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Medication incident error reporting and learning in practice

Gillian Cavell Consultant Pharmacist, Medication Safety Kings College Hospital NHS Foundation NHS Trust spoke at today’s Reducing Medication Errors conference on:

• improving medication error incident reporting
• what should happen when an error is reported?
• identifying themes and learning from errors
• providing feedback on what happens as a result of the incident

In her presentation Gillian discussed improving rmedication error incident reporting by increasing the number and quantity of reports.  Gillian considered how you determin what the right number is and suggested; “rather than look at total numbers it is probably better to look for consistent or increasing rates of reporting, ensuring that the types of errors you would expect to see are being reported.”  

Gillian also looked at what makes a good quality incident report and gave tips for what an incident report should include and what should happen when an incident is reported and how this can be applied to medication error incident reporting. 

Gillian’s full presentation is available for download at the end of this page.

Gillian is Deputy Director of Pharmacy, Medication Safety at King’s College Hospital in London where she leads on development and implementation of strategies to promote safe medicines use.  She has had an interest in medication safety since 1993, when she led the introduction of an anonymous medication error reporting scheme at King’s, one of the first in the UK.  

Gillian has been involved in projects and publications for the Department of Health and the National Patient Safety Agency to raise awareness of medication safety issues nationally.  She has presented at national and international conferences on a variety of topics to promote safe use of medicines.

Future conferences of interest:

Advancing IV Therapy
Thursday 29 January 2015 
ICO conference Centre, London

Electronic Prescribing In Hospitals: Moving Forward
Wednesday 22 April 2015 
ICO Conference Centre, London

Improving Anticoagulation Therapy Services
Monday 18 May 2015 
Hallam Conference Centre, London

Non-Medical Prescribing
Tuesday 2 June 2015 
ICO Conference Centre, London


Download: Gillian Cavell full presentation

27 January 2015

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