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PJ Online | Tackling medication errors: learning from our mistakes

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The Pharmaceutical Journal
Vol 269 No 7220 p579
19 October 2002

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Meetings and Conferences

UK medicines information

Tackling medication errors: learning from our mistakes

UK Medicines Information - summary

Peter Golightly, chairman UK Medicines Information (UKMi) pharmacists group, updated participants on progress being made with the national competency framework for medicines information. “This is the most important strategic framework we have ever had,” he said, “and it is being actively used to help with continuing professional development, recruitment and appraisal throughout the United Kingdom.” National training days have created a number of regional facilitators, who have cascaded their skills down through the medicines information network, so that pharmacists at all levels have taken advantage of the opportunities that the competency framework opens up for reflection and the targeting of training requirements.
The competency framework has been used to inform a restructuring of the national training course for pharmacists new to medicines information. This has again been successful, and heavily over-subscribed, with more than 150 participants in the three three-day courses run in the past 12 months. It is hoped to develop an advanced training resource for more experienced medicines information pharmacists in the near future. This will again be based on the competency framework and medicines information pharmacists will have the opportunity to comment on the draft plan.
Mr Golightly also revealed that next year, UKMi will produce a training workbook for all hospital-based preregistration trainees and basic grade pharmacists. This will form an integral part of CPD for these junior grades and will help local medicines information pharmacists to deliver a consistently high quality of training throughout the UK. The first national training course for medicines information technicians has also been run. This accredited course currently involves 24 technicians.
Medicines information continues to develop ever deeper links with many national organisations including the National electronic Library for Health, NHS Direct, NHS walk-in centres, the National Prescribing Centre, the Department of Health and others. In the face of many changes in the NHS, medicines information has succeeded in not only keeping pace with change but also leading or forming partnerships in many critical areas, he said. “We must continue to be aware of ‘the big picture’, grasp the opportunities afforded by NHS and IT developments, and continually look for areas of collaboration” he concluded.

Department of Health perspective
Dr Jim Smith, Chief Pharmaceutical Officer, Department of Health, congratulated UKMi in launching the new national website. “Making the best use of IT is a key Government priority,” he said “and it is good to see that MI is making very creative and impressive use of it.”
Dr Smith drew participants’ attention to two Government documents. “An organisation with a memory” confirmed that, as in most health care systems, there has been little systematic learning from adverse events and service failures in the NHS. “As a result, patients have suffered unnecessary and avoidable harm because the lessons from past experience have not been heeded,” he said. In particular, this document highlighted the fact that some specific, rare but serious adverse events occur time and time again, despite enquiries concluding that “lessons must be learned”. The recurrent spinal maladministration of vinca alkaloids is the most notable example. Too often, incident enquiries have identified lessons that are not carried through into practice.
In 2001, “Building a safer NHS for patients” set out in more detail the Government’s plans for improving patients safety, including establishment of the National Patient Safety Agency and an improved system for handling investigations and inquiries across the NHS. It stressed that repeated patterns of error are seen that need to be selectively targeted to reduce risks to patients. As a result, mandatory national guidance on intrathecal chemotherapy was issued in 2001 and has now been implemented in all NHS trusts offering this treatment.
Dr Smith offered participants the view that medication errors happen for two principal reasons: first, human error is inevitable and secondly, health care is complex. “Medication is generally safe,” he said “but serious errors happen too often, and the Government is committed to improving this.” He warned that there was no single solution and that a systematic approach was needed. We know something of the factors that cause medication errors, particularly in hospitals. But there is little robust research evidence on the effectiveness of interventions to reduce errors — careful studies are needed to evaluate, for example, possible IT solutions and how checking systems might be improved. NHS organisations need to build on clinical experience in the UK and elsewhere and on the growing research base to develop local strategies that will make medication safer for patients.


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