Improving medication safety in the North‐East of England: The potential enabling role of NRLS data

Abstract

NA project was established to explore the feasibility of using NRLS incident data from local organisation to support a patient safety programme. It was divided into two phases, a pilot and full study. Aims agreed with local organisations included timely, targeted reporting to the NRLS in relation to selected medication errors, one of which was incidents involving anticoagulants. The present report outlines initial experience in the utilisation of data from the pilot phase of the study related to these drugs. The total number of incidents was 55 in the pre-pilot period and 92 in the pilot phase, an increase of 67%. In the Primary Care sector there was a threefold increase in the pilot study while there was a 41% increase the Secondary Care sector. There was no overall reduction in the lag time of reporting incidents although in Secondary Care the median lag time in reporting incidents was 54 days in the pre-pilot phase compared to 38 days in the pilot phase (p = 0.008). Sixty five percent of incidents involved warfarin while low molecular weight heparin was involved in 20% of incidents. The most common type of incident related to blood testing (30%), particularly missing INR results, with communication failures being responsible for 20% of incidents. Prescription errors (16%) and errors in the amount of drug administered (14%) were other common causes of incidents. Targeting increased the reporting rate to the NRLS in the selected area and reduced the lag time in submitting reports in the Secondary Care sector. Copyright © 2009 John Wiley & Sons, Ltd.