Improving the quality of medication error reports and improving the learning from such reports are the twin aims of a 2014 Patient Safety Alert in England and Wales
Christine Clark PhD FRPharmS FCPP(Hon)
As the old saying goes, “you can take a horse to water but you can’t always make it drink”. Similarly, establishing a framework for reporting of, and learning from, medication safety incidents does not, on its own, guarantee that reports of appropriate quality will be submitted or that organisational learning (changes in behaviour) will occur as a result.
The National Reporting and Learning System (NRLS) is a central database for patient safety incidents, including medication safety incidents. As such, it is a valuable resource that can help to identify emerging safety issues and trends that might be dismissed as isolated incidents at the local level. In turn, this can be used to inform the development of safer systems. However, as with any computerised database, this depends very much on the quality of reports received. An analysis of more than 12,000 reports received in March 2013 showed that almost one third of reports failed to record the name of the medicine in question, together with many other coding errors and omitted information. It had also become apparent that incident reports were not always reviewed locally by people with the expertise to check quality and take action if necessary. Finally, it seemed that in some organisations, senior managers were not always aware of important patient safety issues or the quality of reporting and learning systems. This matters because an estimated 2500 deaths are due to medicines each year, about 7% of hospital admissions are due to medication and nearly 100,000 patients admitted to acute hospitals suffer harm due to medications; clearly, a case for treatment.
Against this background, healthcare organisations were instructed to introduce several key measures. Central to the strategy is the appointment of Medication Safety Officers (MSOs) who will promote the safe use of medicines and be the main experts in this area. The MSO should also serve as the essential link for the identification and implementation of (local and national) medication safety initiatives. In addition, local multidisciplinary committees should be established to take action to improve medication safety and review local incident reports. Lastly, to ensure that medication safety has a high profile in the organisation, a board level director with responsibility for overseeing the process has to be nominated.
More than 350 MSOs have been appointed, and many of them are pharmacists. Their appointment in this role represents both recognition of their expertise and an opportunity to help to give medication safety the prominence that it deserves. They will be helped greatly by new ways of handling data. One such development is the NHS Medication Safety Thermometer (www.safetythermometer.nhs.uk/), which provides a dashboard display to show at a glance how an organisation is performing. However, it should not be forgotten that medication safety is not only about high-quality reporting of incidents but also about learning – that is, changing products, systems and behaviour – to improve the safe and effective use of medicines.
For all those pharmacists who have struggled to raise the profile of medication safety, this initiative is a huge helping hand.