Pandemics, Pharmacology, and Preventable Deaths

The Problem

Medicines cause over 1,700 preventable deaths annually in England alone, with drug errors affecting around 20% of patients after hospital discharge, and medicines contributing to up to 7% of hospital deaths. Previous investigations into these avoidable deaths have provided useful lessons for policy and practice, highlighting the systemic problems with care that can be addressed to improve patient safety. However, such investigations into preventable deaths concluded prior to the COVID-19 pandemic, an event which may have influenced the factors underlying such deaths. Therefore, studying the differences is necessary to determine if established trends remain true under pandemic conditions.

The Approach

As a part of the International Union of Basic and Clinical Pharmacology (IUPHAR) World Smart Medication Day 2022 event, focused on the theme of 'Clinical Pharmacology in the Era of Pandemics', we carried out an investigation of preventable deaths caused by medicines across England and Wales. We compared characteristics between the groups of deaths that occurred before and during the COVID-19 pandemic to probe common factors. To screen preventable deaths, we looked at coroners’ 'Prevention of Future Death' reports (PFDs): short letters produced by a coroner in cases where action should be taken to prevent similar deaths from occurring in future. In these reports, coroners summarise the death and highlight contributary factors, referred to as “coroners’ concerns”. By screening these reports to highlight cases where drug and/or medicine use caused or contributed to death, we were able to highlight the prevalence of different medicine types and the key factors underlying these preventable tragedies.

The Medicines

Overall, we assessed 3785 PFDs, revealing that medicines caused or contributed to death in 18.6% of these. Perhaps surprisingly, we failed to detect a significant difference in the drug types driving deaths. Both prior to and during the pandemic, most deaths were driven by opioids, antidepressants, anticoagulants, or hypnotics. The contribution of opioids and anticoagulants increased slightly during the pandemic, and cannabinoids disappeared.

Fig.1 – Comparison of drug classes contributing to preventable deaths before and during the COVID-19 pandemic. Drug classes reported as proportions of total number of drugs mentioned (n) in medicine-related PFDs published July 2013 to February 2022. Outer ring (Red): Pre-pandemic (n=1067) Inner ring (Blue): Pandemic (n=107)

The Concerns

Although most themes of concern were unchanged by the onset of the pandemic, those related to education and training became more prevalent while communication issues became less common. Within these factors of concern, the largest changes related to (i) failures to learn from past events, (ii) inadequate training, and (iii) inappropriate dosages. Interestingly, these increasing concerns mostly related to human error. This possibly reflects an increased reliance on professional judgement during a pandemic, with novel risks and fewer relevant policies, further supported by an augmented number of concerns regarding lack of protocols. Increases in failures to learn from past events may also suggest reduced effectiveness of audits, reviews, or other mechanisms to learn from previous mistakes. Again, this is a significant concern, as these systems exist to encourage improvement; their failings can lead to stagnation and repeated preventable deaths.

Fig.2 - Proportions of themes of coroners’ concerns extracted from medicine-related PFDs published July 2013 to February 2022, grouped through directed content analysis, and compared for pre- and pandemic groups

How might we address this problem? To reduce rates of human errors, we need better policy generation, and to continue to review practice despite the scaling-back of so-called ‘non-essential’ processes during pandemic conditions, such that we can maximise the effectiveness of guidance. The importance of using clinical studies and audits to determine the appropriateness and effectiveness of care is emphasised by our findings, supporting previous suggestions made as early as August 2020. Without an evidence base for guidance, we are unlikely to provide useful information for prescribers and healthcare professionals in the pandemic context, allowing avoidable errors and deaths to continue to occur.

The Reception

We used our findings to generate a research poster, which we submitted to the British Pharmacological Society as a part of the IUPHAR International Student’s Poster Competition. This work placed first in the research poster category at the national level, and was further entered to the international stage of the competition, placing third overall.

Going forward, these results form part of a larger analysis of preventable deaths involving medicines across England and Wales, identifying the main trends related to such deaths and their reporting from a complete sample, which has been presented at the Clinical Pharmacology Colloquium Autumn 2021 meeting and OUCRS FHS Symposium in Summer 2022. This forms an important part of the ongoing 'Coroners’ Concerns to Prevent Harms' series led by other members of our group. Further information regarding the series and use of coroners’ PFD reports to identify important lessons for clinical practice and policymaking are available through the 'Preventable Deaths Tracker', led by Dr Georgia Richards at the University of Oxford.


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Published: 25 Aug 2022

About the author

Harrison France


Harrison France is a fourth-year undergraduate who has recently completed his BA in Medical Sciences as part of an intercalated medical degree at the University of Oxford. His research interests remain broad, with ongoing work regarding clinical pharmacology and the physiology of spaceflight, which he hopes to one day couple. Harrison is a contributing author for The Oxford Scientist, Oxford’s premier, student-led, pop-science magazine, and enjoys long walks in nature.

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