{"id":956,"date":"2010-01-25T15:32:00","date_gmt":"2010-01-25T14:32:00","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=956"},"modified":"2010-02-24T11:21:32","modified_gmt":"2010-02-24T10:21:32","slug":"douglas-noble-on-medication-safety","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2010\/01\/25\/douglas-noble-on-medication-safety\/","title":{"rendered":"Douglas Noble on medication safety"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"alignleft\" style=\"float: left\" src=\"http:\/\/www.bmj.com\/columns\/icons\/douglas_noble.jpg\" alt=\"douglas noble\" width=\"160\" height=\"110\" \/>A <a href=\"http:\/\/www.bmj.com\/cgi\/content\/full\/339\/dec07_1\/b5328\">recent review<\/a> of medication safety revealed a 9% error rate, of which 50% were significant and 2% potentially fatal.\u00a0<\/p>\n<p>Just think of the significance of that for a moment, perhaps between amending drug charts &#8211; for every 500 drug orders written by a doctor, 1 patient could die as a result.\u00a0<!--more--><\/p>\n<p>In the larger world of patient safety, medication errors typically account for 30% of all adverse events and near misses.\u00a0 In fact it could be argued that the recent patient safety movement took much of its momentum from the early work on medication errors by Bates et al. in the USA.\u00a0<\/p>\n<p>Thankfully, the very serious errors, such as the delivery of intrathecal vincristine, become well known, but remain rare.\u00a0 Human factors, culture, stress and lack of education all play a part in causality (at our medical school we had a one hour tutorial on how to prescribe after finals had been passed!?).\u00a0 Yet, problems with drug charts are often one of the main root causes of error.\u00a0<\/p>\n<p>Firstly, they\u2019re just so tatty.\u00a0 And then there\u2019s the continual re-scribing with ever more important drugs slipping into oblivion with every re-write.\u00a0 Despite many years of automated systems being available to correct errors and red flag potential interactions, the manual green pen is still relied upon to keep us right.\u00a0 At the very least having the same drug card across the NHS would be a major protection for patients.\u00a0<\/p>\n<p>Unsurprisingly many drug errors have complex accident trajectories.\u00a0 The pharmacist&#8217;s green pen runs out of ink, the dispensing system is not fully understood, the little pink ones get remanufactured as oval white ones etc. In one of my own errors I prescribed warfarin as a regular medication instead of on the special part of the drug chart.\u00a0 Due to lack of beds the patient was moved as an outlier onto a urology ward.\u00a0 Haematuria began some days later and no-one thought twice about it \u2013 every one on the ward had that!\u00a0 Eventually an INR \u2013 of some ghastly number and warranting a logarithmic scale &#8211; came back from the lab and a panic ensued.\u00a0 A few doses of vitamin K later and all was well, but it could have been tragic.\u00a0<\/p>\n<p>Often though it\u2019s the smaller errors that cause the most serious damage and are sometimes not detected until years later: GP fails to get copy of discharge summary, out-patient appointment letter never arrives, amiodarone et al. becomes an unmonitored homely staple for years to come.\u00a0<\/p>\n<p>Education at medical school and beyond is no doubt key.\u00a0 Unfortunately in my own one hour tutorial it failed to teach me that Augmentin contained penicillin or that digoxin was prescribed in micrograms.\u00a0 The harm was untold, although I\u2019m still sure massive doses of digoxin could be beneficial in anaphylactic shock!<\/p>\n<p>\u00a0<br \/>\n<em><strong>Douglas Noble<\/strong><\/em> <em>has worked in surgery, emergency medicine, public health and for WHO Patient Safety. From 2006 to 2008 he was clinical adviser to chief medical officer for England, Sir Liam Donaldson.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A recent review of medication safety revealed a 9% error rate, of which 50% were significant and 2% potentially fatal.\u00a0 Just think of the significance of that for a moment, [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2010\/01\/25\/douglas-noble-on-medication-safety\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":66,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1576,223],"tags":[],"class_list":["post-956","post","type-post","status-publish","format-standard","hentry","category-douglas-noble","category-guest-bloggers"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Douglas Noble on medication safety - 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