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Reducing Medication Errors in Practice: Improving reporting and learning systems

Professor Liz Kay, Clinical Director of Pharmacy, Leeds Teaching Hospitals NHS Foundation Trust and Council Member, General Pharmaceutical Council discussed reducing medication errors in practice and improving reporting and learning systems at today’s conference. In her presentation Professor Liz Kay discussed:

  • how do we reduce, and monitor the reduction in Medication Errors in an NHSTrust
  • priority areas: where should efforts be focused?
  • improving reporting and learning systems
  • what are the root causes of medication error: our experience and learning

Professor Liz Kay full presentation is available for download at the end of this page.

In her presentation Professor Liz Kay Stated:

“How to reduce – report, report, report, the more we report the more we learn. Find the areas in trouble, use metrics and tour the wards on gemba”

“Culture and clinical leadership – staff engagement – just culture – are key to improved reporting – medication safety - make it everyone’s business, if you know about it you can do something about it”

“It’s about clinical Leadership from senior pharmacy staff and integration of pharmacy into the patient’s journey”

“Change must come from within, not top down, work with clinicians to redesign the systems to take out risks”

“Quality and safety should be primary consideration – not money”

“Variation, work arounds, special people doing it differently – challenge – standardise, errors are Waste – waste harms other patients – where do we focus to minimise risks and reduce waste, complex processes. Waste is anything that doesn’t add value. Find the variation in product presentation, prescribing pattern, handling processes”

“Continuous improvement through user engagement and feedback, continuous improvement projects”

“Trainee huge untapped resource- young revolutionaries”

“Review all complaints”

“Celebrate and share success”

“What’s important about pharmacy – everyone needs it.”

“Medicines Optimisation – focus on patients and outcomes – a change from products and processes”

“Critical for pharmacy to look outwards, critical to involve patients – to hear experience of service design. Patients want a partnership with clinicians, including pharmacists to help them make decisions about own care.”

“Persuade commissioners of the value of pharmacist led services, strong local and professional leadership to respond to pressure in system – older people in social care, technically demanding eg PN, pan organisation eg antimicrobials, venous thromboembolisim, develop consortia in new roles – linked to HEIs”

Future events of interest:

Non-Medical Prescribing
Thursday 3 December 2015 
Manchester Conference Centre, Manchester

Non-Medical Prescribing for Pain
Wednesday 3 February 2016 
Thestudio Conference Centre, Birmingham

Electronic Prescribing In Hospitals: Moving Forward
Tuesday 15 March 2016 
ICO Conference Centre, London

Effective Non-Medical Prescribing in End of Life Care
Friday 15 April 2016 
Hallam Conference Centre, London

Download: Professor Liz Kay full presentation

27 November 2015


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