• Team at Hereford Hospitals NHS Trust worked with a technical support team from Warwick University.
  • Project focused on making prescribing systems safer for emergency medical patients.
  • The team tested interventions including pharmacist support during ward rounds, redesigning pharmacy induction training for junior doctors and using ‘antibiotic crib cards’.
  • Ran from October 2008 until the end of 2013.

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.

Further reading

Research report

Safer Clinical Systems: Evaluation findings

December 2014

Lessons from the second phase of the Safer Clinical Systems programme.

About this programme


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