BSc(Hons) MSSc MPSNI
Medicines Governance Pharmacist
Royal Victoria Hospital
The Audit Commission’s report A Spoonful of Sugar – medicines management in NHS hospitals suggested that nearly 1,100 people die annually in England and Wales alone as a result of medication errors or adverse reactions.(1)
In 2000, the UK Department of Health publication An Organisation with a Memory recommended that action be taken to address specific categories of recurring adverse events, including the stipulation that by 2005 the number of serious errors in the use of prescribed medicines should be reduced by 40%.(2)
In Northern Ireland, there was very little baseline data available on which to judge this reduction. With this in mind, the Department of Health, Social Services and Public Safety (DHSSPS) made funding available to finance a hospital- based medication safety initiative, the Northern Ireland Medicines Governance Project, for a two-year period, starting in August 2002.
The team consists of six senior pharmacists, each located in one of six large acute hospitals. Each pharmacist has additional responsibility for the other hospitals in their vicinity, ensuring that all 18 of Northern Ireland’s hospitals are involved in the project. The work is multidisciplinary, involving close liaison with the hospitals’ risk management, medical, nursing and pharmacy staff.
A multidisciplinary DHSSPS project steering group, consisting of representatives from the Chief Medical, Nursing and Pharmaceutical Officers departments, the Northern Ireland Risk Managers Forum, medical consultants, directors of pharmacy and a patient representative, provides project facilitation and guidance. Figure 1 shows the general structure of the project and its lines of communication.
Our objective is to minimise medication-related risk in the project hospitals by:
- Addressing the underreporting of medication incidents.
- Developing a coding system for managing medication incident data.
- Promoting near-miss reporting.
- Identifying learning points from medication incident reports received.
- Proactively identifying medication-related risk.
- Developing and implementing regional best practice policies for safe medication use.
- Ensuring the wide dissemination of medication safety lessons.
The gross underreporting of incidents was the first problem to be addressed. It quickly became apparent that we needed to discover and understand the reasons for this underreporting in hospitals in Northern Ireland. As a result, a questionnaire was developed to investigate the prevailing reporting culture. Based on an American model,(3) the questionnaire was distributed to approximately 14,000 staff in 12 of the project hospitals. Key barriers to reporting were found to include “a fear of disciplinary action” and “a lack of awareness of what constituted a medication incident”.
These and other barriers were discussed in a series of educational presentations to medical, nursing and pharmacy staff, aimed at promoting the open reporting of medication incidents and explaining the importance of near-miss reporting in ensuring patient safety.
This approach has resulted in a ninefold increase in the number of medication incident reports received since the commencement of the project (see Figure 2). The level of near-miss reporting has also risen, from approximately 5% of reports before the project to 92.5% in the second quarter of 2004.
Before August 2002, medication incidents were being coded in such a way as to prevent further analysis of the data. To ensure consistent regional coding, we have prepared and tested a standardised coding system that includes the stage of the medication use process, the incident type and a severity grade. By working in collaboration with the hospitals’ risk management staff, the coding system has been incorporated into hospital incident data collection systems, and we are now able to identify medication incident trends both in individual hospitals and also at a regional level.
Initially, consistent grading of an incident’s potential severity proved challenging, even within the team. Once this was resolved, we realised that consistency would be an issue for other staff asked to code medication incidents, and a tool to guide the assignment of potential severity ratings is currently in development.(4)
Best practice development
Ongoing incident trend analysis, made possible by the consistent medication incident coding, has led to the development and regional distribution of six safety memos and four best practice policies, as well as many individual trust-specific initiatives. This approach to identifying and addressing areas of medication risk has resulted in the regional implementation of the developed safety solutions.
Safety memos give guidance on medication safety issues that can often be addressed in unidisciplinary fashion by pharmacy staff. To date, topics have included:
- Pneumococcal immunisation.
- Labelling of vancomycin injection.
- Strength of dexamethasone injection.
- Administration of intravenous phenytoin injection.
- Changes to approved medication names.
- Enoxaparin in patients with severe renal impairment.
Policies are used to address larger multidisciplinary medication safety issues and are developed following failure, mode and effect analysis, literature searches and multidisciplinary consultation. To date, our policies have addressed:
- The prescribing and supply of warfarin.
- The use of oral methotrexate.
- The documentation of allergy status.
- The use of oral syringes.
Medication safety education
Since the commencement of the project, the team have participated in over 1,100 educational meetings with various professional groups, providing the opportunity to raise medication safety awareness and promote the team’s work. These meetings have included trust staff induction programs, audit meetings, formal lectures, workshop sessions and lectures for undergraduate professionals in universities.
We also produce a quarterly newsletter, Medication Safety Today, issued electronically and in hard copy to clinical staff at the project hospitals. The newsletter aims to raise the profile of medication safety and provide practical information on avoiding common medication incidents.
A project website allows healthcare staff access to the safety memos, policies, newsletters and other related information produced by the project (see Resources), both inside and outside Northern Ireland.
As the Northern Ireland Medicines Governance Project was originally funded for a two-year period, it was due to finish on 31 July 2004. However, in March 2004, the DHSSPS announced that it was making the funding for the project permanent and recurring, ensuring that this practical hospital medication safety initiative can continue.
- Audit Commission. A spoonful of sugar – medicines management in NHS hospitals. London: Audit Commission; 2001.
- Department of Health. An organisation with a memory. Report of an expert group on learning from adverse events in the NHS. London: DH; 2000.
- Bussone K, Belknap S. Leading a strategic planning effort from the American Hospital Association, Health Research and Educational Trust, and the Institute for Safe Medication Practices, 2002 attachment 1.A4. (W:www.hospitalconnect.com/medpathways/tools/strategic.html)
- News report. Rating medication incidents. Pharm J 2004;273:9.
National Patient Safety Agency
Northern Ireland Medicines Governance Project
National Coordinating Council for Medication Error Reporting and Prevention