News
Medicines mishaps caused by poor communications
9 May 2008
Communication problems, insufficient patient counselling about their
medicines and limited access to patient’s medical and medication history
contribute to preventable drug related admissions to hospitals (PDRAs)
says a new research study.
The study was led by Rachel Howard from the School of Pharmacy,
University of Reading, UK and supported by a grant from the Pharmacy
Practice Research Trust. It found communication problems occurred
between patients and healthcare professionals; different groups of
healthcare professionals such as GPs and pharmacists; and GPs and
hospital doctors.
The study also found that the root causes of preventable adverse
events leading to hospital admission are similar, irrespective of
whether they are associated with a prescribing, monitoring or patient
adherence problem.
Amongst the communication problems identified were insufficient
patient counselling about their medicines, the reluctance of patients to
ask health professionals about their medicines and an assumption by some
community pharmacists that the patient would have received some
medicines counselling from their GP. Some patients couldn’t recall the
information they’d been given or had difficulty in hearing what was
said.
The research also highlighted problems encountered in accessing
complex and up-to-date patient medical and medication records. This
affected both GPs working out of hours and community pharmacists
contributing to a knowledge gap which in turn led to prescribing and
monitoring errors.
“The causes of PDRAs are multifaceted,” concluded Rachel Howard.
“Technical solutions such as computerised assisted prescribing and the
NHS patient care record are unlikely to be sufficient on their own to
improve the situation and community pharmacists are hampered by their
lack of access to the patient’s medical record. Targeting the human
causes, like improving methods of communication, is also necessary.”
In a Foreword to a Trust report of the study, Margaret Dangoor,
Executive Director, Association of Litigation and Risk Management
writes, “This report makes a valuable contribution to the knowledge base
on patient safety and more specifically on preventable medication
errors. It’s notable for its setting in primary care, an area that is
under researched in terms of medication error and although it includes a
relatively small number of incidents, there are lessons to be learnt.”
“The recently published White Paper on Pharmacy in England
recommended that chief pharmacists take the lead role in working to
reduce unintended hospital admissions related to medicines,” said Dr Sue
Ambler, Director of the Trust, “and this study is well placed to
contribute to this, but more studies in the community are needed to
identify strategies to help overcome these problems and improve patient
outcomes.”
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