Modern medicines routinely save and transform lives, but mistakes can be costly – both to patients and the health system as a whole. With staff under ever-growing pressure, errors can happen. A medication error can include a patient being given the wrong medicine, or the wrong dose, but increasingly sophisticated technologies can help make sure people get the right dose of the right drugs.
Research suggests there are an estimated 237m medication errors made in the NHS in England every year, and when patients get drugs through intravenous (IV) infusions, there is a 70% chance of clinical error, 25% of which will be serious. “When you consider that an estimated 90% of people who come into hospital receive IV medication, there’s a huge potential for error there,” says Sian Burgess, national clinical manager at BD Medication Management Solutions.
In the most extreme cases, IV errors can have severe consequences. A serious error is defined as an incident which is likely to lead to permanent reduction in bodily function, which may require surgical intervention; a major permanent loss of function; or is likely to lead to death.
One potential serious error was recently highlighted at an NHS trust where three patients received accidental non-fatal overdoses of the powerful painkiller fentanyl. The Healthcare Safety Investigation Branch (HSIB) launched an investigation after being notified of the accidents. Although the doses were carried out using smart machines with built-in dose error reduction software (DERS), initial findings from HSIB indicate that integrating such smart pumps with existing systems used to administer IV medication, rather than the machines themselves, was the issue. Technology is enhancing every day, but support systems are needed to complement that technology.
But even smaller errors can have a profound effect, says Claire Heron, a clinical consultant at BD MMS – especially if they lead to longer hospital stays that impact on their family or work. “Most patients have faith that they’re going to come in, get better and go home. To have that delayed can be quite hard to cope with.”
The costs to the wider system can mount up. “If you’ve got a medication error you’ve got the potential for litigation,” says Burgess. “You’ve got the costs associated with increased stays. There’s also drug wastage and the cost in nursing time.” And there’s an impact on professionals – often nurses – involved in administering IV infusions, too: “The psychological effect of causing harm can be quite significant, because as nurses we enter the profession to promote patient safety.”
How do errors happen? Human factors are key, says Paul Lee, medical devices training manager at Swansea Bay University health board. “A manufacturer can design the best machine in the world and test it in a laboratory with as many people as possible,” he says, “and then you put it in a real-world environment where you have staff, tiredness, fatigue, distraction, noise, patients, the busyness, the sound and the alarms and everything that’s going on around you. Then it’s a completely different scenario.” A survey by the British Medical Association found that nine in 10 doctors say one of the main reasons for making errors is pressure and lack of capacity in the workplace.
By 2022, the World Health Organization wants to reduce severe, avoidable medication-associated harm by 50% globally. For Lee, a small but crucial part of the jigsaw is increasing the use of DERS: systems that allow infusion pumps to be programmed with bespoke drug libraries for different clinical areas and automatically stop any attempt to give medication at the wrong concentration, rate or volume.
Importantly, Heron explains, the systems don’t just prevent errors – they also record what’s happened, so hospitals can get detailed feedback, allowing them to learn from near-misses.
“For instance, you might see that the alerts are happening quite early in the morning, at the end of the night shift,” says Heron, whose work includes analysing data from DERS to work out factors such as which drugs are causing most problems and what sort of calculation errors are being made. “Then a hospital would change the system so drugs were given by the day shift staff instead of those on the night shift.”
In the US, Lee explains, DERS is used almost universally. But in the UK the figures are much lower. In a 2013 study [pdf], just 39% of NHS organisations that responded reported using some form of DERS. Lee, the chair of the National Association of Medical Device Educators and Trainers (NAMDET), wants to see that number reach 90%. But because errors are stopped by DERS, there’s no harm to patients to record and no national data showing the benefits of the systems.
As a result, NAMDET is currently collating data from infusion devices across the UK, ready to report back to NHS England. “We’ve already had four reports come in from NHS trusts and the figures are startling,” says Lee. “We want to say to NHS England: ‘This is what DERS is and this is what it’s stopping from happening.’”
For Burgess, the standardised approach that DERS allows puts it in line with Lord Carter’s 2016 review of hospital efficiency, which looked into reducing unwarranted variation in cost and outcomes across NHS providers.
“Patients are at the heart of everything we provide,” she says. “We want to ensure healthcare professionals feel confident – whether that’s through education and training or the capabilities of our systems and devices – and that patients are protected from preventable errors.”
