Zero Tolerance to Medication Errors: setting the benchmark at zero
Dr Janine Wright, Consultant Gastroenterologist & Safer Medication Work Stream Clinical Lead at North Middlesex University Hospital NHS Trust discussed Zero Tolerance to Medication Errors: setting the benchmark at zero at today’s conference. In her presentation Janine discussed in depth:
- how ambitious should patient safety goals be in relation to Medication Errors? Our goal of 100% high risk medicines and medicines reconciliation compliance and no medication related Never Events
- 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
Dr Janine Wright's full presentation is available for download at the end of this page
In her presentation Janine covered:
‘Carrot and Stick’ motivation is a simple model to describe motivation. Our hypothesis is that in the current NHS there are many more ‘sticks’ than ‘carrots’ and this leads to cynicism and disengagement with any change process. We believe one of the key reasons for failure of safety initiatives is a lack of junior engagement. This project explores whether positive reinforcement and strong junior engagement at the outset could be successful.
We engaged junior medical staff to lead their own quality improvement projects and using positive incentives create cultural change in prescribing safety. One of the work streams was to improve prescribing safety for warfarin and was named Operation Warfarin.
We set up a Junior Doctors’ Drug Safety Champion scheme at our hospital. Junior medical staff were asked about their frustrations with regard to inpatient prescribing errors. Juniors were then tasked to prove their observation using a service assessment. On completion becoming a ‘Drug Safety Champion’ with a certificate and badge to identify their new role. Through peer discussion, possible solutions were proposed for the systemic problems identified. These audits and solutions were presented to the Hospital Patient Safety Board which gave inertia and senior backing for implementation of the junior’s changes. A repeat service assessment showing the positive results of intervention meant promotion for the junior to ‘Drug Safety Ambassador.’
Areas of poor prescribing were identified and audited as part of the Drug Safety Champion Scheme. Established quality improvement in warfarin prescribing has been demonstrated as a result of the interventions. The hospital currently has 9 Drug Safety Champions and 2 Ambassadors.
Engaging the junior medical staff in the genesis of quality improvement projects, and providing positive, zero-cost incentives, such as management experience on the hospital management board, means cultural change can be successfully implemented without the need for the traditional ‘stick’.
During her presentation Dr Janine Wright stated:
"All my resources are low tech because I don't have any more than that. What I do have is lots of young junior doctors who care and I want to harness that and make use of that."
"It's all about engaging with the people who are making the errors in fixing the errors and making things better."
"What Mayor Gulianni saw in New York when he adopted his zero tolerance party, was that as the smaller crimes came down, murders, Mafia crime, drugs crime, came down with them. This is the broken window theory. If you don't fix the small stuff, the big stuff will come down on top of you."
"The key thing with the juniors is this empowers them to make change in their working environment and make things safe. It's a really powerful way of creating change."
Dr Janine Wright Biography
Janine is a Consultant in Gastroenterology, General Internal Medicine and Acute Medicine at the North Middlesex University Hospital NHS Trust and is the departmental lead for Inflammatory Bowel Disease and Adolescent Gastroenterology. Janine is also the clinical work stream lead for medication safety at North Mid and sits on the Patient Safety Board, Safer Medication Practices Group and the Patient Safety Working Group.
Janine qualified from the Royal London Hospital Medical College and completed subspecialty training and specialty training in the North East Thames region. She obtained a postgraduate qualification in medical education from the Royal College of Physicians and University College London I am the course director of a teaching skills course at the North Middlesex. (TiPs) course. Janine is also a Fellow of the Royal College of Physicians.
Follow Janine on twitter at @drjaninewright
Future related events:
Medicines Optimisation: Ensuring the safe and effective use of medicines
Non-Medical Prescribing for Pain
Electronic Prescribing In Hospitals: Moving Forward
Reducing Medication Errors: Improving Patient Safety: Towards Zero Tolerance
Download: Dr Janine Wright's full presentation1 July 2015