisational policy and processes should be standardised. They should make it as easy as possible for staff to get it right first time, and as difficult as possible for mistakes to occur.
Our series of articles considers a four-step approach to build barriers to protect patients:
- Understanding design for safety in medicines packaging and labels (SPS Page): to help health care professionals identify potential safety risks
- Purchasing for safety (SPS Page): purchasing medicines that meet best practice guidance, wherever practicable
- Managing medicines safely in pharmacy (SPS Page): establishing working and storage practices that reduce the chance of incorrect supply
- Managing medicines safely in clinical areas (SPS Page): establishing working and storage practices that reduce the chance of incorrect administration
No single step is sufficient on its own. There will always be some LASA medicines, so a purchasing for safety approach has its limitations. Safe working practices in pharmacies will ensure correct supply to clinical areas, but safe working practices are still needed in clinical areas to ensure patients receive the correct medicines.
It is important to consider any unintended consequences that may result from actions to minimise the risk of harm.
All key processes should be routinely audited, and remedial action taken where necessary.
Collaboration
A range of professions are involved in the journey of the medicine from supply to the point of administration to the patient. Collaboration is essential to understand the use of the medicine from the perspectives of a range of professionals. It provides essential insight into ‘real-world’ use within a specific clinical area and by specific healthcare professionals.
The number of individuals and professional groups that should be involved is dependent on the process under review and the clinical area. Individuals could include nursing staff, prescribers, pharmacists, pharmacy technicians, clinical procurement and ordering staff.
The article on collaboration opportunities to improve medication safety (SPS Page) provides more information about the individuals and teams that must work together to deliver an effective purchasing for safety process.
Learning from errors
If errors occur, these should be used as a learning opportunity to prevent similar errors in future. The article learning from medication incidents and harms (SPS Page) provides practical guidance on ensuring these events are translated into shared local and national learning.
Escalation of concerns
Safety concerns should be reported via local systems and escalated to the most appropriate organisation or group:
- the Marketing Authorisation Holder (MAH)
- the Medicines and Healthcare products Regulatory Agency (MHRA)
- local patient safety and clinical risk management groups
- local or regional procurement groups or Medicines Procurement and Supply Chain (MPSC) for future purchasing decisions
- local or regional Medication Safety Officer networks for information, see the article on practice support for the Medication Safety Officer (SPS Page)
Escalating safety concerns through NHS England’s learn from patient safety events (LFPSE) service allows for new or under-recognised safety issues to be quickly identified and acted upon widely.