I was just reading a report from the National Patient Safety Agency entitled ‘Safety in Doses’ (See link below). This report gives a review of medication errors reported to them during 2007. The majority of these involve general medical settings although 9% of them (6551) happened within mental health services. Luckily, 96% of all incidents are not serious, in that nobody got hurt – however there were 100 cases of death and severe harm.
In mental health and learning disabilities settings the most common problems are caused by omission of anti-convulsant medications, generally, omission of medications is a serious problem. Incidents involving methadone and clozapine were also frequently seen. A big problem is found in the interface between primary and secondary care settings. Given the complexity of modern mental health care provision the number of such interfaces and the potential for confusion is greatly increased.
I can remember a couple of incidents from practice in which medication was administered incorrectly. Fortunately neither case caused any harm to anyone but I will never forget the feeling of absolute horror when I realised what had happened.
Less fortunate were the patients being cared for by these Nurses practising at Heartlands Hospital in Birmingham – I can remember reading about this truly dreadful incident. It is very easy to understand the anger felt by the widow of of one of the patients killed.
How many of us can say that we have never made a mistake when working with drugs?
Those of you who are a little older will remember the ‘drugs assessment’ that every student nurse had to pass. This involved studying the contents of a drug trolley, learning the nature and purpose of every drug as well as it’s usual dosage and most common side effects. It was a tough test to pass!
I just wonder if we need something like this now?
I guess a lot of people will say that nurses are often working in stressful situations, there isn’t always the level of staffing & resources needed to do things as well as we would like. I certainly don’t think that all errors are down to nurses lacking knowledge.
What others think? Do you as qualified staff feel that students are as well prepared as they ought to be? – what about students, are you ready to take responsibility for administering medication? Also, if there are errors being made then why do you think this happens?
I would really love to hear from people.
Photo at top of blog from Flickr creative commons by Charles Williams (click on picture)
PS On an unrelated note I had an email from the RCN asking that I draw your attention to the RCN election website – there are two links below for your attention