Introduction
A medication error, defined as ‘any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health professional, patient or consumer’, can be associated with any stage of the patient medication journey.¹ The Government has set a target of reducing serious errors by 40%.² Such a reduction will require full understanding of all processes involved in medicine use, as well as the causation and prevention of errors. This research aimed to investigate two aspects of the medicines processes in secondary care: the focus on medicines during initial patient consultations; and the extent of changes to prescribed medicines.

Method
The study comprised two phases. In phase 1, a convenience sample of 10 patients admitted to the medical receiving unit of a major teaching hospital was recruited. After obtaining informed consent, a researcher observed the first interactions between practitioners and patients, recording verbatim and timing all discussions relating to medicines. In phase 2, data were recorded for 50 consecutive patients identified at the point of discharge from two medical wards, excluding those not receiving any discharge medication or those where the medical notes could not be located. These data included: drugs on admission, drugs prescribed on each consecutive day and at discharge. Data were analysed to determine the number and types of changes made, with changes classified according to criteria agreed between senior pharmacists, academic staff and researchers.

Results
Very little time (< 1 minute) was devoted to discussing drugs during the first interaction. None of the practitioners adopted a systematic approach and most employed only closed or leading questions. Of note, little emphasis was placed on compliance, adverse drug reactions, previous medicines or over the counter medicines.

A total of 811 changes were made during stay in the 50 patients studied, with most changes taking place on the first (n=257, 31.7%) or second day of admission (n=142, 17.5%). The median number of changes per patient stay was 14 (range: 3-39). The most frequent changes were new drug (n=278, 34.3%) and stopped drug (n=230, 28.4%). Comparing drugs on admission to drugs at discharge gave a median of 4 changes per patient (range: 0 to 13).

Discussion
Despite the small sample size, several issues were identified worthy of further investigation. The lack of systematic questioning relating to medication may result in decisions being made on the basis of incomplete information. In addition, drug therapy was observed to change frequently from one day to the next during the hospital admission. Marked differences were observed between medication on admission to and discharge from hospital. These frequent changes may contribute to the likelihood of prescribing and administration errors as well as patient confusion. This work is continuing with patterns of changes in therapy being compared across different ward types.

References

1. National Co-ordinating Council for Medication Error Reporting and Prevention. Available at www.nccmerp [accessed 7 December 2004]

2. Department of Health. Building a safer NHS for patients. Department of Health 2003: London. DH Publications.