Medication errors

Question 1

Where do medication errors occur?

Answer 1

1. Care homes
2. Primary care
3. Secondary care

Question 2

Why do medication errrors occur?

Answer 2

1. Administration
2. Prescribing
3. Dispensing
4. Monitoring
5. Transitioning between medicines

Question 3

NHS patient safety strategy

Answer 3

1. Insight
2. Involvement
3. Improvement

Question 4

Insight

Answer 4

• Measurement
• Incident response
• Medical examiners
• Alerts
• Litigation

Question 5

Involvement

Answer 5

• Patient safety partners
• Curriculum and training
• Specialists
• Safety II

Question 6

Improvement

Answer 6

Improvement programmes to enable effective and sustainable change in the most important areas

Question 7

Reactive approach

Answer 7

• After the event
• Report/record incidents/patient safety events
• MHRA – Yellow Card reporting

Question 8

Reporting incidents - HCP

Answer 8

• Record on their local risk management systems (LRMS).
• LFSE is a new approach being trialled.

Question 9

LFSE

Answer 9

• Learn from patient safety events
• Central service for recording and analysis of patient safety events that occur.
• In the final stages of development

Question 10

Root cause analysis (RCA)

Answer 10

• Evidence-based, structured investigation
• Identify cause of incident, and actions needed to prevent it happening again.
• Understand what, why and how a system failed

Question 11

RCA process

Answer 11

1. Identify incident
2. Gather information & map incident
3. Identify care & service delivery problems
4. Analyse problems & identify CFs and RCs
5. Generate solutions & recommendations
6. Implement solutions
7. Write the report

Question 12

Disadvantages of RCA

Answer 12

• Simplistic
• Typically completed with very limited resources and time frame.
• Does it take a systems approach?