Context Two paediatric intensive care units within the same trust.
Problem Medication errors are a common, avoidable, occurrence, with significant associated morbidity and mortality. The aim of this project was to define the extent of the problem in our units and institute measures to reduce it.
Assessment of problem and analysis of its causes An anonymous audit was performed, which found numerous medication errors, with significant underreporting of errors occurring.
It was felt that the busy nature of the units contributed to the error rate, as staff were often unable to prescribe or administer medicines without interruption, leading to mistakes. There also seemed to be a general culture discouraging incident reporting, as staff felt that they were a tool for blame, with no benefit seen in completing them.
These findings highlighted the need for a culture change, from a ‘blame culture’ to one of ‘fair accountability’, with incident reporting seen as a tool for change, and staff given feedback on its positive outcomes. Staff also needed to treat medicine safety as a priority, with time, space and resources dedicated to empowering staff to say no to interruptions during prescribing and administration.
Intervention A dedicated prescribing area was set up, equipped with drug monographs, a BNF, a calculator and headphones to block out extraneous noise. A prescribing guideline was developed, instructing prescribers to use the dedicated area to write prescriptions without interruption. The guideline also instructed nurses to wear special aprons while preparing and administering medicines, protecting them from interruption.
Strategy for change Junior doctor and nursing involvement was a necessity in implementing this change, as they did the majority of the prescribing and administering. “Safety Champions” at each site were tasked with disseminating information, promoting good prescribing and administration habits and leading on-going audits.
Plans were disseminated to staff by email, in clinical practice meetings and through a poster campaign, including messages empowering staff to say no to interruptions.
Staff were also encouraged to report any errors with the promise that incident reports were solely to be used to highlight systematic issues, and that staff would receive feedback on the outcomes of an incident form.
Measurement of improvement Monthly audits of medication errors were carried out, assessing the number and type of errors occurring, and comparing this to the number of electronic incident reports completed.
Effects of changes The audits showed an increase in the proportion of medication errors reported electronically, with an emphasis placed on blame-free reporting, and positive results obtained from resulting investigations, such as highlighting areas in which extra checks may be useful.
However, despite some improvement, underreporting of errors still continues. Staff have been empowered to prescribe and administer medications without interruption, but it remains difficult to accurately measure the effect of this intervention without a reliable screening and reporting method. The monthly audit process has resulted in fatigue from nursing staff, resulting in unreliable reporting, and therefore its usefulness has become limited - a new approach is currently being planned.
Lessons learnt Junior doctor and nursing involvement in attempting to create a medication safety culture has resulted in greater engagement with the process, highlighting the importance of involving all relevant stakeholders in a change project. However, ongoing projects can result in staff fatigue, so methods need to be considered to maintain momentum.
Message for others Incident reporting can be improved through a targeted programme including appropriate feedback and a ‘no blame’ approach. Successfully implementing this kind of culture change requires a multidisciplinary approach and trainee involvement.
Medication incidents are often related to distraction, but assessing the effect of a project to reduce interruptions requires a reliable method of measuring outcomes.
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