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Reducing Medication Errors: National Summit

This Summit aims to bring together clinicians, managers and medication safety officers to understand current national developments, and to debate and discuss key issues and areas they are facing in improving medication safety and reducing medication errors. 

The conference opened with an update from Professor Martin Stephens Pharmacy Consultant (Chair Wessex Pharmacy LPN & Chair & Visiting Professor University of Portsmouth) on 'Reducing Medication Errors in Practice'. In his presentation Professor Stephens discussed:

• how do we avoid being lone voices? 

• are we measuring the right things for the right people? 

• developing a culture of patient safety from board to ward 

• improving reporting and learning systems 

• how do we reduce, and monitor the reduction in Medication Errors 

• priority areas: where should efforts be focused?

In his presentation Professor Stephens stated:

- Know what communication method is right for your audience

- don't worry about formal structure levels, you can still use ways and means to get your point to senior staff

- quoting George Bernard Shaw "All progress depends on the unreasonable". Unless you go against the flow a bit you aren't going to get what you need

- you need to work out what matters to your audience, like finance

- get connectivity between board and Ward

- need clinical engagement to get good medical safety

- if resources are limited you need to choose the things that bring the biggest benefits

Full presentation available here

Dr Alice Oborne Consultant Pharmacist, Safe Medication Practice & Medicines Safety Officer, Co-Chair Trust Medicines Safety Forum Guy’s and St Thomas’ NHS Foundation Trust Honorary Clinical Reader in Medicines Safety School of Biomedical Sciences Kings College London on 'Medication Errors: setting the benchmark at zero'. In her presentation Dr Oborne discussed:

• how ambitious should patient safety goals be in relation to medication errors? our goals of high risk medicines: reduce errors with high risk medicines by 100 per cent that is, to zero and all other medicines: reduce errors with all medicines by 25 per cent every year 

• establishing a baseline for medication errors to enable progress to be tracked 

• high risk drugs: where to prioritise medication error reduction programmes 

• focusing on the medication errors that cause the most harm to patients 

• accountability for delivery of patient safety improvement targets with relation to medication errors

Alice commented:

‘We have found that 10% of all incidents occur in children aged 0-4 and adults aged 80 plus. It does happen over all ages but with these groups we feel there is more potential for confusion’

‘The highest risk medications are insulins, stong opiats, and sedatives’

‘There are more incidents in the extremes of age as well as extremes of body weight’

‘Patients expect us to deliver safe care’

‘Staff at our hospital are encouraged to share what happened with their incidents, we hold forums at our hospital every Friday afternoon’

‘We haven’t got to zero incidents, but we are monitoring and we know what is happening. People are getting better at reporting errors – they are less afraid to’

‘The UK is moving towards electronic prescribing, this can be helpful in reducing errors depending on the software’

‘We have new thinking about changing the focus from when things go wrong to when things go right’

 

Further conferences of interest:

Improving Anticoagulation Therapy Services
Tuesday 29 November 2016 
Hallam Conference Centre
London

Book

Electronic Prescribing In Hospitals: Moving Forward
Friday 27 January 2017 
De Vere West One
London

Book

Effective Non-Medical Prescribing in End of Life Care
Friday 24 February 2017 
De Vere West One Conference Centre
London

Book

Non Medical Prescribing in Cardiology
Friday 31 March 2017 
De Vere West One Conference Centre
London

Book

8 November 2016

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