LEAFLETS SHARE LEARNING ON MEDICATION ERRORS

[NHS RESOLUTION has published a suite of seven information leaflets relating to medication errors in order to share learning from clinical negligence claims with healthcare professionals.

It describes medication errors as ‘any patient safety incidents where there has been an error in the process of prescribing, preparing, dispensing and administering, monitoring or providing advice on medicines’. Such errors can occur at many steps in patient care, from ordering the medication to the time when the patient is administered the drug.

From 1 April 2015 to 31 March 2020 NHS Resolution received 1,420 claims relating to errors in the medication process. Of those claims 487 were settled with damages paid, costing the NHS £35m, excluding legal costs.

Initial data for medication errors indicates that anticoagulants, opioids, antimicrobials, antidepressants and anticonvulsants are the most common medications to be implicated in incidents.

The seven information leaflets, published in the Did You Know series cover:

• Anti-infective medication errors

• Extravasation

• General practice medication errors

• Heparin and anticoagulants

• Insights into medication errors

• Maternity

• Paediatric medication errors

The leaflets can be downloaded from resolution.nhs.uk q

The NHS Resolution report said: “Cause of death was not disputed. Symptoms commenced in about July 2019 and a formal diagnosis of mesothelioma was made in September that year. However, the defendant argued that Mr Wilson was exposed to extremely low levels of asbestos dust while working at the hospital, at a time when the risk of injury from such limited exposure was not generally known.”

Prior to his death Mr Wilson had made a statement in which he described the use of asbestos mats in the laboratory. He categorised them as ‘very fragile’ and said: “…they would simply break and the edges would be flaky. If you placed the board down onto the desk heavily it would just break into pieces and cause so much dust to emerge.”

The defendant engaged an occupational hygiene expert witness, whose opinion was that the level of exposure during Mr White’s second spell at the hospital as a senior biochemist was minimal. During his first spell there the exposure was higher but still low. During that time the risks of low exposure were not known. It was only in 1965 that a paper was published exposing the risk.

The judge concluded that, during his first period in the laboratory Mr Wilson was exposed to very low levels of asbestos dust. Since the entirety of this period was before publication of the key paper in 1965, it was not foreseeable to the hospital authorities that there was a risk the deceased might develop mesothelioma or some other malignant disease from very low level exposure to asbestos dust. During the second period of employment, the degree of exposure was very low indeed. Consequently, although causation had been accepted, it was not foreseeable to the employers at the time that Mr White might be exposed to a risk which they had a duty to guard against. Judgment was therefore given in favour of the Secretary of State. q