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Tuesday, 18 December, 2001, 08:03 GMT
Prescription drug deaths surge
pills and bottle
Medication mistakes are a major problem, says the report
The number of patients who die after being given the wrong drugs in hospital is increasing dramatically, according to a major report.

Approximately 1,200 people died last year in England and Wales as a direct consequence of the drugs they were prescribed - a rise of 500% over the past decade.

Some of these deaths were due to medication errors by doctors or nurses, others due to adverse reactions to medicines.

The Audit Commission's "A Spoonful of Sugar" report says many of these deaths were entirely avoidable as they were a result of doctors not having the right information about the patients at hand - either because notes are illegible, incomplete or missing altogether.

Statistics suggest than one in 10 people in hospital suffer some kind of "adverse event", half of which are preventable.

One third of these lead to additional illness - or death - and on average each adds eight-and-a-half days to a hospital stay.

Mistakes found in one hospital
Cancer patient prescribed sleeping tablet temazepam instead of anti-cancer drug tamoxifen
A toxic medicine was prescribed to be given daily instead of weekly
An anti-cancer medicine prescribed at 1,000 times the correct dose
A contraceptive steroid prescribed in the place of an anti-psychotic drug
Nick Mapstone, one of the report's authors, said: "The health service is probably spending half a billion a year making better people who experienced an adverse incident or error - and that does not include the human cost to patients."

He said that modern medications could be far more effective - but had the potential to cause more harm if wrongly administered.

"It is relatively straightforward to fix but it requires investment," said Mr Mapstone.

He said that as many as three quarters of the "avoidable" errors could be eliminated by introducing computerised prescribing systems.

Best practice 'ignored'

The government has pledged to introduce these by 2005, but Mr Mapstone told BBC News Online that he did not believe that this deadline was likely to be met.

A series of high-profile cases have shown the frequency with which fatal drug mistakes can be made by doctors.


The health service is probably spending half a billion a year making better people who experienced an adverse incident or error

Nick Mapstone, Audit Commission
One of the most recent involved teenager Wayne Jowett, who died at Queen's Medical Centre in Nottingham after having an anti-cancer drug wrongly injected into his spine.

The report says that managers should take care to make sure safety rules are being observed throughout hospitals.

It says: "The recent events at Queen's Medical Centre illustrate how day-to-day pressures can lead to acknowledged best practice being ignored."

Sir Andrew Foster, chairman of the Audit Commission, said: "There is a significant opportunity to improve quality, reduce clinical risk and minimise waste, by using current and future resources much more effectively and ensuring pharmacists are central to patient care."

Spotting errors

The government is to introduce a series of measures to try to check the increase in medical errors in the NHS.

Its report, "An Organisation with a Memory", called for compulsory reporting and monitoring of adverse incidents so that hospitals and the NHS in general can learn from mistakes.

Ministers have also set up the National Patient Safety Agency to co-ordinate this.


This is a culture where mistakes do unfortunately happen

Dr Trevor Pickersgill
Dr Trevor Pickersgill, of the British Medical Association's junior doctors committee, told the BBC there were a number of reasons for the rise in errors.

"The number of drugs is increasing, the effectiveness - and therefore often the toxicity - of drugs is increasing, the number of people on multiple medications is increasing, and that increases the risk of interaction.

"We must also remember that there one in six pharmacy posts in hospitals are unfilled, and new doctors who are doing the work on the wards are overworked as well.

"This is a culture where mistakes do unfortunately happen."

Jackie Glatter, from the Consumers' Association, said: "The report shows there is a strong need for detailed and clear patient information about treatments and medicines - not just in hospitals but also when people are taking medicine at home.

"The National Patient Safety Agency should address medication errors as soon as possible."

 WATCH/LISTEN
 ON THIS STORY
The BBC's Karen Allen
"The problem is escalating"
Stella Brackenbury, Wayne Jowett's mother
"There was no way back from this mistake"
Dr Trevor Pickersgill
"The culture makes it likely that mistakes will happen"
See also:

18 Dec 01 | Health
Prescription errors: Case study
03 Aug 01 | Health
Patient safety watchdog appointed
26 Jun 01 | Health
Milburn calls for 'end to blame'
03 May 01 | Health
Smear test errors: The history
19 Apr 01 | Health
New rules to save patients' lives
19 Apr 01 | Health
Drug blunder death 'accidental'
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