Connected Conversations: Dipak Duggal, global director of medicines management solutions, BD

With recent figures revealing that an estimated 237 million medication errors occur in the NHS every year, Digital Health Age speaks to former NHS director of Pharmacy and global director of medicines management solutions at medical technology company Becton, Dickinson and Company (BD), Dipak Duggal, about what digital strategies and solutions the NHS are using to help avoid medication errors.

 

  1. Has the NHS been too slow to adopt digital technologies to help prevent issues such as medication errors?

With a recent report showing that the estimated NHS costs of definitely avoidable adverse drug reactions (ADRs) are £98.5 million per year, consuming 181,626 bed days, causing 712 deaths, and contributing to 1,708 deaths annually, it seems clear that some urgent action on reducing all medication errors is called for.[1]

Although it’s true the NHS could have been faster – and could still be faster – in adopting the technology that is readily available to improve safety in prescription, dispensing and administration procedures, a particular contributory factor seems to be the slow pace in establishing and nurturing a consistent, widespread, blame-free culture of safety. At a medication level this means abiding by ‘The Five Rights of Medication Administration’ which require the hospital to ensure the right drug is administered to the right patient, at the right dose, via the right route and at the right time.

It’s perhaps telling that the first hospital in the world to introduce a fully automated, secured, hospital-wide prescription medicines supply chain is not based in the UK, but in Thun, Switzerland.  I’d like to tell you a little about this solution as it’s an aspirational example.

The STS AG hospital has introduced all-encompassing, integrated BD systems from pharmacy to ward to improve patient safety.

Traditionally, pharmacy and ward medication dispensing cabinets are manually filled and replenished with drugs by the hospital pharmacy. The new solution instead provides space-efficient, secure storage of drugs in pharmacy and on the ward- and therefore closer to the patient- and facilitates improved patient safety and efficiency in medication dispensing. Individual drugs are tracked and stored in separate drawers and pockets to avoid confusion with look-a-like packages and if stock is low the automated dispensing cabinet (ADC) automatically sends a replenishment order to the hospital pharmacy’s dispensing robot without wasting staff time. In addition to this, ward staff can call up the drugs prescribed by the doctor directly on the ADC screens in the ward, ensuring the right drug is going to the right patient at the right dose at the right time. Ad hoc interfaces were developed by BD especially to enable this direct flow of communication between pharmacy and ward, a requirement that responds to the specific needs of the hospital and that is grounded in research into real-life ward practices and processes.

 

  1. How can electronic prescribing systems help stop prescribing errors and what problems come with implementing them across the NHS?

It’s a fact that most MEs occur during the prescription and administration phase,[2] making these ideal candidates for automation. E-prescribing, in the form of automated and standardised physician planning can help curb instances of MEs, but also critically helps to improve transparency, making processes easier to audit. It also helps to free up doctor time which can instead be spent with the patient. It’s only part of the solution as there are around 30 steps in a medication’s journey to the patient i.e. from prescribing to preparation, dispensing and administration, with a 45% risk of an error occurring over them.

E-prescription at the hospital level has been described as complex, yet many of the difficulties the NHS has encountered with e-prescribing arguably boil down to the lack of an overall framework and culture which the technology should slot into in order to help deliver patient safety. Instead, far too often, disparate, stand-alone solutions are implemented without suitable training or customisation and so integrate with difficulty into existing processes. A holistic approach to closed loop medication management solutions is called for.

 

  1. Do you think workforce pressures are another reason for prescribing errors?

Staff workloads resulting from shortages combined with patient ageing demographics exacerbate risk and increase the chances of medication errors. Data shows that the number of vacancies in the NHS continues to climb, having increased by 8,000 places between 2016 and 2017, with nurses and midwives accounting for the highest proportion of shortages, with over 30,000 vacant posts.[3]

There is also, however, a need to improve transparency and make auditing and (through a blame-free culture) the reporting of errors and near misses more frequent so as to enable hospitals to  understand the circumstances in which errors are made. Automation of prescribing, dispensing and administration can also help to empower staff to question prescriptions, that appear unsuitable, as they are rules based solutions.

 

  1. What are Trusts currently doing to prevent medical errors?

There is an increasing interest in looking at how automation can help prevent medication errors and this is great news.  Although automation and e-prescribing are certainly ways to help reduce the incidence of this type of error, the Health and Social Care Secretary also recently referred to a greater need for ‘teamwork and communication’, an important combination that we at BD would argue is critical to ensuring patient safety across the board.[4] 

The entire medication management process needs to be optimised and while technology will play a critical role, the way these solutions are implemented and work processes changed and standardised throughout the hospital setting is what will make the biggest impact on patient safety.

 

  1. Beside technology solutions, what other practical measures can be taken to help reduce medical errors?

Learning from root cause analysis of reported errors, competency based training especially of new staff, but also informal activities such as ward-walks and interviews with nursing and pharmacy staff, play a critical role in supporting hospitals to manage risk alongside the implementation of automation solutions.

Flexibility is another core requirement. A truly customisable solution should allow a hospital or Trust to integrate basic parameters of complex compounding, dispensing and administration workflows with ease. Advocates of automation in dispensing of medication highlight how this releases time for care for nurses and pharmacists, enabling them to focus more on patients.

 

  1. What do you think of Jeremy Hunt’s plans to speed up access to e-prescribing systems?

At BD we’ve long been campaigning to bring the right level of attention to patient safety across a variety of potential adverse events including medication errors, so any type of commitment from government, or indeed attention to aspects of practice that can help improve patient safety, are welcome, especially  if they contribute to bringing about a wider change in mentality. Having said that, it’s clear that e- prescribing systems alone will not deliver the required reduction in risk so investment in proven technical solutions needs to be made across the entire medication management system.

 

  1. Are there any other digital systems you’d like to see implemented across the NHS?

More wide-spread dispensing automation, bar coded medication administration in combination with digitalisation and actionable data analytics would be a positive step in the right direction, given the rate of medication errors at the dispensing and administration stage. We at BD feel that more focus should be placed on standardising processes to deliver consistent quality outputs at these stages.

A number of studies show that more than half of medication errors are likely to be linked to IV infusion, which is not surprising given that 90% of hospital patients receive a medication via the IV route at some point,[5] making this a key process to focus on for improvement for example by implementing IV pumps with dosage error reduction software.[6]

Dispensing stage errors are also frequent and under-reported, meaning their incidence could indeed be much higher than we think. Typically these errors are due to human error such as confusing medication look-alikes and sound-alikes, high pharmacy and nurse workloads, low staff numbers, staff inexperience, and rushing to complete tasks.[7]  Secure, automated space-efficient storage solutions that quickly and accurately dispense medication or that automatically alert the pharmacy when the ward is running out of a drug are available and can have a significant impact on these incidences. Increasingly as time goes on these will support Trusts in meeting the Falsified Medication Directive (FMD) to ensure no falsified or counterfeit medicines are introduced into hospital supply chains.

References 

(1)Buckley MS, Erstad BL, Kopp BJ et al. Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Med.

2007;8

(2):145-52; Kopp BJ, Erstad BL, Allen ME et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med. 2006;34(2):415-25.

(3)NHS Digital, NHS Vacancy Statistics England, February 2015 – March 2017, Provisional Experimental Statistics

(4) Jeremy Hunt, From a blame culture to a learning culture, Health Secretary addresses the Global Patient Safety Summit on improving safety standards in healthcare, 3rd March 2018

(5)Husch M, et al. Qual Saf Health Care 2005;14(2):80-86.

(6) Ross M, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83(6):492-7;  Terkola R, Czejka M, Bérubé J. Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study. Journal of Clinical Pharmacy and Therapeutics. 2017;42(4):446-53; . Kaushal R, Bates DW, Landrigan C et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20.

(7) European Medicines Agency. Guideline on good pharmacovigilance practices (GVP). 2014. Report No.: EMA/873138/2011 Rev 1.

 



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