13 May 2011 | Medication Safety
Medication errors are an ongoing and potentially serious cause of harm, says Commission Chief Executive Dr Janice Wilson.
“As a result of medication errors, some patients will be harmed, have to spend extra time in hospital, and need additional medication or procedures.
“While we cannot go back in time and prevent particular events, we can – and must – learn from them and reduce the likelihood of this kind of avoidable harm in the future.”
She says New Zealand has an excellent health system by international standards and the vast majority of patients are treated safely and effectively. However, for a small number of people, preventable incidents occur.
“Learning from these incidents is essential if we are to continually improve the safety and quality of care provided by our hospital services.”
Commission Board member and intensive care specialist at Middlemore Hospital, Dr David Galler, says District Health Boards (DHBs) throughout the country are working hard to reduce medication errors. One example is the national medication chart for adult patients which is currently being rolled out in DHBs. The chart is a simple, inexpensive but effective way of reducing medication errors.
“The chart is expected to be in place in most public hospitals within the next seven or eight months, and will enable easy identification of signatures, clear documentation of a patient’s adverse drug reactions and allergies and the separation of regular and non regular medicines.”
Dr Galler says another effective way of reducing medication errors is through the use of a formal medicine reconciliation process.
“The 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, in order to detect discrepancies which require follow up.”
An electronic prescribing service is also being trialled in the community, which will improve patient safety by making prescriptions more accurate; by reducing manual data entry and therefore transcription errors; and by the ability to send status updates to the prescriber if requested, for example notifying a doctor when a prescription has been picked up.
Hospital admissions can be reduced because prescribers and pharmacists will be able to better support patient adherence to their medication plans.
For further information contact Liz Price, Health Quality & Safety Commission Communications Advisor, 0276 957 744, 04 527 3290