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Initiatives to Identify and Mitigate Medication Errors in England

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Abstract

In response to the EU Directive on Pharmacovigilance, the National Health Service (NHS) in England and the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK have formed a partnership to work together to simplify and increase medication error reporting, improve data report quality, maximise learning and guide practice to minimise harm from medication errors by sharing incident data. This initiative will facilitate implementation of new requirements for medication error reporting and reduce the need for duplicate data entry by frontline staff. The initiative is also intended to provide new types of feedback from the National Reporting and Learning System run by the NHS England and from the Yellow Card Scheme run by the MHRA and to improve learning at the local level by clarifying medication safety roles and identifying key safety contacts to allow better communication between local and national levels. Finally, the partnership has established a new National Medication Safety Network to provide a forum for discussing potential and recognised safety issues, and for identifying trends and actions to improve the safe use of medicines. This article describes the initiative, the structure of which may act as a template for other countries.

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Notes

  1. Large healthcare provider organisations in England comprise all NHS trusts, large independent healthcare and medicine homecare companies and community pharmacy companies with 50 or more community pharmacies registered with the General Pharmaceutical Council.

References

  1. NHS England and MHRA. Patient Safety Alert; Stage 3 Directive. Improving medication error incident reporting and learning. 2014. Available from: http://www.england.nhs.uk/2014/03/20/med-devices. Accessed 30 Oct 2014.

  2. Monitoring Medicines Consortium. Monitoring medicines: optimising drug safety; monitoring to enhance patient safety and enhance health outcomes. Available from: http://www.monitoringmedicines.org. Accessed 30 Oct 2014.

  3. European Union Directive 2010/84/EU. Pharmacovigilance. Available from: http://www.eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2010:348:0074:0099:EN:PD. Accessed 24 Aug 2014.

  4. Lewis PJ, Tim Dornan T, Taylor D, et al. Systematic review of the prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug Saf. 2009;32(5):379–89.

    Article  PubMed  Google Scholar 

  5. Avery T, Barber N, Ghaleb M, et al. Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study. Prevalence and causes of prescribing errors in general practice: a report for the GMC. 2012. Available from: http://www.gmc-uk.org/Investigating_the_prevalence_and_causes_of_prescribing_errors_in_general_practice___The_PRACtICe_study_Reoprt_May_2012_48605085.pdf. Accessed 24 Aug 2014.

  6. James KL, Barlow D, McCartney R, et al. Incidence, type and causes of dispensing errors: review of the literature. Int J Phar Pract. 2009;17:9–30.

    Article  Google Scholar 

  7. Kelly J, Wright D. Medicine administration errors and their severity in secondary care older person’s ward: a multi-centre observation study. J Clin Nurs. 2011;21(13–4):1806–15.

    PubMed  Google Scholar 

  8. Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, Farrar K, Park BK, Breckenridge AM. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ. 2004;329:15–9.

    Article  PubMed Central  PubMed  Google Scholar 

  9. National Reporting and Learning System. Available from: http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safety-incidents. Accessed 15 Oct 2014.

  10. Cousins DH, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010). Br J Clin Pharmacol. 2012;74(4):597–604. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477327. Accessed 31 Oct 2014.

  11. World Health Organization. International drug monitoring: the role of national centres. A report of a WHO meeting. Technical Report Series No 498. 1972. Available from: http://whqlibdoc.who.int/trs/WHO_TRS_498.pdf. Accessed 24 Aug 2014.

  12. World Health Organization. The importance of pharmacovigilance. 2002. Available from: http://apps.who.int/medicinedocs/en/d/Js4893e. Accessed 28 Dec 2014.

  13. Bencheikh RS, Benabdallah G. Medication errors: pharmacovigilance centres in detection and prevention. Br J Clin Pharmacol. 2009;67:687–90.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Alj L, Touzani MDW, Benkirane R, Edwards IR, Soulaymani R. Detecting medication errors in pharmacovigilance database: capacities and limits. Int J Risk Saf Med. 2007;19:187–94.

    Google Scholar 

  15. Benabdallah G, Benkirane R, Khattabi A, Edwards IR, Bencheikh RS. The involvement of pharmacovigilance centres in medication errors detection: a questionnaire-based analysis. Int J Risk Saf Med. 2011;23:17–29.

    PubMed  Google Scholar 

  16. Human Medicines Regulations 2012, Advisory Bodies Annual Report 2013, Presented to Parliament pursuant to Part 2, Section 12 (2) of the Human Medicines Regulations 2012. Available from: http://www.mhra.gov.uk/home/groups/l-cs-el/documents/websiteresources/con437432.pdf. Accessed 1 Dec 2014.

  17. Jadeja M. Data extraction from MHRA Sentinel database. Accessed 28th July 2014. Medicines and Healthcare Products Regulatory Agency.

  18. Rawlins MD. Spontaneous reporting of adverse drug reactions. 1: the data. Br J Clin Pharmacol. 1988;26:1–5.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. Bem JL, Mann RD, Rawlings MD. Review of yellow cards, 1986 and 1987. BMJ. 1988;296:1319.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  20. Lumley CE, Walker SR, Hall GC, Staunton N, Grob P. The under-reporting of adverse drug reactions seen in general practice. Pharm Med. 1986;1:205–12.

    Google Scholar 

  21. Martin MR, Kapoor KV, Wilton LV, Mann RD. Underreporting of suspected adverse drug reactions to newly marketed (“black triangle”) drugs in general practice: observational study. BMJ. 1998;317:119–20.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  22. Smith CC, Bennett PM, Pearce HM, Harrison PI, Reynolds DJM, Aronson JK, Grahame-Smith DG. Adverse drug reactions in a hospital general medical unit meriting notification to the Committee on Safety of Medicines. Br J Clin Pharmacol. 1996;42:423–9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Sweis D, Wong ICK. A survey on factors that could affect adverse drug reaction reporting according to hospital pharmacists in Great Britain. Drug Saf. 2000;23:165–72.

    Article  CAS  PubMed  Google Scholar 

  24. Reporting adverse drug reactions: a guide for healthcare professionals. 2006. BMA Board of Science.

  25. Heeley E, Riley J, Layton D, Wilton LV, Shakir SAW. Prescription-event monitoring and reporting of adverse drug reactions. Lancet. 2001;358:1872–3.

    Article  CAS  PubMed  Google Scholar 

  26. Griffin JP, Weber JCP. Voluntary systems of adverse reaction reporting. In: Griffin JP, editor. Medicines: Regulation, research and risk. 2nd ed. Belfast: The Queen’s University; 1992.

    Google Scholar 

  27. Haramburu F, Begaud B, Moride Y. Temporal trends in spontaneous reporting of unlabelled adverse drug reactions. Br J Clin Pharmacol. 1997;44:299–301.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  28. Moride Y, Haramburu F, Requejo AA, Begaud B. Under-reporting of adverse drug reactions in general practice. Br J Clin Pharmacol. 1997;43:177–81.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  29. Belton KJ, Lewis SC, Payne S, Rawlins MD, Wood SM. Attitudinal survey of adverse drug reaction reporting by medical practitioners in the United Kingdom. Br J Clin Pharmacol. 1995;39:223–6.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  30. Eland IA, Belton KJ, van Grootheest AC, Meiners AP, Rawlins MD, Stricker BH. Attitudinal survey of voluntary reporting of adverse reactions. Br J Clin Pharmacol. 1999;48:623–7.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  31. Medicines and Healthcare Products Regulatory Agency. Corporate research Ipsos Mori polls. Available from: http://www.mhra.gov.uk/Publications/Corporate/Research/index.htm. Accessed 31 Oct 2014.

  32. World Health Organization. Reporting and learning systems for medication errors; the role of pharmacovigilance centres. 2014. Available from: http://www.who.int/medicines/areas/quality_safety/safety_efficacy/emp_mes/en/. Accessed 27 Oct 2014.

  33. European Medicines Agency. European Union regulatory workshop on medication errors 28th February: 1st March 2013. European Union regulatory workshop on medication. Errors. Available from: http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/events/2012/10/event_detail_000666.jsp&mid=WC0b01ac058004d5c3. Accessed 24 Aug 2014.

  34. European Medicines Agency. Follow-up actions from workshop. Implementation plan 2014: 2015. 2014. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/Other/2014/04/WC500165496.pdf. Accessed 31 Oct 2014.

  35. Medicines and Healthcare Products Regulatory Agency. Adverse drug reactions. Available from: http://www.mhra.gov.uk/Safetyinformation/Reportingsafetyproblems/Reportingsuspectedadversedrugreactions. Accessed 31 Oct 2014.

  36. Medicines and Healthcare Products Regulatory Agency. Impact of the Yellow Card Scheme. Available from: http://www.mhra.gov.uk/Safetyinformation/Howwemonitorthesafetyofproducts/Medicines/TheYellowCardScheme/UsingYellowCarddatatoprotectpublichealth/ImpactoftheYellowCard/index.htm. Accessed 31 Oct 2014.

  37. Medicines and Healthcare Products Regulatory Agency. Drug safety update. Available from: http://www.mhra.gov.uk/Publications/Safetyguidance/DrugSafetyUpdate/index.htm. Accessed 31 Oct 2014.

  38. National Reporting and Learning System. Available from: http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safety-incidents. Accessed 31 Oct 2014.

  39. National Reporting and Learning Service. NRLS quarterly workbook up to March 2013. http://www.nrls.npsa.nhs.uk/resources/?entryid45=135228. Accessed 27 Dec 2014.

  40. National Patient Safety Agency. Seven steps to patient safety. 2004. Available from: http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787. Accessed 24 Aug 2014.

  41. National Patient Safety Agency. List of medication safety alerts and guidance. Available from: http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/medication-safety. Accessed 24 Aug 2014.

  42. NHS England. National Patient Safety Alerting System. Available from: http://www.england.nhs.uk/ourwork/patientsafety/psa/national-psa-system. Accessed 31 Oct 2014.

  43. NHS England and MHRA. Patient Safety Alert; Stage 3 Directive. Improving medical device incident reporting and learning. 2014. Available from: http://www.england.nhs.uk/2014/03/20/med-devices. Accessed 30 Oct 2104.

  44. Medicines and Healthcare Products Regulatory Agency. Best practice labelling and packaging medicines. Guidance note 25. 2003. Available from: http://www.mhra.gov.uk/home/groups/comms-ic/documents/publication/con007554.pdf. Accessed 29 Dec 2014.

  45. National Patient Safety Agency. Design for patient safety series of publications 2003–2010. Available from: http://www.nrls.npsa.nhs.uk/resources/collections/design-for-patient-safety. Accessed 29 Dec 2014.

  46. European Medicines Agency. Good manufacturing practice. Available from: http://www.ema.europa.eu/ema/index.jsp?curl=pages/regulation/document_listing/document_listing_000154.jsp. Accessed 15 Oct 2014.

  47. European Medicines Agency. Good vigilance practices. Available from: http://www.ema.europa.eu/ema/index.jsp?curl=pages/regulation/document_listing/document_listing_000345.jsp. Accessed 30 Oct 2014.

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Funding and conflict of interest

No sources of funding were used to assist in the preparation of this review. David Cousins, David Gerrett, Natalie Richards and Mitulsinh M. Jadeja have no conflicts of interest that are directly relevant to the content of this review.

Theme issue

This article is part of a theme co-edited by Elliot G. Brown, Shanthi Pal and Sten Olsson. No external funding was used to support the publication of this theme issue.

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Correspondence to David Gerrett.

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Cousins, D., Gerrett, D., Richards, N. et al. Initiatives to Identify and Mitigate Medication Errors in England. Drug Saf 38, 349–357 (2015). https://doi.org/10.1007/s40264-015-0270-3

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