Creating safe and resilient prescribing systems Hereford Hospitals NHS Trust

A team at Hereford Hospitals NHS Trust worked with a team at Warwick University on a project to reduce medication errors by making prescribing systems safer and more reliable for emergency medical patients.

Following an assessment of areas where systems were failing, the project focused on: poor information flow; lack of training and procedural support; and an absence of feedback concerning prescribing errors.

The team tested interventions, including:

• pharmacist support during ward rounds
• redesigning pharmacy training for junior doctors
• using ‘antibiotic crib cards’.

The percentage of prescription items not requiring an intervention by the pharmacist increased from 79% in November 2008 to 87% in April 2010.

Learning points from phase one

• Focusing on ‘reliability’ was more positive than ‘error’ and invoked less of a blame culture.
• Taking a system-focused approach helped everyone understand how system weaknesses can increase the risk associated with human factors such as tiredness.
• Proactive methods of dealing with risk were powerful. The team now focus on identifying factors that contributed to the error.
• Existing incident reporting systems were of limited use. Using only numeric indices to indicate safety was limiting – narratives and qualitative information were needed as well.
• There remained a frustration with the wider system, for example, when obtaining a medical history, junior doctors knew what they should be doing but the system didn’t allow them to do it.
• The process empowered staff. Attitudes changed from ‘that’s the way it is, nothing will change’ to a feeling of much greater control.