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Reducing Medication Errors: Learning from patients

Nicola Davey Trustee Clinical Human Factors Group spoke at today’s Reducing Medication Errors conference on:

• learning from patients and involving patients to reduce medication errors
• using staff and patient stories to inspire the team to improve
• engaging patients to self manage medications

In her presentation Nicola made the following comments; 

"High reliability organisations pay the same level of attention to non-catastrophic errors as they do catastrophic, I think we've got a long way to go in healthcare to achieve this

Up to a third of prescriptions have some sort of error on them

It's a system problem and needs a system change approach - you need to have clinical leaders who really really believe the system needs to change"

Abstract of Nicola’s talk
Reducing Medication Errors: Learning from Patients 

What I need, when I need it’… 
In my life I am surrounded by people who take medicines some or all of the time. What do they say about reducing medication errors? Well not a lot. In the main they think that they must have been unlucky. When they need medicines they take them – sometimes they take them as on the label, and sometimes they don’t. What do they say about medication errors – well not what you might expect as I hope the patient stories I am about to tell you will illustrate. 

If I am working at a hospital I am surrounded by people who take medicines away from patients on admission some or all of the time….. and give them back on discharge some or all of the time. What do they say about reducing medication errors? Well it depends on whether they are junior or more experienced, whether they are a nurse, a doctor of a pharmacist, and whether they see this as someone failing to do the right thing or a systems failure. 

So whose job is it to fix medication errors? In most places this would be the pharmacist – they are the last line of defence. 

I am a pharmacist – but if I become a patient and am admitted to a hospital or discharged home - Well it’s a different story… I have to take medicines when I am given them, my own medicines are taken away from me, or have not been prescribed, or not supplied or can’t be found. Is this right or wrong? And whose job is it to fix? 

Key Learning points: 
As professionals we explain our actions on the basis of our specialist insight achieved through years of experience. At the same time, and without any situational awareness, we loose sight of what it feels like for the patient. 

Standing in their shoes the view is very different: things that seem trivial or unimportant to us as professionals take on a much higher meaning; and conversely things that seem mission critical suddenly take on a much lower significance. 

This session is designed to provide an opportunity for challenge and self reflection.

Nicola's full presentation is available for download at the bottom of this page. 

Nicola is an experienced pharmacist and quality improvement practitioner who specialises in service improvement. She has worked in the acute and primary care sectors, at local, regional and national level. She was Senior Associate at the NHS Institute for Innovation and Improvement for 5 years and is now Director of the Quality Improvement Clinic. Nicola is a Trustee for the Clinical Human Factors Group (CHFG), a charity which works with clinical professionals and managers to make healthcare safer. She is also Faculty Lead for England for the IHI’s Open School supporting clinical trainees. 

Future events of interest:

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

Patient Experience Insight: Demonstrating Responsiveness to Feedback
Wednesday 4 February 
Colmore Gate, Birmingham

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: Nicola Davey full presentation

27 January 2015


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