UK medicines information
Tackling medication errors: learning from our mistakes
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.
|
