Almost 6,000 people harmed by prescription errors in NHS last year

A pregnant woman who died after being given the wrong dosage of drugs was one of almost 6,000 people harmed, and 29 killed, following prescription errors in the NHS in England last year.

Figures from NHS England show that 98 hospital trusts experienced an increase in the number of prescription errors reported in 2021, including cases where patients were given the wrong drug, wrong dosage or were not given medicine when needed. Meanwhile, the number of errors fell at 105 trusts.

Leeds Community healthcare trust had six times more prescription errors, with 111, up from only 17 in 2020.

At the Royal National Orthopaedic Hospital, London, errors rose from 60 to 193, while Hertfordshire Partnership University NHS Trust had 55 errors, a rise from 20 in 2020.

The NHS said almost one in six trusts still did not have a fully funded plan to introduce electronic prescribing, meaning they are still partially using paper notes.

Chief executive of Action against Medical Accidents, Peter Walsh said: “These are very disappointing statistics and behind every one is a story of personal suffering or tragedy. What is particularly frustrating is that prescription errors are probably easier to avoid than many things that go wrong in healthcare.

“The fact that almost one in six trusts don’t have a funded plan to reduce these errors is quite shocking. Even with those that do, having a plan is not enough.

“We are particularly concerned about vulnerable people, such as the elderly or disabled in care homes, who may be more at risk because they may be less able to check for themselves and because they tend to get a less personalised service than the average patient.”

The vast majority of prescription errors, 86%, were recorded as causing no harm to the patient, and on the whole, the number of prescription errors recorded on the national reporting and learning system (NRLS) fell from 44,928 in 2020 to 43,452 in 2021.

However, 5,349 were recorded as causing a low level of harm, which means they required extra observation or minor treatment. A further 520 incidents caused a moderate degree of harm, which can lead to further treatment, potential surgical intervention, cancelling of treatment, or transfer to another area.

There were 49 incidents that caused severe harm, while 29 incidents led to patients’ deaths.

In one case a patient was seen in anticoagulant clinic. She informed them she was pregnant, meaning that her anti-blood clot medicine warfarin was stopped as it is deemed unsafe in pregnancy.

A series of communication errors meant that instead, the patient was prescribed twice as much dalteparin as she should have been and later died of a brain bleed. The incident came to light only 10 months later when the coroner requested a report from the doctor.

NHS England said that while the NRLS was intended to record the actual degree of harm suffered by the patient, the large number of organisations reporting to the system means that cases were not always coded accurately.

The NHS is undergoing a transition to a new system for recording patient safety incidents.