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Practice Repository

Reducing medication errors – a tripartite approach. Small steps – better outcomes

Abertawe Bro Morgannwg University Health Board, Morriston Hospital ·

Summary

Summary of the example

This is a practical demonstration of team working where like-minded individuals from three disciplines formed a Tripartite alliance to reduce medication errors.  Working together has demonstrated palpable change and through a PDSA cycle we have implemented changes in a step wise fashion. Having done this we have demonstrated reduction in medication errors within our department.

The team shared a common purpose and nurtured a vision for change. This change was achieved without any added costs and proves the point that to achieve effective change human performance has to be altered. Our alliance has enabled a change in the department and also propelled the creation of a regional network to share good practice. This alliance has resulted in three successful study days with a theme of reducing medication errors in children. The most recent study day was attended by 80 people spread across the three disciplines of medicine, pharmacy and nursing from across South Wales. We continue to be inspired with this success and consolidate our ethos of working together to improve standards and reduce medication errors in children.

Why we think it’s important

The education package through the tripartite approach has achieved a substantial change in the overall rate of prescription errors in children and young people.

Small steps can bring measurable change provided staff are continually motivated to improve patient outcomes. The co-productive approach brought together professionals from three areas to work, share ideas and arrive at common goals.

We continue to promote education and awareness of decreasing medication errors as key aspects of improving patient safety. Our second study day had over 35 participants from medicine, nursing and pharmacy working towards minimising medication errors. This helps the overall aim of patient safety of avoiding unintended or unexpected harm to children.

 Following on from our second study day, we had expressions of interest in our project and participants were inspired to introduce this in their areas.

Measurable change was achieved with innovative educational packages. This project and tripartite alliance embodies the key principles of prudent health care to minimise harm to patients and usage of innovative educational interventions.

Learn more about the example

Aims and objectives of the work

Paediatric medication errors have everyday potential to cause unintended harm1.

Our aim was to reduce paediatric medication errors on a busy general paediatric medical ward.

Methodology

A prospective audit in 2016 looked at the number and severity of medication errors. The severity of the errors was graded as per the EQUIP study2.

A study afternoon was arranged to highlight the common themes followed by a multidisciplinary brainstorming exercise to gather suggestions on reducing medication errors.

An education package was introduced:

  • Medical – all trainees completed a mandatory online module designed by the Royal College of Paediatrics and Child Health, which provides an overview of safe prescription practice in children and common themes leading to errors. Further teaching was provided in departmental meetings and the lead paediatric pharmacist undertook  an hour-long targeted teaching during induction of new starters.
  • Nursing – All staff were encouraged to complete an in house competency package based around the  ‘5 rights’ (Right Drug, Right Dose, Right Time, Right Route, and Right Patient), the Health Board controlled drug policy and the All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal. Through one on one sessions, lasting approximately 15 minutes with the practice development nurse, staff were coached to follow the ‘five Rs’ and completed two competency forms with a peer during preparation and administration of a prescribed medication, one of which was a controlled drug.  The lead pharmacist provides an hour-long teaching session on a monthly ‘Paediatric Skills’ study day raising awareness of medication errors.
  • Pharmacy – An education tool called Druggle3  was introduced where, at the end of the daily safety huddle, the pharmacist spends 15 – 30 minutes discussing medication interventions that may have happened on the ward. Through this tool formative education was provided to junior doctors and nurses.

Re-audit – After six months of intensive education, a prospective re-audit was undertaken.

Key findings

The results showed that 88.6% (141/159) of children admitted had medication errors. 61.2% (87/141) of errors were minor, 34.7% (49/141) significant, 2.8% (4/141) serious and 1.3% (1/141) potentially lethal.

The results of the re-audit showed that 12.1% (57/470) of children had medication errors. 77.2% (44/57) of errors were minor and 22.8% (13/57) significant. There were no serious or potentially lethal errors reported.

This showed an overall reduction of 76.5% medication errors in the children admitted following the introduction of the education package.

The education package through the tripartite approach has achieved a substantial change in the overall rate of prescription errors. We believe medication errors are a significant but preventable cause of harm to children and young people .To ensure this change of practice is sustained we aim to continue the emphasis of  education and change management to improve patient safety.

Medication errors are constantly monitored and we encourage a culture of openness, where staff have been able to ‘self-report’ incidents. Due to close links with the tripartite team, if any trends in errors are noted, these are highlighted by the lead pharmacist and targeted ward teaching arranged accordingly. The ward teaching takes approximately 10 hours over 2 weeks.

Background

National guidance, data and publications

  1. Cass H. Reducing paediatric medication error through quality improvement networks; where evidence meets pragmatism. Arch Dis Child, 2016;101:414-416.
  2. EQUIP final report. http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf
  3. DRUG-gle (Druggle). http://www.medsiq.org/tool/drug-gle-druggle