Medicines governance increases incident reporting
Medication incident reporting has increased ninefold in Northern Ireland's acute hospitals since a pharmacy-based medicines governance team was established.
Tracey Boyce, Northern Ireland medicines governance team leader, said
that the increased level of reporting has enabled the team to remedy
some common medicine-related problems.
For example, some patients were routinely receiving pneumococcal vaccine
twice, due to an unwitting clash of primary and secondary care policies,
and developing severe site reactions. In another example, reports of
serious adverse reactions due intravenous administration of undiluted
vancomycin led to the discovery that the package information contained
no instructions for dilution.
The medicines governance team, comprising six pharmacists and an administrator,
serves the 16 acute trusts in Northern Ireland. During the first year
of operation the team developed a reporting culture questionnaire that
was sent to more than 14,000 members of staff. One key finding was that
many staff were not reporting incidents because they did not know what
constituted an adverse medication incident, said Ms Boyce. The full results
of the survey will be published soon.
Ms Boyce, who was speaking at a European Foundation for the Advancement of Healthcare Practitioners conference on medication errors, held in
London last week, attributes much of the team’s success to “getting
out there and talking to people.” Awareness of the importance of
reporting medication incidents has been raised progressively through
the introduction of a uniform reporting system, personal contacts, safety
memos and a quarterly newsletter. Safety memos are brief, to the point
and deal with common problems that have been identified through the reporting
system.
A medication safety website has also been set up to help to share the
team’s information as widely as possible.
The National Patient Safety Agency’s incident reporting scheme
for England and Wales is due to go live in November. |
