3 Jun 2011 | Medication Safety
Medication Safety is the first of a series of factsheets from the Commission. The factsheets, focusing on Commission programme areas, will be released every two months. The July factsheet will feature infection prevention and control.
Commission Chief Executive, Dr Janice Wilson, says medication errors are an on-going and potentially serious cause of patient harm.
“The latest report on serious and sentinel events showed that 17 serious medication errors were reported in our hospitals during the 2009/2010 period.
“This is just the tip of the iceberg – estimates vary, but somewhere between 2 and 13 percent of patients admitted to hospital are estimated to have an adverse drug reaction of some description.”
She says two initiatives currently being rolled out by District Health Boards – the national medication chart and medicine reconciliation – have the potential to greatly reduce medication errors.
“The national adult medication chart is a simple, inexpensive but effective way of reducing medication errors. It is expected to be in place in most public hospitals by January 2012.
“The chart will enable the easy identification of signatures, clear documentation of a patient’s adverse drug reactions and allergies and allow standard training for all health professionals using it.”
Dr Wilson says one simple design feature of the chart that may in itself save lives is a pre-printed decimal point to avoid ten-fold errors in dose.
The new factsheet also has information on medicine reconciliation.
“The use of formal medicine reconciliation is another effective way of reducing medication errors,” Dr Wilson says.
“This process ensures patient medicines are checked at critical handover times, such as when patients are admitted to or discharged from hospital.
“The clinicians responsible for the patient’s treatment reconcile the medicines prescribed with the medicines listed as being taken by the patient, using a second source of information as confirmation.”
The factsheet is attached, and hard copies can be ordered from firstname.lastname@example.org