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Case studies highlight medication errors

Jeremy Hunt said the research commissioned by his department shows errors are causing ‘totally preventable’ harm and deaths.

Research commissioned by a Government department has highlighted how millions of medication errors are made in the NHS every year.

The mistakes, which include giving patients the wrong medication, may cause around 1,700 deaths annually in England and contribute to up to 22,000 each year, according to the study commissioned by the Department of Health and Social Care.

Health and Social Care Secretary Jeremy Hunt said the findings show medication error is “a far bigger problem than generally recognised” and causing “totally preventable” harm and deaths.

Colin Whalley died on November 19 2011, three days after being admitted to Whiston Hospital with an exacerbation of his chronic obstructive pulmonary disease (COPD), a condition which commonly causes breathing difficulties.

Nurse Mary Sanchez admitted she failed to administer aminophylline, a drug used to open constricted airways, “in line with the prescription” when she treated the 68-year-old at the hospital in Merseyside.

The patient was due to be given two doses of the drug, one undiluted over a period of 20 minutes and another diluted over a period of 24 hours.

The second dose was incorrectly administered undiluted in just over an hour, a misconduct hearing at the Nursing and Midwifery Council in London heard in February 2016.

Ms Sanchez was given a caution order for one year, after which it would be removed from her record, the panel said at the time.

Another medication error saw staff at a “very busy” Boots pharmacy supply an RAF veteran with another patient’s prescription, an inquest was told.

Douglas Lamond, 86, who was registered blind, received his weekly medicines in pill boxes assembled at his local branch, with tablets placed in separate plastic compartments to take on different days.

He received many different medications for complaints including heart problems and type 2 diabetes.

In March last year, Suffolk Coroner’s Court heard how a dispensing error was made on a day when the pharmacy was “very busy”, and responsible pharmacist Mihaela Seceleanu did not notice this when completing checks.

Dispenser Susan Hazelwood said Mr Lamond’s prescription changed and he required extra pills – and in slitting open a box she thought was for him, she added the pills and re-sealed the box – something that was against standard procedures.

But she had accidentally picked up a completed box for another patient with a similar surname, Antony Lampard, which was two shelves above the boxes for Mr Lamond.

Mr Lamond, of Stuart Close, Felixstowe, died on May 12 2012, two days after the pills were delivered to him.

He was wrongly dispensed the anti-diabetic drug gliclazide, which is used to lower blood sugar levels, and he did not receive his usual prescription of bisoprolol, a beta-blocker used to treat high blood pressure.

Suffolk Coroner Dr Peter Dean recorded a narrative conclusion and said that Mr Lamond died from the combined effects of his serious pre-existing medical conditions and the consequences of “a very significant accidental dispensing error which resulted in him receiving another patient’s medication”.

The Crown Prosecution Service (CPS) said there was insufficient evidence to charge anybody with gross negligence manslaughter.

Following a right to review appeal by the family of Mr Lamond, Ms Seceleanu was cautioned under the Medicines Act 1968.


From Belfast Telegraph