Electronic systems needed to prevent medication errors

The Health and Disability Commissioner is calling for the nationwide roll-out of electronic systems to reduce the significant harm caused by medication errors.

Health and Disability Commissioner Anthony Hill today released a report analysing complaints to HDC where a medication error had occurred.

“There is a person and whānau at the centre of every error and it is important to take every opportunity to learn and reduce harm,” Anthony Hill said.

“Human error happens so it is important that organisations have systems with defences built into them to prevent those errors from reaching a patient.

“I am concerned by the lack of progress in rolling out electronic medicine management systems, such as electronic prescribing, across the health sector. Having a good system in place, that was fit for purpose, would have helped prevent a number of these errors from occurring in the first place.

“Having an electronic health record that allows a patient’s medication information to follow them as they move through the health sector would also avoid mistakes that occur during transfers of care.”

Anthony Hill said it was important to understand the trends and patterns in complaints to help identify common issues and possible solutions.

“Medication is the most common healthcare intervention and most of the time the care provided in regards to medicine is very good. However, medication errors have the potential to cause significant harm and it is vital lessons are learnt.”

In addition to having robust electronic systems in place, Anthony Hill said that it was important that health professionals ensured that they were doing the basics well every time and that organisations fostered a culture that supported them to do their jobs well.

“It is incumbent on prescribers, dispensers, and those administering medication to think critically each time they deliver a medication — considering the drug, the patient, and the context in which the medication is being delivered — to ensure that the medication is being delivered safely.”

Anthony Hill noted that failing to follow basic procedures contributed to a number of the errors studied in the report.

“Some cases point to a culture of tolerance, where not following policies had become normalised. Organisational leaders must be alert to such issues, and ensure that staff are supported to do what is required of them, and foster a culture where adhering to policies is the way we do things around here.

“I encourage all health professionals, when reading this report, to consider, could this happen at my place? and, if so, what changes could be made to prevent it?”

The report is the latest in a series using HDC complaints data to identify trends and patterns in a particular area and highlight opportunity for improvement.

The full report is available on the HDC website https://www.hdc.org.nz/resources-publications/search-resources/other-reports/medication-errors-complaints-closed-by-the-health-and-disability-commissioner-2009-2016/