Medication Errors in the NHS and the need for interoperability


Publish date: Sep 27, 2022

It's important that, despite all of the current NHS challenges, we ensure patient safety and reduction of medication errors remains paramount. It is in this context that ‘Medication Safety’ has been selected as the theme for World Patient Safety Day 2022, with the slogan ‘Medication Without Harm’ (WHO, 2022).

The issue of medication errors and the challenges facing the NHS

As reported by The National Reporting and Learning Systems (NRLS), (NHS England, 2014) a ‘patient safety incident’ (PSI) is ‘any unintended or unexpected incident, which could have or did lead to harm for one or more patients receiving NHS care’. Medication errors are any PSIs where a mistake was made during the prescription, preparation, dispensing, administration, monitoring, or guidance procedure for medications. Errors occur at all stages of the medicines use process, but a report shows that prescribing (21.3%) and administration (54.4%) had the highest rates for errors. (House of Commons Health and Social Care Committee, 2022)

In a recent report from the House of Commons Health and Social Care Committee (2022), it was reported that NHS England is currently facing its biggest staffing crisis in its history due to a shortage of 12,000 hospital doctors and more than 50,000 nurses and midwives. As the volume of patients increases, quality of care decreases without the funding the NHS so crucially needs, which leads to avoidable mistakes. Every year, 237 million medication errors occur in the NHS (Elliot R, Camacho E, Campbell F, et al., 2018). These errors can be caused by health worker fatigue, overcrowding, staff shortages, poor training and the wrong information being given to patients, among other reasons. Any one of these, or a combination, can affect the prescribing, dispensing, consumption, and monitoring of medications, which can result in severe harm, disability and even death, although this can be completely avoidable.

Though there is a yearly financial cost of £98.5 million (WHO, 2022) to the health system, the cost in terms of patient safety is immeasurable. If decisive action is not taken, the post-pandemic strains, which are already exerting themselves on the health system and are expected to worsen, thus, increasing the risk of medication errors. This makes this year’s World Patient Safety Day that much more important, as it is reinforcing the objectives of the WHO Global Patient Safety Challenge: Medication Without Harm launched by WHO in 2017, which aims to reduce severe avoidable medication-related harm by 50%, globally in the next 5 years. (WHO, 2022)

Where we are now

Hospitals are currently trying to balance the demand and backlog of elective work and emergency capacity. The REAL Centre estimates it will cost up to £16.8 billion by 2024 (Rocks S, Boccarini G, Charlesworth A, et al., 2021) to enable the NHS to clear the backlog of people waiting for routine elective care and treat millions of ‘missing’ patients who were expected to receive care during the pandemic. The number of ‘missing’ patients is now approaching an estimated 8 million, and the current waiting list is expected to grow to 12.5 million.

As is well known, COVID 19 contributed to the rapid adoption of digital innovation in the NHS, and we need to maintain this pace of change. Medication management has become a national priority due to the shortage of medications and the prevalence of medication errors. However, UK healthcare industry as a whole has only seen a 7% decline in medication errors, (Elliot R, Camacho E, Campbell F, et al., 2018) despite healthcare systems investing billions in other technologies. For the NHS to ensure patient safety; medication management is an essential process, and there can be up to 50 information transfer steps or risk opportunities (Watcher R, 2015) between the prescription and administration of a medication to a patient illustrating the potential benefits of investing in interoperable connected medication management systems, which demands targeted investment. Online consultations, automated medicine dispensing cabinets, and IV compounding procedures are just a few examples of how technology is easing constraints. Hospitals are able to share data and improve interoperability thanks to automation, allowing for easy information transmission between sites.

In a report published in 2020, ‘Transforming NHS Pharmacy Aseptic Services in England’, Lord Carter of Cole’s (2020) outlined a goal for the NHS to "become a leader in standardised aseptic services”. Automation could help to streamline the pharmacy workflow and boost productivity while improving medication safety and patient safety.

BD’s ongoing commitment to patient safety

Nearly two years after Lord Carter's report, the path towards automation is still too slow, despite all the clear benefits and the willingness from the health industry. BD has a unique portfolio of products and services and capabilities. With a range of solutions that includes cutting-edge technologies and services, we can support with error reductions by standardising and automating drug prescription, transcription, and preparation. Medication management is required to support the improvement of patient safety, as over 50% of medication errors occur during administration (House of Commons Health and Social Care Committee, 2022). This is made possible with BD Pyxis™ medication management software and pharmaceutical dispensing devices, to guarantee that, across care settings, the right medications and supplies are available when and where they are required, which also allows staff to concentrate on what matters most, which is patient care.

We are committed to ensuring medication safety at each point of the medication process. Collaboration with the NHS, stakeholders and beyond, in order to reduce medication errors across the entire patient journey, sustain health workers, and optimise technology to improve overall patient safety is a central part of BD’s ambition.

Since the pandemic, there has been a growing need for digitalised services that are more effective and paperless. We may soon see an end to antiquated processes because there are currently solutions available to make this happen. Medication errors are an avoidable occurrence that can be eliminated through use of digital solutions. The compromise on patient safety should make eliminating medication errors a key focus, particularly considering BD's dedication to cross-sector collaboration. Following on from this, we will explore BD's work with patient advocates; Lisa Richard-Everton’s story is a powerful one that shows the personal impact medication errors can have on families.

About the Author: Dipak Duggal GPhC, Director Medical Affairs, BD
About the Author: Dipak Duggal GPhC, Director Medical Affairs, BD

As part of BD Medication Management Solutions (MMS) since 2015, Dipak leads the medical affairs function for BD dispensing in Europe and internationally. He is responsible for external professional relationships with key opinion leaders (KOL), evidence generation and provides clinical input and support to R&D and regulatory functions. A former NHS Chief Pharmacist and Hospital Clinical Executive Director, Dipak also went on to join EY’s health management consulting practice prior to working at Medtronic IHS.

  1. WHO. World Patient Safety Day 2022. Available at: Last accessed: August 2022
  2. NHS England. 2014. Improving medication error incident reporting and learning. Available at: Last accessed: August 2022
  3. House of Commons Health and Social Care Committee. 2022. Workforce: recruitment, training and retention in health and social care. Available at: Last accessed: August 2022
  4. Elliot R, Camacho E, Campbell F, et al. 2018. Prevalence and Economic Burden of Medication Errors in the NHS in England.
  5. WHO. Medication Without Harm. Available at: Last accessed: August 2022
  6. Rocks S, Boccarini G, Charlesworth A, et al. 2021. Health and social care funding to 2024/25. Available at: Last accessed: August 2022
  7. Watcher R. The Digital Doctor. 2015.
  8. Lord Carter of Coles. 2020. Transforming NHS Pharmacy Aseptic Services in England - A national report for the Department of Health and Social Care. Available at: Last accessed: August 2022

About BD

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Troy Kirkpatrick

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