Medication without harm: how far have we come?

Combining clinical expertise with research evidence has so far proven to be a most effective strategy for keeping patients safer from medication-related harm in hospitals and residential aged care

MEDICATION errors continue to be the leading cause of avoidable harm in health systems around the world, and arguably the most preventable. In Australia, it is estimated that there are 250 000 medication-related hospital admissions, at a cost of $1.4 billion annually to the health system.

The World Health Organization estimates the global cost of medication errors is USD$42 billion annually and “Medication without Harm” is the theme for the current global patient safety challenge.

With the WHO World Patient Safety Day marked around the world on 17 September, it is worth reflecting on how far we have progressed in Australia and where the challenges lie.

Electronic medication management systems deliver benefits

For many health systems, investments in medication-related technologies have been a priority, and the expected benefits have underwritten many business cases for the introduction of electronic health record systems. Replacing paper medication charts in hospitals with electronic medication management systems (eMM) enabling clinicians to prescribe, dispense and administer medications and provide real-time decision support has great potential for reducing errors and harm. While GPs were early adopters of these systems in Australia, hospitals have been slower to progress. The first New South Wales hospitals implemented these systems nearly 20 years ago and early evaluations demonstrated a significant reduction in the rate of prescribing errors.

Similar benefits have been seen in hospitals internationally with a recent systematic review showing nine out of ten studies reported a reduction in prescribing errors following eMM introduction. Much less is known about how effective these systems are for paediatric inpatients, for whom prescribing is more complex.

We have recently completed the first randomised trial of eMM implementation in paediatrics which showed no improvement in prescribing error rates in the first 70 days of use, but 12 months later it showed a significant 36% reduction.

Demonstrating harm reduction

Despite these very promising findings the challenge of demonstrating reduced harm remains.

Internationally, data showing actual harm associated with medication errors are very limited and there are significant methodological challenges in being able to measure these effects.

Our study in paediatrics set up panels of experienced clinicians (pharmacists, paediatricians, nurses) to review detailed case studies of children who had experienced prescribing and administration errors that were judged to present a potentially serious risk to the child. Of these errors, which reached a child, we found actual harm to children from prescribing errors in 1.5 medication orders per 1000 orders. However, these reviews relied on retrospective audits of patient records and the documentation on many occasions failed to provide sufficient details for the panel to make an accurate assessment.

Documentation of harm relies upon someone detecting an error and then monitoring for effects. In our study, which identified over 5300 prescribing errors, less than 15% of cases had evidence in the patients’ records that a staff member had detected the error.

Dose errors among children in hospital were the most frequent at a rate of seven errors per 100 orders and were most often implicated in errors that caused actual harm to patients.

Optimising systems to support clinicians to reduce the risk of dose errors should be a priority. This includes the use of dose calculators, alerts to flag major variations in patient weight likely to result in a dose error, and weight-based filtering of order sentences. Such optimisation should also occur in hospitals that treat both adults and children.

Medication safety in residential aged care settings

Medication management systems in the residential aged care sector are in the early stages of implementation but present many opportunities for improving the monitoring and safety of medication use. With over 95% of residents taking medications, and 41% taking ten or more medications, the risk of harm from poor medication management is considerable, as reported in findings from the Royal Commission into Aged Care Quality and Safety.

Electronic systems provide an opportunity to both improve the identification of residents at risk and support prescribing with decision support to enhance decision making. For example, our study showed 65% of aged care residents taking antipsychotics received these for over double the recommended 3 months. Simple decision support tools to flag these residents could assist in ensuring more standardised reviews of medication use.

These technologies can go beyond reducing medication-related harm and increase evidence-based medication management. For example, residents with certain conditions, such as osteoporosis, would be expected to be receiving regular medications. Linking resident conditions to their medication use can identify residents who may be missing out on important medications.

Challenges to safer systems

Technology, of course, brings its own risks and can facilitate errors, such as incorrect selection from drop-down menus, not possible in paper-based systems.

A highly controversial recent case in the US involved a nurse bypassing various safeguards on an automatic drug dispensing machine which, in combination with a range of factors, led to the death of a patient. Cases such as these highlight that the human–technology interface is critical to driving safer systems. Consequently, implementation of electronic systems is not the endpoint. Ongoing system optimisation, monitoring and governance are required to ensure systems support clinicians to deliver safe and effective care.

Looking ahead

The National Medication Safety Symposium is being held on 21 September at Macquarie University to report results from our National Health and Medical Research Council partnership grant with Sydney Children’s Hospitals Network (SCHN) and eHealth NSW. The symposium will report on findings answering important questions about how medication technologies can reduce errors and associated harm, and also share lessons for how this type of partnership (research, clinical, technology and policy) can benefit organisations seeking to improve care through rapid evidence adoption and system optimisation.

Innovations in eMM, combined with rigorous evaluations, rapid feedback, and improvement loops, will progress the WHO goal of reducing medication errors. Combining clinical expertise with research evidence has so far proven to be a most effective strategy for keeping patients safer from medication-related harm in hospitals and residential aged care.

Professor Johanna Westbrook, Director of the Centre for Health Systems and Safety Research at the Australian Institute of Health Innovation, Macquarie University, and National Health and Medical Research Council Elizabeth Blackburn Investigator Leadership Fellow.

Dr Magdalena Z. Raban, Senior Research Fellow, Centre for Health Systems and Safety Research at the Australian Institute of Health Innovation, Macquarie University.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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