A pregnant woman who died after being given the wrong dosage of drugs was one of almost 6,000 people harmed and 29 killed following prescription errors in the NHS in England last year.
Figures from NHS England show that 98 hospital trusts experienced an increase in the number of prescription errors reported in 2021, including cases where patients were given the wrong drug, wrong dosage or were not given medicine when needed. Meanwhile, the number of errors fell at 105 trusts.
Leeds Community healthcare trust had a sixfold increase in prescription errors – with 111 errors, up from just 17 in 2020. At the Royal National Orthopedic hospital errors rose from 60 to 193, while Herefordshire partnership university NHS trust had 55 errors, up from 20 in 2020
The NHS said almost one in six trusts still did not have a fully funded plan to introduce electronic prescribing, meaning they are still run at least partially using paper notes.
Peter Walsh, the chief executive of Action against Medical Accidents, said: “These are very disappointing statistics and behind every one there is a story of personal suffering or tragedy. What is particularly frustrating is that prescription errors are probably easier to avoid than many things that go wrong in healthcare.
“The fact that almost one in six trusts don’t have a funded plan to reduce these errors is quite shocking. Even with those that do, having a plan is not enough.
“We are particularly concerned about vulnerable people such as elderly or disabled people in care homes, who may be more at risk because they may be less able to check for themselves and because they tend to get a less personalized service than the average patient.”
The vast majority of prescription incidents – 86% – were recorded as causing no harm to the patient, and on the whole, the number of prescription errors recorded on the national reporting and learning system (NRLS) fell from 44,928 in 2020 to 43,452 in 2021 .
However, 5,349 were recorded as causing a low level of harm, which means they required extra observation or minor treatment. A further 520 incidents caused a moderate degree of harm, which can lead to further treatment, potential surgical intervention, canceling of treatment, or transfer to another area.
There were 49 incidents that caused severe harm, while in 29 cases incidents were recorded as leading to deaths of patients.
In one case a patient was seen in an anticoagulant clinic. She informed them she was pregnant, meaning that her anti-blood clot medicine Warfarin was stopped (it is deemed unsafe in pregnancy). A series of communication errors meant that instead, the patient was prescribed twice as much dalteparin as she should have been – and later died of a brain bleed. The incident only came to light 10 months later when the coroner requested a report from the doctor.
NHS England said that while the NRLS was intended to record the actual degree of harm suffered by the patient, the large number of organizations reporting to the system means that cases were not always coded accurately.
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The NHS is undergoing a transition to a new system for recording patient safety incidents.
An NHS spokesperson said: “Patient safety is paramount, and while they are rare in the context of the millions of patients who receive hospital care every year, it is vital any prescription errors are swiftly reported and action taken to prevent future errors.
“As part of this action, over the last three years the NHS has invested £75m in electronic prescribing systems, which can reduce prescribing errors by almost a third, and more than five out of six trusts now have a fully funded plan to introduce electronic prescribing.”
Steph Lawrence, the executive director of nursing and allied health professionals at Leeds Community healthcare, said: “Leeds Community healthcare NHS trust recognize that a good safety culture relies on incidents being reported by staff as they occur. We are proud of the safety culture within the organization.
“Thirty-seven per cent of all incidents involving medication reported by LCH staff occur in some other part of the health and social care system. Our staff play a key role at the interfaces of care between hospitals and GPs, identifying and resolving issues which can include issues with prescribed medication, and this is reflected in the figures reported to NRLS.”