Our latest report, published 11 April 2019, emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. 

The report puts forward a number of recommendations aimed at driving national improvement to reduce potentially fatal medication errors. This follows an investigation launched after we were made aware of a nine-year old child wrongly administered an oral liquid drug into a vein during a planned renal biopsy. The child stayed in the hospital for monitoring and was discharged with no adverse effects a day later. 

Confusing system

Our investigation identified that there are a number of professional and regulatory bodies involved in the implementation of system wide safety standards and guidance, dissemination of safety messages and professional training. It concluded that the current system is confusing with a lack of clarity over roles and responsibility. It also acknowledges the influence of human factors on medication administration and the range of cognitive demands placed on staff during critical stages of the process. 

Safety recommendations

The report sets out four recommendations:

  • Three are addressed to NHS Improvement. These are focused on the work of the National Patient Safety Committee (NAPSAC) to review alerts, improving skills and knowledge in risk analysis and hazard identification (to feed into the wider National Patient Safety Strategy) and a formal evaluation of the banding, time and resource given to the Medication Safety Officer (MSO) role.
  • One is addressed to the Royal of College of Physicians to work with other royal colleges and bodies to standardise professional development and postgraduate learning in medicine safety. 

Chief Investigator’s statement

Keith Conradi, Chief Investigator, said: “This investigation highlighted how challenging it is to make improvements at a national level, due to the complex nature of safety processes and the number of human interactions needed to prevent errors from occurring. By applying a human factors perspective, working with subject matter experts and engaging with national bodies, a clear picture emerged of where the pressure points are for healthcare staff carrying out invasive procedures in busy working environments. 

“The case we looked at for the investigation demonstrated that whatever the level of harm, medication errors have a devastating impact on all those involved – patients, families and staff.  

“We recognise all the good work already undertaken but there is more to be done. The recommendations set out in the report are focused on ensuring consistency in standards and training. We trust this collaborative and cohesive work at a national level will improve medicine safety processes across the system.” 

Safety observations

The report also makes seven safety observations and highlights seven safety actions already undertaken including the launch of the National Medicines Safety Programme led by NHS Improvement in response to the launch of the third global patient safety challenge by the World Health Organization (WHO). 

Read the report

Download and read the ‘Inadvertent administration of an oral liquid medicine into a vein’ report