http://www.nytimes.com/2001/12/20/international/20BRIT.html
December 20, 2001
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More Deaths in England, Due to Error,
Report Says
By SARAH LYALL
Outlined in a report by the Audit Commission, the errors included
administering the wrong medicine — in one case, a breast cancer patient was
given the sleeping drug Temazepam instead of the cancer drug Tamoxifen — to
giving out the wrong dosage of the right drug, to unknowingly prescribing a
drug that caused a fatal reaction.
The death toll was five times higher than that in 1990, according to the
report. In addition, the thousands of patients who survive medicine-related
mistakes each year invariably become sicker, requiring more treatment that
create an extra expense for the National Health Service, the report said.
"The health service is probably spending half a billion pounds ($725
million) a year making better people who experienced an adverse incident or
errors, and that does not include the human cost to patients," said Nick
Mapstone, an author of the report.
Mr. Mapstone said that many of the most common errors are avoidable and
could be rectified if the health service introduced computerized patient record
and prescription systems. As it is now, patients' notes are often illegible,
incomplete or missing altogether, the report said, making it impossible for
doctors and nurses to have accurate information.
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The government has promised to introduce computerized prescriptions — which
could include a standard national system for coding medicines and the use of
bar codes to support development of electronic prescribing systems — by 2005,
but Mr. Mapstone said he did not think it would meet the deadline.
Addressing the issues raised by the report, Dr. Trevor Pickersgill, a
spokesman for the junior doctors' committee of the British Medical Association,
said that understaffing in hospitals and the increasing complexity of modern
drug therapy have created a culture "where mistakes unfortunately do
happen."
"The number of drugs is increasing, the effectiveness — and therefore
often the toxicity — of drugs is increasing, the number of people on multiple
medications is increasing, and that increases the risk of interaction,"
Dr. Pickersgill told the BBC.
"We must also remember that one in six pharmacy posts in hospitals are
unfilled, and new doctors who are doing the work on the wards are overworked as
well," he said.
A number of highly publicized cases of drug-related error in recent months
has brought home the problem. In one case, a cancer patient was prescribed and
administered a drug at 1,000 times the recommended dose, according to the
report.
In another case, at Queen's Medical Center in Nottingham, a teenager, who
was a cancer patient in remission, fell into a coma and died after an
anticancer drug was mistakenly injected into his spine.
"The recent events at Queen's Medical Center illustrate how day-to- day
pressures can lead to acknowledged best practice being ignored," the
report said.
Jackie Glatter, a spokeswoman for the Consumers' Association, which lobbies
for patients' rights, said: "The report shows there is a strong need for
detailed and clear patient information about treatments and medicines — not
just in hospitals, but also when people are taking medicine at home."
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