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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 'Improving Medication Safety and Reducing Medication Errors'. In his presentation Professor Stephens discussed:

  • changing the culture to improve medication safety and reduce medication errors 
  • building support for safer medication use 
  • improving reporting and learning systems 
  • how do we reduce, and monitor the reduction in Medication Errors 
  • priority areas: where should efforts be focused?

Full presentation available here

Professor Martin Stephens comments: "Often where lack of alliances/support for doctors/nurses/pharmacists is where errors happen

“Just because you’re the lone voice in the wilderness it doesn’t mean you’re wrong” – Ghandi


Understand people & their behaviour – how are they motivated?

How do you convince people? – get evidence right

If you don’ relevance to the audience/individual you won’t convince them

Be aware of & relate the down side of your argument

Be passionate - If you don’t care about your argument, then neither will your audience


Present – get out to the right places & see right people

Personalise – relate argument to the audience in order to convince them

Persuasive – what is the evidence

Passionate – believ in your own argument

Persistent – be prepared to continue argument to achieve target


Of organisation is what people do when no-one is looking

In order to change errors we have to shift culture

Learn from errors, be positive & make changes


Making it easy (electronic systems) – if not people will be reluctant to do it

Don’t penalise – make space in their days/schedule to be able to report/make changes"

Pre event abstract:

Those seeking change need to build alliances to be successful – this is certainly the case for those seeking reductions in medication errors in healthcare settings. Marchant, in Harvard Business Review, explains the need to create relevance, understand the weak points of your own case, understand people and to really care about your goals – the five Ps of gaining support covers this ground. For organisational improvement to be achieved there needs to be organisational culture shift, the Institute of Healthcare Improvement have addressed this and the ‘Board to Ward’ work in the NHS seeks to implement. There are barriers to reporting and learning from errors – overcoming these is a key step to error reduction. Once the reports arrive, targeting action to achieve change is the next step – lessons from economics can be sought as resources are always scarce and we know that some of the more effective actions take greatest effort.

Introduction to risk re medicines: Risks with medicines, G Cavell, chapter 12 in Hospital Pharmacy, ed M Stephens, Pharmaceutical Press, 2005 (second edition)

Developing a safety culture: Institute for Healthcare Improvement website

Putting safety first: A webinar from 2015 Sign up to Safety

Barriers to reporting: A Sarvadikar, G Prescott, D Williams, Attitudes to reporting medication error among differing healthcare professionals, Eur J Clin Pharmacol 2010 66(8) 843-53;

S Williams, D Phipps, D Ashcroft, Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study, Res Social Adm Pharm 2010 9(1) 80-89.

Basic health economics: Chapter 5 in Strategic Medicines Management, M Stephens, Pharmaceutical Press, 2005.

Professor Stephen's Biography:

After working in a number of hospital pharmacist posts in the West Midlands Martin became Chief Pharmacist at Wolverhampton in 1989 before moving to Southampton in 1997.There he led pharmacy until 2006 when he took on wider clinical leadership role in divisional and clinical effectiveness positions. Martin was National Clinical Director for Hospital Pharmacy 2008-2011. His final full time post was as Chief Executive of Wessex Academic Health Science Network. Martin now chairs Wessex pharmacy Local Professional Network. He edited Hospital Pharmacy and wrote Strategic Medicines Management.

Continuing the morning session is Helen Young Director of Maternity and Newborn Transformation/Chief Nurse Birmingham Women’s NHS Foundation Trust who will give an extended session on 'Managing a medication incident and ensuring change occurs' and will cover:

  • managing a medication incident 
  • supporting staff who make a medication error 
  • how do we effectively communicate the learning from medication errors, and safety alerts to frontline staff 
  • ensuring learning and action plans leads to change in behaviour and practice 

Helen comments: "There is no average trust any more. More mergers etc mean more trusts deal with wider range of complex areas

Same issues are still occurring as 20 years ago but for different reasons
-    Numeracy still an issue with nurses/midwives/junior doctors; not tested as well as it should be; have they got the skills that they need to complete the work you’re going to give them
-    IT: fear of technology for generation X/Y although is improving
-    Overseas Nurses: names of medication often different in different areas
-    About time we take  in education of nurses/midwives
-    Increasing workloads & less time increases risk ratio
Electronic prescribing – 1 of most significant technological improvemtnts that can be made, but it is still quite slow roll out & even where it has it doesn’t yet cover all areas
Written – dates unclear/changes made & overwritten
Standardization is key as differences across trust in hospitals/community etc make it difficult to monitor

Kit not charged – monitoring & prescribing
Alerts – break concentration of nurses/midwife
Storage – working out how many steps needed in process
2 patients – dual screens; 1 for mum, 1 for baby – often causes confusion & errors

-    Communication from pharmacy: intranet & newsletter – staff don’t always have time to read through all their emails etc
-    Promoting Self Medication: large proportion are willing/able/safe to self medicate; often know better about when & what they need; prevents late meds
-    Medicines Reconciliation: historically assume job of pharmacist; best time is at admission & worth using appropriate practitioners (nurse/midwife) or pharmacy support
-    1:1 training with Junior Doctors: very difficult to negotiate this time; now booked half hour session with Meds Mgt Team
-    Competency Frameworks
-    Building Relationships with local academic partners: had to get involved in the curriculum to make sure key competencies covered were correct; basic literacy/numeracy tests at beginning, middle & end of course
-    Audit Programme: understanding in reality what is happening

What do we do when staff make a mistake?
-    Well done: have to actively encourage reporting; if you report it, we will act on it & we will not follow a disciplinary action"

Helen's Biography:

After training as a nurse at Westminster Hospital in London, Helen held Sisters posts in Surgery and Critical Care and Medicine before setting up a Nurse Led Development Unit with Leeds University. She is passionate about developing nursing practice, education and leadership and completed her Masters in Education.

She has held posts as Head of Practice Development and Education in Guys and St Thomas and then Chelsea and Westminster as well as Deputy Chief Nurse and Chief Nurse positions in a number of large acute Trusts, including East Kent, Conwy & Denbighshire, Croydon University Hospitals Trust, Oxford University Hospitals Trust, Kings College Hospital FT, as well as six years in a national role as Clinical Director and Chief Nurse for NHS Direct.

Having recently been Chief Nurse and Chief Operating Officer at Birmingham Women’s NHS Foundation Trust, she has now moved in to a joint Trust role for Birmingham Women’s and Birmingham Children’s FT’s, as Director of Maternity & New-born Transformation.

Helen is a Visiting Professor at Birmingham City University, a Florence Nightingale Leadership Scholar and Harvard University Graduate.

She is a also a Trustee of Dorothy House Hospice, Chief Nurse for national charity called ACROSS, Regional Nurse for a national children’s charity, HCPT  and executive member of her local Soroptimist  International Club, an organisation that works to empower, educate and enable women and girls in the UK and worldwide.    

Omar Ali Visiting Lecturer Value Based Pricing & Innovative Contracting of New Medicines University of Plymouth and External Adviser NICE Adoption & Impact Programme Reference Panel speaks during the afternoon on 'Electronic Prescribing and Medication Errors' and asked delegates can eprescribing create new types of medication error?

Omar comments "Sharing lessons from putting EPMA project together

1 in 20 admissions caused by medication error is preventable

Monitoring of treatment
Integrating clinical guidelines/Formulary decisions with ePMA

Decision Tree:
Are you treating a condition or just choosing a drug?

Different systems might it make it more difficult than it needs to be in choosing the right drug

Finding a balance when trying to prioritise the alerts that you want to come up & those that can be put to the back

Access to Terminals? Computer Fatigue Syndrome? – we’re all spending more of our time in front of a computer screen
All prescribing can be done from anywhere now, without any patient contact. This needs to be thought about & in some trusts they insist that you are with the patient when prescribing.
-    Project team formed early
-    Change
-    Training
-    ‘Go-live’
-    Beyond – system optimisation – do not reduce level of resource post go-live

-    Clinical & non-clinical
-    Senior executive to end users: promote ownership trust-wide
-    Workshops

-    Shown to reduce serious errors/introduce new types of error
-    It will always take longer at the beginning
Epma is a tool to help us do our jobs NOT do it for us

Linking Technology – Epma & ID e-allergy bracelet
-    Changes dynamics"

Omar's Biography:

Qualified with a hospital pharmacy background, Omar has been working as the Formulary Advisor for Surrey & Sussex Healthcare NHS Trust for over 15 years, sitting on the regional Joint Drugs & Therapeutics Committee as well as the CCG/Commissioning Prescribing Clinical Network.

Omar has been a visiting Lecturer at UCLH Pharmacy Programme and was both Lecturer & Examiner on the Independent Prescribing V300 Course at the University of Surrey and has over 30 publications to date. He has been appointed as Visiting Lecturer on Value Based Pricing & Innovative Contracting at the University of Portsmouth (*starting August 2016)

He is an Editorial Content Adviser to Guidelines and has recently been invited to the position of Associate Editor to the Canadian Journal of Population Therapeutics & Clinical Pha rmacology. In 2010, Omar has served a position on the External Reference Group on Cost Impact Modelling for NICE for 5 years and in 2016 was appointed Panel Member for the newly formed Adoption & Impact Program Reference for NICE. He advises foreign investors (US Embassy) on ‘Value Based

Assessments (hosted by the UK Department of Trade & Industry) and recently delivered a Healthcare NHS Reform program to over 40 Healthcare Insurance Provider delegates visiting from the US.

Future related conferences:

Electronic Prescribing In Hospitals: Moving Forward
Thursday 13 July 2017 
Manchester Conference Centre, Manchester

Non Medical Prescribing in Cardiology
Monday 18 September 2017 
De Vere West One Conference Centre, London

Effective Non-Medical Prescribing in End of Life Care
Friday 6 October 2017 
De Vere West One Conference Centre, London

19 May 2017


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