Risks with medicines are usually identified through incident-reporting systems.
Identifying risk
Risks with medicines
are usually identified through incident-reporting systems.
All NHS
organisations are required to have incident-reporting systems in place to
capture patient safety information, including information on adverse events
with medicines. Review of reports
submitted to local incident-reporting systems is essential to gain an
understanding of the medicines and processes which are prone to error or
introduce risk in individual organisations. Incident reporting is voluntary and
relies on recognition of an adverse event, understanding the need to report,
knowing how and what to report and willingness to report. Because of these and
other factors, such as fear of blame and disciplinary action, there is
underreporting to local incident-reporting schemes. Information collected
through such schemes is limited but it does provide valuable qualitative
information about medication error types. Voluntary reporting schemes cannot be
used for quantitative analysis of error frequency or as a measure of the safety
of medicine use systems.
Medication errors
that have a noticeable clinical impact on a patient and can be attributed to a
particular medicine are most likely to be reported as an adverse incident.
Investigation of these incidents is usually carried out locally within the
organisation by a multidisciplinary team to identify root causes and
predisposing factors. Steps can then be taken to raise awareness of risks or
make changes to eliminate risks.
Because incident
reports are completed and submitted by individuals the amount of information
they contain varies widely and descriptions may lack sufficient detail to
understand fully exactly what events led to the incident. Electronic reporting
systems set mandatory fields to be completed but accur-ate supplementary
information is essential to the usefulness of reports. Because of this and
other limitations of voluntary incident-reporting systems, proactive methods of
identifying risks are useful.
The NPSA and the
National Reporting and Learning System aggregate incident reports from NHS
organisations in England and Wales to identify themes and trends.
Centralisation of data increases the opportunity for the NHS to recognise
recurring themes and identify rare but serious untoward events and issue
guidance to NHS organisations to take action to prevent patient harm.
The NPSA issues
patient safety alerts, rapid response reports and signals to NHS organisations
detailing these actions and giving deadlines before which recommendations
should be implemented.
Triggers are used as
a proactive tool for identifying adverse drug events. Triggers can be changes
in a patient’s clinical condition, an abnormal labora-tory test or a
prescription for a drug which might prompt investigation into a
medicine-related cause of the event. Medicines which might be triggers for adverse
drug events include vitamin K to reverse overanticoagulation in patients
receiving warfarin, glucagon for insulin-induced hypoglycaemia, naloxone for
opioid toxicity and flumazenil for oversedation with benzodi-azepines.
Pharmacists should be prompted to investigate the reason why trigger drugs are
prescribed and report any adverse drug reactions or medi-cation errors
identified. Similarly, abnormal laboratory results may indicate
medication-related problems. Elevated serum potassium levels may indicate inappropriate
use of potassium-sparing diuretics and rapid falls in haemoglo-bin may indicate
gastrointestinal bleeding in a patient receiving non-steroidal
anti-inflammatory medicines. Pharmacists can use triggers to identify risks
with medicines proactively, prevent patient harm by contributing to changes in
medication regimens and report adverse incidents.
Triggers are used in
the Patient Safety First campaign to measure the incidence of patient safety
incidents, including medication incidents.
Related Topics
TH 2019 - 2025 pharmacy180.com; Developed by Therithal info.