In the UK, there are an astonishing 237 million drug errors a year, and in England alone 700 deaths a year are caused by drug errors. Whilst 20% of errors relates to hospital care, it is the errors within the community which can be the hardest to identify and rectify where individuals may be at home, taking their tablets without any supervision and with any new symptoms going unidentified. Errors can be divided into:-
- prescription errors e.g. doctors wrongly prescribing a medication, prescribing the right medication at the wrong dose or the written prescription being misunderstood due to illegible handwriting; and
- dispensing errors e.g. pharmacists giving the wrong medication or dispensing the wrong dose or strength of the correct medication.
Doctors owe patients a duty of care to ensure that they are only prescribing medication which is considered to be appropriate for their symptoms and safe for them to take. Similarly, pharmacists owe a duty to ensure that any medication they provide is accurately dispensed in line with a valid doctor’s prescription. If a pharmacist has their own concerns about the medication or dose prescribed then they must refer these back to the doctor directly and cannot alter the prescription themselves. If your doctor or pharmacist makes an error with your medication, you could be missing out on important treatment which you should be taking and running the risk of any ongoing symptoms worsening. Equally, there is a risk that you may suffer new side effects as a result taking medication which was not prescribed for you.
There can be many reasons why doctors or pharmacists prescribe or dispense the wrong medication and, whilst no excuse, can include human error, lack of concentration or a lack of knowledge. A doctor should ensure that they understand the potential benefits and risks of the medication they prescribe. They should also exercise attention to detail to ensure that medication names are checked to avoid any errors arising from similarly named products and that their prescriptions are both clear in their instructions and legible to minimise the risk of error and potential injury. All pharmacies should have a double check system in place as recommended by the National Pharmacist Association (NPA) which means that the work of the dispensing assistant is reviewed by a senior pharmacist to try to ensure a fail safe system before any medication is handed over to a customer. Unfortunately, this does not always work. BBC News reported recently that a Pharmacy in Basingstoke had dispensed high blood pressure medication to a 51 year old man instead of insomnia medication. The senior pharmacist did not notice the error at the time and handed over the medicine to the unwitting customer. Fortunately the error was discovered before any lasting damage was done to him, albeit he endured a very uncomfortable few days until the medication was out of his system.
To minimise the risk, always check your prescriptions following collection or delivery. Whilst some brand names change, always check for the familiar signs of your medication including the shape, colour and any markings on the pills. If you have received something that is different to normal, you don’t recognise the name of it or don’t understand why you’ve been prescribed it, you should query it with your dispensing pharmacy or GP as soon as possible and preferably before you take it. However, if you have inadvertently been taking medication which has been incorrectly prescribed or dispensed, please seek medical advice from your GP, NHS24 or local hospital as soon as possible.
Pharmacists alone handle around 1 billion prescriptions per year, according to the NPA, which equates to 1 in 5 prescriptions being affected by an error. In addition, there is no knowing how many other incidents have gone unreported. When mistakes happen, the reach of these errors cannot be underestimated ranging from no harm to the patient to life-threatening and even fatal consequences.
