Quality | 2009.09.03
NHS medical errors double in two years
Most mistakes had no serious effect, but 100 resulted in serious harm or death, says report
The number of medication errors reported to the NHS has more than doubled in two years, figures reveal today.
A report from the National Patient Safety Agency (NPSA) found a "significant" rise in the number of errors and near misses reported by NHS staff.
In 2005, 36,335 incidents were reported, rising to 64,678 in 2006 and 86,085 in 2007.
A total of 96% of these incidents resulted in low or no harm to NHS patients – but 100 resulted in serious harm or death, said the report.
The NPSA chief executive, Martin Fletcher, said the rise reflected a willingness by NHS staff to report errors and a more open reporting culture.
But Professor David Cousins, a senior pharmacist at the NPSA, said only around 10% of incidents were actually reported. This suggests there was as many as 860,000 errors or near misses involving medicines across the NHS in 2007.
Today\'s report listed the top five medication errors in the NHS in England and Wales as the wrong dose, medicines being missed or delayed, the wrong drug, the wrong quantity (such as too much chemotherapy), and mismatching, where patient A\'s medicine is given to patient B.
Examples included an anti-coagulant drug given in error to a patient with a similar name, a strong sedative given to a patient instead of insulin, and heart medicine given instead of an anti-inflammatory.
One patient received 100mg of morphine instead of 10mg.
The figures for England and Wales are from reports filed by NHS staff in hospital trusts, mental health trusts and in primary care.
The NHS medical director, Sir Bruce Keogh, said: "The vast majority of NHS patients experience good quality, safe and effective care and this is reflected in today\'s figures which show that the majority of medication incidents - 96% - had clinical outcomes of low or no harm to patients.
"However, we expect all NHS organisations to examine the NPSA\'s recommendations carefully and where necessary take steps to implement them in order to ensure that the services they provide are as safe as possible."
The study found that 41% of the most serious incidents occurred when a medicine was administered, mostly by nursing staff, while 32% were due to errors with prescribing.
Of those incidents that caused death (37) or severe harm (63), 62% were to do with injectable medicines.
Errors with medication are the third largest group reported to the NPSA after patient accidents, such as falls which could have been avoided, and errors with treatments or procedures.
Fletcher said: "Millions of medicines are prescribed in the community and in hospitals across England and Wales each day - the majority of these are delivered correctly and do exactly what they are meant to do.
"However, when an incident does occur, it is vital we learn from this to ensure patients are not harmed."
The Liberal Democrat health spokesman, Norman Lamb, said: "Settling claims for damages costs the NHS nearly £1bn per year which could be spent on patient care.
"In an organisation the size of the NHS there are always going be some accidents, but we have to ensure that robust systems are in place that minimise risks and prioritise patient safety.
"The fact that some errors are being made over and over again needs to be looked at much more closely.
"It is vital that the NHS has a robust and rigorous reporting culture so that mistakes can be rectified as soon as they are made."
For more information, please visit
http://www.guardian.co.uk/society/2009/sep/03/nhs-mistakes-npsa-report
