Zero harm

We all need to be concerned about safety all of the time. We also need to be constantly aware of the potential for harm and learn from our experiences. It is our responsibility to ensure the safety of all our patients, families and staff. Zero harm is achievable if we want it. Here the Medicines Management Improvement Programme is described.

In healthcare, 97 per cent of all hospital patients receive medicines. The prescribing, preparation and administration of medicines requires focused concentration from the individuals involved and whilst there may be guidelines or policies in place to ensure safe practice, there are many stages in these processes where errors may occur or where safeguards are not in place. Adverse Drug Events (ADEs) cause mild to severe discomfort for patients and occur in 19 per cent of hospital inpatients, with more than half of ADEs being preventable.

In paediatrics, prescribing error rates have been estimated at 3 – 37 per cent and poor communication is estimated to generate up to half of all medication errors. On commencement of improvement work to reduce medication errors at GOSH, the Patient Safety First campaign in England was underway, and informed us of areas for focus, including high risk medicines.

The Medicines Management Improvement Programme aims to develop reliable systems and processes to prevent harm to children from medication errors and adverse drug events. It has two high-level aspirations:

1. High risk medicines: reduce errors with high risk medicines by 100 per cent – that is, to zero

2. All other medicines: reduce errors with all medicines by 25 per cent every year

Three high risk areas were identified to start improvement work:

1. Haematology & Oncology wards

2. Cardiac Intensive Care Unit (CICU)

3. Paediatric Intensive Care Unit (PICU)

• Individual feedback – pharmacists give explicit feedback to doctors whenever they identify their prescribing errors

• Group feedback – pharmacists regularly feedback collective prescribing error themes to group of doctors and discuss lessons learned

• Supported prescribing – doctors new to the unit will be supported in their prescribing, and undertake training and testing

On the Paediatric Intensive Care Unit, the introduction of a dedicated prescribing area fully equipped with everything needed to prescribe, a formulary, standardisation of doses, elimination of interruptions during prescribing, and immediate feedback of errors resulted in a marked decrease in medication prescribing error. Zero tolerance was introduced to ensure the bundle was implemented reliably. This has been published in the Intensive Care Medicine Journal. A similar programme was successful in CICU.

This page was last updated on 17 June 2013