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News from todays Reducing Medication Errors in Hospitals National Summit 2018

Medication Errors & Medication Related Harm: National Findings
Prof Rachel Elliott
, Professor of Health Economics, University of Manchester
Pre Event Abstract
We used published United Kingdom-based literature on the prevalence of medication errors (in prescribing, dispensing, administration and monitoring), and associated healthcare resource use, to estimate the annual number and burden of errors to the NHS. In estimating the burden of errors, avoidable adverse drug events (ADEs) were used as a measure of harm. Burden included health care resource use (such as inpatient admissions) and deaths associated with medication errors.
We estimate that 237 million medication errors occur at some point in the medication process in England per year, of which 71% occur in primary care. 72% have little/no potential for harm and 66 million are potentially clinically significant. Prescribing in primary care accounts for 34% of all potentially clinically significant errors. Definitely avoidable ADEs are estimated to cost the NHS £98,462,582 per year, consuming 181,626 bed-days, and causing or contributing to 1,708 deaths. This can be divided into primary care ADEs leading to a hospital admission (£83.7 million; causing 627 deaths), and secondary care ADEs leading to a longer hospital stay (£14.8 million; causing 85 deaths and contributing to 1,081 deaths). 
Ubiquitous medicines use in health care leads unsurprisingly to high (estimated) numbers of medication errors, although most not clinically important. There is significant uncertainty around estimates of burden due to the assumption that avoidable ADEs correspond to medication errors, use of studies involving 1-2 centres, and lack of data around longer term impacts of errors. Data linkage between errors and patient outcomes is essential to progress understanding in this area. Work being carried out as part of our NIHR programme grant (PRoTeCT) aims to identify and quantify the link between errors, harm and economic burden.
Full powerpoint presentaion

New Measures to Reduce Medication Harm: National Update
Paul Brown
, Clinical Specialist, NHS Digital
Pre event abstract
There will be a dependency on data and technology if we are to successfully respond to the World Health Organisation third global patient safety challenge to reduce severe avoidable medication-related harm by 50% over five years. This dependency was reflected in the recommendations in the report of the Short Life Working Group (Department of Health & Social Care).
Work led by NHS Digital and other organisations is contributing to improvement in both the quality and breadth of data available and the digital capability that will contribute to NHS Improvement’s medication safety programme. The Medicines Data programme (NHS Digital) is working towards introducing a single source of consistent and comprehensive national medicines data covering both primary and secondary care. NHS Digital is also working to integrate pharmacy and other care settings, facilitating the safe and secure transfer of information about patients including medicines supplied and other interventions.  
A set of metrics has already been developed and published linking patient level primary care prescribing data available from NHS Business Services Authority with hospital episode statistics (HES) data collected by NHS Digital. The metrics measure the rate of hospital admission for gastro-intestinal bleeds associated with four prescribing scenarios that increase the risk of a gastro-intestinal bleed. A fifth metric measures admission rates for acute kidney injury based on work that commenced two years ago to develop a suite of polypharmacy comparators. Work is in progress to develop more hospital admission metrics with the aim is to publish these by December 2018.
National primary care medicines data could be better. Nationally we are mainly working with data from systems established for community pharmacy reimbursement. We still do not have information about other details about the medicine and/or patient that would support further metrics e.g. indication for use, dose and frequency, monitoring, pathology tests and results. As mentioned in the Short Life Working Report, GP computer software tools such as Pincer, Eclipse and Optimise Rx can make use of this information to support safety interventions at practice level.   
Drawing on some of the experiences of working with data and technology in primary care, there is a need to develop measures that address the safe use of medicines in secondary care. Nationally we start from a position of little helpful data being available, particularly data at patient level, data about medicines prescribed and administered and data that allows for linkage to other useful datasets. The further roll-out of EPMA will be key to improving the data. Some of the functionality requirements outlined in the recent announcement about EPMA implementation funding are being explored by NHS Digitals Medicine Data programme – secondary use of data, dm+d compliance inter-operability with other systems particularly electronic patient records.
Full powerpoint presentation 

Electronic Prescribing: Reducing Medication Errors
Caroline Anderson,
Principal Pharmacist, Electronic Prescribing, Kings College Hospital NHS Foundation Trust
Pre event abstract
In February 2018 the ‘Report of the short life working group on reducing medication errors’ acknowledged  the potential for electronic prescribing and medicines administration systems reduce the number of high risk medication errors by half. This was followed by a financial commitment from the Government to ‘help hospitals progress’ with implementing e-prescribing systems. This session will examine the practical ways in which electronic prescribing systems can be configured and utilised to maximise safety and prevent medication errors in hospitals.
Full powerpoint presentation

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14 September 2018


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