Select Committee on Health Written Evidence

Memorandum by Professor Matt Griffiths (PS 03)



  This evidence is aimed at focusing on Patient Safety from the perspective of medicines management and the way that clinicians from all professions may impact on patient safety. The evidence is presented as answers to the main questions as laid out in the terms of reference for this inquiry, with the main recommendations listed in the section below


  The author of this evidence is an experienced nurse, who has spent the last 5 years as the Prescribing & Medicines lead for the Royal College of Nursing. He is a practicing nurse and a qualified prescriber. He has taken part in advisory boards for the National Patient Safety Agency and was on their advisory group for the fourth report from the Patient Safety Observatory, Safety in doses: medication safety incidents in the NHS.[27]

  Professor Griffiths regularly contributes to other advisory boards and committees and recent work includes the Nursing and Midwifery Council's "Standards for Medicines", the Nursing and Midwifery Council's "Standards for Prescribers", "The Shipman Inquiry" and subsequent committees for the Department of Health, and The Resuscitation Council UK anaphylaxis guidelines.

  Professor Griffiths is well published and has co-edited a book on "prescribing", and is currently co-editing another book on the "safety with medicines" for Cambridge University Press. The author is a Visiting Professor of Prescribing & Medicines Management at The University of Northampton, and the Senior Nurse for Medicines at The University Hospitals of Leicester NHS Trust, one of England's largest acute trusts. However the evidence is being submitted by Professor Griffiths as an individual with a great deal of interest in this area.

1.   What the risks to patient safety are and to what extent they are avoidable, including:

Role of human error and poor clinical judgement

  Para 1 Human error and poor clinical judgement related to medicines does play a large part in risks to patients' safety. It is estimated that preventable harm costs the NHS in England alone around £750 million. (NPSA 2008). In the US up to 9% of patients suffered an adverse event in hospital, with 29% of these being a prescribing error. Prescribing errors were the commonest single type of patient safety incident. (Nuckols et al 2007)[28]

Systems failures

  Para 2 In relation to medication errors, reporting appears to be poor in certain areas, with the vast majority of cases reported to the National Patient Safety Agency (NPSA) via the National Reporting & Learning System (NRLS) (around 80% of 60,000 cases over an 18 month period) being from hospital even though the majority of patient contact occurs in the community. This would highlight the potential that a large number of medication incidents affecting patient safety occur in primary care, and are not necessarily recognised or reported. This is supported with the fact that recent studies indicate that around 6.5% of all hospital admissions are a direct result of medication related harm/incidents. (Pirmohamed M et al 2004)[29]

How far clinical practice can be risk-free; the definition of "avoidable" risk; whether the "precautionary principle" can be applied to healthcare

  Para 3 Risk free practice is not in practice going to be realistic, as nearly every medicine has side effects and the potential to cause harm, however we can reduce the risks further if we are more stringent in our reporting of medication incidents and near miss incidents. These can then be actioned to prevent further harm in the future. As per paragraph 2, there seems to be a deficit of primary care medication error/incident reporting in relation to the amount of medication management that occurs in this area, but there are also deficits in terms of Adverse Drug Reaction (ADR) reporting, with recent practices implemented to improve and increase the "yellow card" reporting in this country, still it is estimated that Adverse Drug Reaction reporting only accounts for around 10% of all Adverse Drug Reactions, and so further work in necessary to ensure that this becomes a professional if not legal obligation of clinicians involved.

The role of public perceptions of risk in determining NHS policy

  Para 4 Patient perceptions to medicines and risk do seem to be relatively poor. Public health messages regarding the overuse of antibiotics are really difficult, and the general population are not always accepting of risks to increased antimicrobial resistance such as MRSA or the increased risk of Clostridium Difficile (C-Diff) after broad spectrum antibiotics have been used. Patients perception of need for medication does not always relate to their clinical need (or not) for medication. This can cause friction between clinicians and patients and schemes such as delayed prescribing do have potential for reducing the use of medications in situations like this. Patients perception that other medications such as Over The Counter (OTC) preparations ie paracetamol or ibuprofen or herbal medications are safe, also impacts on their own safety, and sometimes in consultations patients need additional probing to gain a true medication history. My own personal anecdotal experience would indicate that many patients do not perceive these groups including daily regular medications such as contraception as medication, therefore they don't always volunteer this information on questioning. There are obvious risks to such medications not being disclosed, such as accidental overdose with paracetamol or Non-Steroidal Anti Inflammatory Drugs (NSAID) products, or the potential for drug-on-drug interactions for example with St John's Wort (a herbal over the counter medication).

2.   What the current effectiveness is of the following in ensuring patient safety:

a.   local and regional NHS bodies, and other organisations providing NHS services (including primary and community care, and mental health services)

  Para 5 Personal experience has been good as a clinician receiving CASCAID and NPSA alerts etc information which does seem to be disseminated through to clinicians at the front line.

How far the Boards of NHS bodies have established a safety culture

  Para 6 unable to comment

b.   systems for incident reporting, risk management and safety improvement

5Whether adequate measurement and assessment is undertaken and acted upon

  Para 7 There is a perception from many clinicians that old paper reporting systems never seemed to be acted upon. This is really detrimental, as it breeds a culture where clinicians who see no change to reported problems, become disenfranchised from the reporting system with a "what's the point?" attitude. The reported incidents do need feedback to the original reporters as they will often have been actioned in one way or another. Computerised systems such as DATIX do allow reporting practitioners to be able to copy in relevant managers and ensure that the relevant people are included in resolving problems. Preliminary findings from the Healthcare Commission comparison of inpatient and staff surveys at 166 acute trusts in England, indicate that there is a strong link between areas with good reporting systems for incidents and a higher patient satisfaction of services received. (Nursing Standard 2008).[30]

The impact of the changing public-private mix in provision

  Para 8 This public/private mix in provision of healthcare is going to change the face of health services for the UK population. There are obviously concerns that some organisations in both the private and public sector, may "cut corners" with regard to staffing or training to ensure that the business side is financially healthy as they are competing under a commissioning process for work. These organisations need to be reminded of the bigger picture regarding litigation against their services and the fact that staff training and investment will lead to a happier and well skilled workforce in turn leading to better retention of staff. This increased investment will of course impact on patient safety.

c.   national policy

The appropriateness of the objectives set out in national policy statements, including Safety First and High Quality Care for All, and what progress has been made in meeting them

  Para 9 —Unable to comment

Whether past spending on patient safety has been sufficient and cost effective, and what future spending should be—

  Para 10 Unable to comment on the budget provided for this, however medication safety does seem to be very low on many people's agendas, especially considering the NPSA report which has estimated costs of errors and incidents to the NHS in England alone being approx £750,000,000. Some organisations are putting increased resources into Medication safety, and ensuring that clinical governance systems and procedures are in place. However other factors in the health service as a whole, such as staffing levels remain a lower priority, which means increased pressure on staff, tired staff, poor concentration etc. These are obviously times when the increase in clinical incidents can occur. Legislation was introduced for Junior Doctors to ensure decreased working hours under the European working time directive. Pilots and lorry drivers have strict controls in place to ensure safety. Yet nursing staff are often running wards with poor levels of staffing, poor skill mixes and a rotation of working hours meaning less than statutory breaks between early, late and night shifts.

The appropriateness of national targets

  Para 11 Targets can be beneficial in many areas of health such as waiting list initiatives etc, however they also increase the pressure on staff, which is a contributing factor to most errors. In emergency care there has been much debate regarding whether it is sometimes better to breach the 4 hour wait, if it ensures that patients are clean, warm, fed and painfree etc. If staff are rushing to get some of these needs dealt with, concentration and distraction are contributing causes to incidents.

d.   the National Patient Safety Agency and other bodies, including:

    —  Healthcare Commission / Care Quality Commission

    —  NHS Litigation Authority

  Para 12 The NPSA is extremely relevant—however reports such as the NPSA's fourth report from the Patient Safety observatory, Safety in doses: medication safety incidents in the NHS, was not widely publicised. My concern is that this report should have been an important read for any practitioners dealing with medicines. It provided excellent statistics, case studies and ways to improve practice, but rather than being read by the practitioners who would have adjusted their practice, it is probably gathering dust with many other reports, on bookshelves. Dissemination of key pieces of information like this are key to reducing medication errors and incidents, as personal case studies supported by research are often a powerful tool to ensure we reflect on our own practice at the same time as highlighting errors that have occurred so that we can learn from them.

e.   education for health professionals

  Para 13 This is an area requiring increased resources. Poor funding in recent years partly as a result of the NHS deficits and the raiding of educational funds by NHS organisations, has meant that we have under invested in recent years. As the NHS deficits have now turned into NHS surpluses there needs to be a shift to invest this money back into education to increase training in Pharmacology, Medicines management and calculation skills. These are all areas where staff highlight the need to increase their knowledge, and where there appears to be the greatest deficit at present.


Whether the measures taken to improve patient safety are supported by adequate evidence regarding their clinical effectiveness and cost effectiveness

  Para 14 There is a great deal of evidence regarding the amount of medication errors, the deaths, severe harm or no harm that they cause, and the estimated costs to the NHS. These have been published but remain low profile within the NHS, therefore I do believe that the secret is to highlight what is already known, so that organisations change their priorities and therefore how they resource them.

How to determine best practice and ensure it is spread throughout the whole NHS

  Para 15 National guidance regarding resources into these areas, which could be promoted through the commissioning process of healthcare providers. If organisations want the business, they will ensure they comply.

How to ensure that learning is implemented

  Para 16 again through the commissioning process of provider services—see paragraph 15.

What should be measured and assessed; and what data should be published

  Para 17 There is excellent published data already available. This just needs disseminating to the appropriate managers and clinicians alike, and research within this area needs to be developed and repeated to see if any improvements occur as a result of implemented changes ie increased reporting, less errors, etc.

What incentives there should be to improve patient safety

  Para 18 Patient safety shouldn't need any incentives. It really is in all of our (and our families' and loved ones) best interests to ensure that healthcare is as safe as possible. Medication safety will always remain a concern, however with so many preventable errors occurring, we do need to invest in the areas that we can prevent.

How patients and the public can be involved in ensuring that services are safe

  Para 19 Increased awareness of medication safety, and the potential risks of medicines. More patients are buying medication over the internet, another huge area for safety concerns, and by including the public and patients in the debates on medicine it will increase their knowledge and therefore their understanding of the pitfalls. Many patients with chronic conditions are experts with their own condition and medicines, these are excellent groups to work with if focussing on specific areas of medicine, although some generic work needs to be done in partnership with the general public to ensure that OTC medicines and antibiotics are also areas of priority.


  Encouraging increased reporting for both incidents, near misses and Adverse Drug reactions, there maybe a need to make this a statutory requirement to ensure that as much data as possible is received. (see Paragraph 2, 3 & 7)

  Work with Connecting for health for increased access to healthcare records and the use of IT to prevent/reduce errors (not covered in paragraphs above)

  Better communication with patients to increase awareness regarding Over The Counter (OTC) and herbal medications, and responsible antibiotic use. (see Paragraph 4 & 19)

  Ensure that more resources are placed directly towards medication safety, encourage healthcare providers to recognize where they can reduce incidents, through education, governance and investment in staff. (see Paragraph 10,12 & 13)

  Review the 4 hour wait in Emergency Care, to allow breaches in return for increased safety (see Paragraph 11)

  Ensure staff levels for health services are adequate, they are obviously linked to patient safety, yet are often neglected.(see Paragraph 10).

Professor Matt Griffiths RGN, A&E Cert, BA (Hons), FAETC, NISP

July 2008

27   The National Patient Safety Agency (NPSA)-The fourth report from the Patient Safety observatory, Safety in doses: medication safety incidents in the NHS. NPSA. 2008. Back

28   Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. Rate and types of events reported to establish incident reporting systems in two US hospitals. Qual Saf Health Care. 2007; 16(3):164-8. Back

29   Pirmohamed M et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. British Medical Journal.2004; 329: 5-9. Back

30   Doherty L. Culture of reporting errors linked to higher satisfaction for patients. Nursing Standard 2008. Vol. 22, No 51:5. Back

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