Soaring toll of NHS patients harmed by being given the WRONG MEDICINE
AvAN driver survives a major crash with serious, but not life-threatening, injuries — only to suffer a fatal cardiac arrest in intensive care when a bungling doctor gives him adrenaline instead of a sedative.
A cancer patient’s allergy to penicillin is clearly recorded in her medical notes, but when she develops a chest infection, she is still given penicillin, and dies after suffering anaphylactic shock.
A great-grandfather being treated for lung disease is killed after a nurse mistakenly gives him an entire day’s dosage of a medicine in less than an hour.
Arnold Harper, 56, from Barrow, Philippa Gillespie, 59, from Haverfordwest, and Colin Whalley, 68, from St Helens are just three of the victims of medication errors in NHS hospitals whose stories have emerged in the past 18 months alone.
Inquests into each of their deaths concluded that drug errors had either caused or played a significant part.
And shockingly, their needless suffering is far from unusual.
Just last weekend it was reported that the father of a top NHS surgeon died in hospital after being mistakenly given insulin instead of dextrose.
Robert Welch, 93, a war veteran, died in June last year in the Diana, Princess of Wales Hospital, Grimsby, after suffering a cardiac arrest. The coroner said ‘inadequate supervision of relatively junior nursing staff, together with inadequate training in the preparation of medication contributed to the mistake’.
Recent headlines about the NHS crisis have focused on the situation in A&E, the lack of hospital beds and yesterday, the cancellation of even cancer operations — but the crisis is having an effect everywhere, not least in the alarming rise in the number of patients falling foul of medication errors.
It hardly needs spelling out that hospitals are meant to help patients, not poison them. But this investigation by Good Health has found that medication errors in the NHS are on the rise — by 6 per cent in a year — despite a major initiative to stop them.
We’ve also discovered that the vast majority of errors were made by nursing staff, reinforcing concerns that many wards may be dangerously understaffed. Furthermore, in some NHS trusts patients have as much as a one in 200 chance of becoming a victim.
Good Health’s findings are ‘very concerning’, says Katherine Murphy, chief executive of The Patients Association.
‘Medication errors are distressing for the staff concerned but, as the evidence shows, they can be catastrophic for the patients and their families.
‘We urge the Government to investigate the figures and work with healthcare professionals to find ways to reduce medication errors.’
Patients ‘place their trust in a health professional to provide them with safe care’, added Susan Osborne, chair of the Safe Staffing Alliance, a campaigning group supported by the Royal College of Nursing and The Patients Association. ‘The NHS is in crisis and medication errors are an inevitable consequence of unsafe staffing levels of registered nurses, now seen throughout the service,’ she said.
DEATHS CAUSED BY WRONG MEDICATION
LAST year more than 205,000 medication errors were made in the prescribing, dispensing or administering of drugs throughout the NHS, according to official figures from NHS Improvement, the organisation that tracks patient safety incidents.
These errors include giving the wrong medicine, the wrong dose of the right medicine — or even giving medicine to the wrong patient.
The NHS says that ‘ only’ 12 per cent of all reported medication errors last year caused actual harm to patients — an attitude that is ‘shocking and complacent’, says Susan Osborne, who is a former director of nursing at St Mary’s Hospital, London.
Indeed, that ‘only’ will be little consolation to the thousands of patients affected, let alone to the devastated families of the 55 patients who died and the 169 who suffered permanent harm that year as a result.
The NHS says a further 25,000 patients suffered ‘ low’ or ‘ moderate’ harm, meaning they needed anything from extra observation and time in hospital to additional treatment after suffering ‘significant but not permanent harm’.
Around a quarter of the errors were made by community nurses, mental health services and High Street chemists. But the vast majority, nearly 150,000, were made in hospitals.
Official figures don’t reveal which group of medical professionals is responsible. However, our investigation shows that the majority of these medication errors in hospital are being caused by nursing staff.
We sent Freedom of Information requests to all the NHS trusts in England and Wales. Two thirds (112) replied, revealing a total of 125,506 medication errors. Nearly 29,000 were prescription errors (ie, made by doctors) and 14,000 were dispensing errors (pharmacists) — in either case, typically the mistake was an incorrect dose rather than the wrong drug.
MOST ERRORS ARE BY NURSING STAFF
BuT 75,000 other errors, almost 60 per cent of the total, were linked to the way drugs are given to patients — nursing errors.
For example, Barts Health, a group of five hospitals in London, reported the highest number of errors (more of that later), 3,293 — their figures show that 1,294 were as a result of failings in the way drugs were administered, such as giving the wrong drug or the wrong dose, giving a drug to the wrong patient, delays in administering drugs and — in an astonishing 254 cases — failing to give a drug at all.
Jonathan Nolan, head of nursing practice for the Royal College of Nursing, insists that ‘comparing errors between professional groups, or comparing error rates between prescribing and administering can be very misleading’.
Errors were ‘frequently outside nurses’ control’, he told Good Health, ‘for example where a drug is not available, so a dose is missed or late, would be logged as an error, even if the nurse was aware and trying to source the drug, which may not have been available from the pharmacy’.
However, analysis of the breakdown in errors for Barts shows that supply problems accounted for just 304 of the 3,293 errors, less than 10 per cent.
The Royal College of Physicians (RCP) says doctors or nurses are ‘much more likely’ to give patients the wrong drug or the wrong dose ‘if they are tired, stressed, hungry and thirsty’.
Such problems ‘are becoming more common with the increase in medical admissions and staff shortages’, says Dr Kevin Stewart, the RCP’s director of clinical effectiveness and evaluation.
‘Nurses work tirelessly for their patients, but without the right numbers, systems are more likely to break down and this can increase the risk of mistakes,’ adds Wendy
Preston, head of nursing practice at the Royal College of Nursing.
‘These findings are yet another example of how the nursing shortage is impacting on patient care, and how crucial it is that the Government works with us to find a solution.’
ARE THERE ENOUGH NURSES ON WARDS?
NURSING staffing levels across the NHS have been under the spotlight since the public inquiry into the ‘ conditions of appalling care’ that led to hundreds of deaths at Mid Staffordshire NHS Foundation Trust.
The 2013 Francis report found that between 2005 and 2009 there had been more than 1,700 ‘serious untoward incidents’ in which inadequate nurse staffing levels had played a part.
The subsequent Berwick review into patient safety identified ‘nurse-to-patient staffing ratios’ as a serious safety issue across the NHS.
Following these two reports, the National Institute for Health and Care Excellence (NICE) was asked to develop safe staffing guidelines for nursing.
NICE duly published guidelines in July 2014. ‘Medication administration errors,’ it said, was one of nine ‘safe nursing indicators’ trusts should put in place.
But then came the bill for bringing staffing levels up to scratch: it would cost an estimated £414 million on top of the £4 billion being currently spent on nurses for acute wards (the Safe Staffing Alliance said many hospitals were so understaffed that the true cost would be closer to £1.25 billion).
In June 2015 the NHS ordered NICE to shelve the safe- staffing programme. But according to the Safe Staffing Alliance, the number of properly qualified staff on duty is the single most important issue when it comes to patient safety.
There is, it says, overwhelming evidence that ‘lower nurse-patient ratios are associated with more “excess” deaths’ and that ‘ 45 per cent of wards in England are operating at unsafe levels’.
The ratio of one registered nurse to eight patients was the point at which ‘significant harm is more likely to occur’. But ‘we know that about 50 per cent of trusts in the country are now operating with an unsafe level of registered nurses’, says Susan Osborne, chair of the alliance.
A survey of nurses published in April 2016 by Unison, the public service union, found that on one randomly selected day in February last year more than 55 per cent of nurses were caring for eight or more patients, a figure that rose to 70 per cent during night shifts.
(Even if trusts could pay for more nurses, one in ten nursing posts across England is currently unfilled, which the RCN says amounts to a shortage of 20,000.)
Commenting on our findings, Dr Mike Durkin, NHS National Director of Patient Safety, told Good Health that while ‘on very rare occasions things can go wrong’, it was ‘vital providers and staff are open and honest about errors so lessons can be learnt’.
WHAT HAPPENED TO SAFETY NET?
EVERY one of the 112 trusts surveyed by Good Health confirmed that, in accordance with a directive from NHS Improvement, since September 2014 they had a named ‘Medication Safety Officer’, whose job is to champion drug safety in the trust and prevent such errors.
yet despite this, 80 of the trusts reported more errors in 2015 than in 2014 — a rise of 6 per cent across the trusts, though some individual hospitals fared far worse: Barts Health reported almost 40 per cent more errors.
Barts treats a lot of patients — nearly 1.8 million in 2015, including admissions, out- patients and accident and emergency — so around one in 500 patients experienced a medication error.
yet this is not simply a problem for the biggest hospitals. For the risk is much higher, at The Dudley Group, a group of three hospitals in the West Midlands, which treated 550,000 patients and had nearly 3,000 errors in 2015. So here, around one in 200 patients experienced a medication error.
(In fact, the risks could actually be much higher, as these figures have been calculated assuming that all patients who visit a hospital are prescribed medication, when clearly some aren’t.)
Size doesn’t necessarily matter. It isn’t simply that bigger trusts are more likely to have more errors simply because of the numbers of patients they see — other trusts that treated close to a million patients reported relatively fewer errors.
For instance, Lancashire Teaching Hospitals NHS Foundation Trust saw 970,000 patients, but reported only 1,000 errors in 2015, meaning the risk of errors there was almost half that at Barts.
A spokesperson for Barts told us: ‘We deeply apologise for errors we have made,’ adding that while the vast majority of medication errors resulted in no harm to patients, ‘every mistake is one too many and we are working hard to learn from incidents to minimise the risk of them being repeated’.
As part of the trust’s efforts ‘ to create a safety culture and reduce the numbers of incidents that cause harm’, it was ‘encouraging all staff to report incidents so that we can fully investigate, and we believe this accounts for the total increase in reported incidents’.
Dr Paul Harrison, acting chief executive at The Dudley Group, said the trust’s ‘safety culture includes an honest and open reporting system which encourages learning and improvements in patient safety’.
The trust is also investing in ‘an electronic prescribing and drug administration system which we believe will result in a further significant reduction in the numbers of incidents’. Electronic records and prescription systems can help. ‘The computer offers you only the correct doses and if the patient is allergic to something it will tell you,’ says breast surgeon Dr Philippa Whitford, who is the SNP MP for Central Ayrshire and vicechair of the All Party Parliamentary Group on Patient Safety.
But such systems can’t prevent the type of administering errors identified by Good Health.
‘When it comes to mixing up the patient with someone else, or the ward being so busy that someone doesn’t give the drug at all, these are human errors much more subject to being understaffed or having agency nurses who don’t know how the system works,’ says Dr Whitford. ‘The more the system’s under stress, the worse it’s going to get’.
EVEN ONE DEATH IS TOO MANY
SOME have suggested that the worst performing hospitals may be those more willing to recognise and record errors — and that they will be able to learn from their mistakes in a way less open hospitals will not.
But the fact remains, one mistake is one too many, especially if it is fatal, as a devastated Roy Conolly knows only too well.
It’s almost three years ago to the day that his partner, Philippa Gillespie, died after she was mistakenly given penicillin despite her allergy being recorded in her notes — and her repeatedly telling hospital medics she was allergic to it — he says he is ‘horrified’ by the picture revealed by our investigation.
He recalls hearing Philippa, his partner of 30 years and the mother of their two sons, being asked on five occasions, by five members of staff, if she was allergic to any medication.
‘Each time, Philippa told them she was allergic to penicillin and it was duly noted down,’ he says.
Despite this, a junior doctor prescribed an antibiotic containing penicillin, which was administered by a nurse. Even as the drug was being given, Philippa rapidly fell ill, suffered a cardiac arrest and stopped breathing.
Both Philippa and Roy’s mothers were nurses, as was his father who, says Roy, was ‘dumbfounded that standards had slipped so far as to make what happened to Philippa possible in this day and age.
‘ In the three years since her death, the basic error that so dramatically cut short her life should have been made impossible to repeat,’ Roy adds.
‘Checks, and double-checks, when prescribing and administering medication should eliminate any chance of a patient being given medication that will cause harm to them.
‘The fact that such errors are on the increase is chilling news and hardly inspires confidence in the NHS.’