UK. The National Patient Safety Agency (NPSA) has announced a package of practical solutions to reduce errors associated with the use of oral methotrexate. Oral methotrexate tablet is taken as a weekly dose by thousands of people in the UK for the treatment of moderate to severe rheumatoid arthritis and severe psoriasis. The weekly dosing regimen raises opportunities for dosing errors, with errors occurring during the transfer of information from hospitals to GPs and due to problems with information technology support systems that fail to give clear information on the frequency of dosing. The NPSA has identified 25 deaths and 26 cases of serious harm linked to improper use of oral methotrexate in a community setting over a 10-year period in England. The Committee on Safety of Medicines (CSM) in 2002 had recommended improvements in the labelling of methotrexate tablets to reduce the potential for error. More recently, the NPSA, in collaboration with health professionals, patient groups and pharmaceutical industry and medical and pharmaceutical software suppliers, has proposed 3 national solutions:

1. A new patient treatment diary with complete information to empower patients with appropriate knowledge and help keep their own track record (for frequency of dosing, monitoring etc).

2. New packaging designs with a view to help improve safety when methotrexate is prescribed by healthcare staff and administered by patients and their carers.

3. A project to adapt IT systems in GP surgeries and community pharmacies to incorporate flagging mechanisms and default settings to support staff by designing out opportunities for human errors in prescribing the drug.

These solutions will be developed in collaboration with the major stakeholders and subject to further testing and risk assessment by the NPSA.

Reference:

1. News & Updates, 11 Jul 2003. Available from URL: http://www.druginfozone.nhs.uk

2. British Medical Journal; 327:70, 2003. Available from URL: http://bmj.com