The Medication Safety Officer role was created by NHS England in 2014 with the primary aim to improve reporting of, investigation of, and learning from medication incidents.
Within our local Trust the majority of learning was historically in the form of a monthly email bulletin sent to all prescribers, pharmacy staff and ward sisters to promote within their teams. Although the bulletins have positive feedback, with many non-medical prescribers citing that they use these as a resource during the NMP revalidation process, we are aware that a significant number of front line staff do not have easy access to emails.
Following a discussion at our Medication Safety Group, a literature search was conducted to find out if there is evidence to support other methods of improving learning about medication incidents.
We’ve looked into different ways in which medication incident and safety information can be more effectively shared amongst your local teams.
Incident bulletins are commonly used to share learning. A study of an email medication safety bulletin at the Royal Cornwall hospital showed that there was enthusiasm for such an intervention but suggested that this learning could be improved by distributing hard copies to wards, as many doctors did not use their Trust email, and linking this with face to face feedback by pharmacy staff at ward level. We are now encouraging ward managers to print hard copies for staff rest rooms.
Safety huddles are becoming established practice in healthcare, with one study showing awareness of safety issues improving by up to one-third. A study in a critical care unit concluded that the pre-round safety huddle is a time efficient communication method to improve knowledge around safety projects. Within our Trust we are currently piloting a series of monthly medication messages focusing on medication related Never Events and high risk medicines. A short summary is prepared for inclusion at safety huddles with key messages for prescribers and nursing staff. Supporting information in the form of a bulletin is also sent to the ward for email distribution and hard copies for rest rooms and notice boards.
Although we could find no evidence to support this, a trial of a member of the medication safety team visiting wards to talk about specific issues has received positive feedback. Due to workforce pressures it is challenging for staff to leave the ward for training and this method allows the mediation safety team to engage with staff on the ward to provide a key update or message which is followed up with printed information. Specific topics have included management of Addison’s disease and preventing missed doses of critical medicines. Although ad hoc, informal and time consuming for medication safety staff, this is well received by nursing staff.
Junior doctors have identified that access to pharmacist-led teaching improves communication and learning from medication incidents. At our Trust, in addition to formal teaching sessions on set topics and presentations at clinical governance sessions, we have started attending lunchtime sessions on the wards to discuss recent incidents. These have proved popular and although attendance is sporadic, learning is often shared between colleagues. These informal sessions also provide an opportunity for prescribers to raise issues of concern and suggest solutions.
Low certainty evidence suggests that feedback on prescribing errors may reduce future errors. Within our Trust individual feedback on errors or incidents to nursing and pharmacy staff is common and is often evidenced in incident investigations. However, we have found feedback to prescribers to be sporadic as often the original prescriber is not on the ward when the incident is discovered and feedback during the investigation depends on the individual reviewer.
Ideally, all incidents would be fed back and reflected on in prescriber portfolios. Researchers at the University of Exeter have developed a toolkit and self-assessment framework for optimising feedback conversations and this is something we are keen to progress with support from educational supervisors. Other interventions have focused on pharmacist buddies who can have regular catch ups with prescribers to discuss individual incidents in a supportive way.
There are a variety of options available to raise awareness of prescribing errors. Although evidence for these is limited, it would seem sensible to use a variety of approaches to appeal to a range of staff, different learning styles and communication preferences.
The benefits of these approaches are difficult to quantify. Pharmacy is a key stakeholder in this but the support of other professionals to increase engagement is also essential. Colleagues are encouraged to consider the effectiveness of methods used within their own organisations and how sharing learning from medication incidents could be further improved.
- Ciapponi et al. Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews; 2021; (11), pp. CD009985.
- Hayman S et al. Learning from medication errors: The ‘bulletin’ as a communication tool. International Journal of Pharmacy Practice. Conference: Royal Pharmaceutical Society Conference 2011. 19(SUPPL. 2) (pp 65).
- Flaherty B et al. Evaluation of a daily pre-round huddle to improve knowledge of safety and QI projects. Critical Care Medicine. Conference: 50th Critical Care Congress. 2021; 49(1 SUPPL 1) (pp 560).
Thanks to Kathryn Aylward, Librarian, for her assistance with the literature search.
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.