Review finds errors occurring at all stages of medication process Review finds errors occurring at all stages of medication process

4 June 2009

A literature review of medication safety in the community, conducted by the National Prescribing Service Ltd (NPS), has found adverse drug events* and medication errors are a significant problem in Australia.

The study, which cites more than 300 articles from Australia and overseas, is the first comprehensive review of medication safety issues and possible solutions in the community setting.  

It explores the prevalence, contributing factors, and outcomes of adverse drug events and medication errors in the community. It also considers the impact of methods to improve medication safety including medication reviews, medication reconciliation, patient education and e-health interventions.

“This review confirms that medication errors continue to occur at all stages of the medication process - prescribing, supply, administration, monitoring and documentation. Up to 73% of these events are preventable, meaning patient safety is being jeopardised and avoidable burdens are being placed on our health system,” NPS CEO, Dr Lynn Weekes said.

Some key findings from the report include:

• Those at high risk of adverse events associated with medicines are older people, those with serious health conditions, those taking multiple medications, those using high risk medicines and those being transferred between community and hospital care
• Around 6% of hospital admissions in Australia are associated with adverse drug events, with almost one third of admissions for the elderly associated with adverse events
• Consistently high error rates occurred during transfer of care between hospital and community settings
  
• 10% of general practice patients in Australia report experiencing an adverse drug event; while 25% of high risk patients reported adverse events associated with medicines.

The most commonly reported contributing factor of medication errors and adverse events was poor communication, which is highlighted when patients are transferred between hospital and community settings.

The review also found that while many interventions do not have a significant impact on patient outcomes, those that take a comprehensive approach to managing specific disease states (interventions including medication reviews, home visits and/or telephone follow ups; states such as heart failure) do show positive patient outcomes.

“For medication management to be effective it must involve the patient and/or their carer, and all members of their health care team. Interventions should be monitored, assessed and if necessary, revised. To address medication issues that arise during the transfer of care a systems-based approach must be developed and implemented nationally,” Dr Weekes said.

To view the full report online, go to http://nps.org.au/research/med_safety/.

* Adverse drug events are any incidents involving a medicine that cause harm to the patient. They include harm that results from known adverse drug reactions, medication errors or system failures associated with the manufacture, distribution or use of medicines.

ENDS