Medication errors

Better leadership and engagement key to improving error reporting, study finds

An international project funded by the Qatar National Research Fund has explored medication error reporting to better understand the problem and suggest measures for improving error reporting.

aerial view of Doha capital city of Gulf state Qatar


Findings were presented at the 4th Qatar International Pharmacy Conference in Doha, Qatar

Positive leadership and increased engagement are key to improving medication error reporting across the world, a study has found.

The two-year, international project, funded by the Qatar National Research Fund, explored aspects of medication error reporting from the perspectives of healthcare professionals and those in positions of power and influence.

The research was conducted in three phases. First the researchers explored aspects of safety culture among health professionals, including concerns over non-punitive responses to medication errors and levels of staff during evenings and weekends.

Then the team focused on the barriers that existed against healthcare workers reporting errors and found that one of the key barriers related to emotional factors, for example, some workers would consider the impact of reporting on career progression and professional reputation.

Finally, the team interviewed decision-makers in the areas of policy, healthcare practice and education to gather their thoughts on the outcomes of the first two phases of the study.

Understanding the issues

Derek Stewart, who presented the findings at the 4th Qatar International Pharmacy in Doha, explained that splitting the research into three parts enabled the team to understand the feelings of individuals working with medication every day as well as discussing measures with those in power.

“Concerns around medication error and safety are common worldwide and it is not only important to understand why but to discover what those working in and around healthcare believe will improve matters,” he said.

“While this two-year study has uncovered some enlightening results, which we believe a lot of good can come from, we are now planning a follow-up study to examine the situation in even greater detail.”

Sarah Slight, a reader in pharmacy practice at Newcastle University and associate editor for the Journal of Patient Safety, said health information technologies were important to consider when it came to reducing medication errors.

“There are different types of errors, and it is important to put electronic systems in place to help identify and prevent these errors from occurring,” she said.

New NHS reporting system

Also looking at ways to improve error reporting, the Community Pharmacy Patient Safety Group, which is made up of community pharmacy medication safety officers across the sector, is helping to test and design a new reporting and learning system for the NHS as part of the .

Over the next three years NHS Improvement is working closely with stakeholders to provide resources to support safety improvement by way of the DPSIMS project.

The new system will succeed the current National Reporting and Learning System (NRLS), which NHS Improvement says is more than 13 years old and due for an upgrade.

It will aim to meet both local and national needs in terms of accessibility to both staff and patients/carers; integrate with other systems; strike a balance of confidentiality and transparency; and support an open and honest NHS culture devoted to continuous learning and improvement of patient safety.

Anyone interested in informing the development of this project can take part in a  which is open until the end of January 2018.

Citation: The Salvadore DOI: 10.1211/PJ.2017.20204118

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