PATIENT SAFETY
Standardising medication systems
PaulO’Hanlon,managing director,OmnicellUK & Ireland,warns that a standardisedmedication system is urgently required in hospitals in order to improve patient safety.
With 237 million medication errors occurring each year and more than 22,000 deaths linked to errors, the message is out there loud and clear – something needs to be done.1 Behind these startling statistics is someone’s life – a son, father or someone’s daughter. And while there is no one magic fix to reduce medication errors, so much more can be done. This is why we all need to continue to work together and speak openly in order to find a way to reduce the risks of mistakes being made, and to learn from them for the future. Recently, a health summit was held in
Westminster hosting attendees from NHS Trusts and patient groups from across the UK to discuss ways in which healthcare professionals could embrace a range of initiatives to reduce medication errors. The summit was chaired by Andrea Jenkyns, MP and Chair of the All Party Parliamentary Group for Patient Safety. The summit heard that errors are cutting across multiple sectors and clinical professions and come at a cost to patients and to the NHS. It’s a global problem and one that the World Health Organization (WHO) has recognised – calling for medication errors to be cut by 50% in the next five years.2
Andrea Jenkyns MP, Yinglen Butt, Steve Tomlin and Paul O’Hanlon
This has prompted the Department of Health and Social Care to commission its own research and its review, ‘Prevalence and Economic Burden of Medication Errors in the NHS’ was accompanied by a report outlining an implementation plan to tackle the issue. The key priorities identified were employing new technology, improving transparency and fostering a culture of learning rather than blame.
The scale and impact in secondary care
Areas of discussion at the health summit included moving towards ‘closed loop prescribing and administration’ where automation and software is integrated within hospitals to ensure the right patient is administered the right dose of the right drug at the right time. Another important
Medical professionals transfer and rota to different hospitals and in each setting, often different medication systems are used. This
can be complicated and confusing for staff. Steve Tomlin, chief pharmacist at Great Ormond Street Hospital
AUGUST 2019
area of focus was around safe staffing levels and learnings from mistakes. Yinglen Butt, associate director of quality and regulation at the Royal College of Nursing, gave a passionate speech outlining the impact of medication errors on the nursing profession. Approximately 40% of nurses’ clinical time is spent on administering medications, translating to 12 to 16 hours in any given working week. Yinglen commented: “The workforce impact of these medication errors is monumental, including psychological trauma, loss of confidence, disciplinary action and in a few extreme cases, even suicide. “Nurses are the ‘second victims’ of these tragedies. Yet to even contemplate moving forward and adopting learnings, there needs to be a cultural shift and change to improve the reporting of medication errors without fear of repercussions.”
There was consensus among those in the room that the NHS needs to get better at sharing best practice and the need to adopt a ‘one system approach’. Steve Tomlin, chief pharmacist at Great Ormond Street Hospital, discussed how the National Health Service needed to be more ‘national’ by reducing variation and standardising systems to drive patient safety forward. He explained that embracing
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