Medication Safety Practice & Human Factors

Medication Error

any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer

Pharmacy Order 2022

In regards to preparation and dispensing errors - hospital and other pharmacy services

• removes the threat of criminal penalties of inadvertent prep and dispensing errors

• include pharmacy staff, care home staff and some integrated care board staff (ICBs)

Examples of types of medication errors

• none - wrong medication dispensed but identified before admistration

• low/minimal harm - nephrotoxic medication not withheld following AKI requiring postponing discharge

• moderate - significant haemorrhage following lack of APTT monitoring with IV heparin infusion resulting in HDU admission

• severe harm - Gentamicin otoxicity following incorrect dose calculation and overdose

• catastrophic harm - Death due to anaphylaxis following administration of flucloxacillin to a patient with documented penicillin allergy

Never Event

• Serious Incidents that are “wholly preventable” because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers

5 Main Never Events

• Administration of medication by the wrong route

• Overdose of insulin due to abbreviations or incorrect device

• Overdose of methotrexate for non cancer treatment

• Mis-selection of strong potassium solution

• Mis-selection of high strength midazolam during conscious sedation

Duty of Candour

• established in 2015

• legal requirement

• if care provided has or may have contributed to unexpected or unintended moderate or severe harm or death

• any errors need to be shared with the service users

• must provide an apology for the error

Purpose of Patients Safety Strategies

maximises the things that go right and minimise the things that go wrong

Patient Safety INcidence Response Framework

• Compassionate engagement and involvement of those affected by patient safety incidents

• Application of a range of system-based approaches to learning form patient safety incidents

• Considered and proportionate responses to patient safety incidents

• Supportive oversight focused on strengthening response system functioning and improvement

Incidence reporting

• High reporting culture is a safe, open, honest, learning culture.

• Organisations should adopt a positive, open, and fair approach to incident investigation, based upon improvement through learning rather than punishment, where all staff will feel safe to report incidents and safety issues.

• All unexpected or unintended events or near misses are classified as incidents and should be reported.

• Any staff member involved in or who has witnessed or identified an incident involving patients, staff or others is responsible for ensuring an incident form is completed.

Issue with blame

• It allows the cause of errors to be boiled down to individual competence and asserts that the problem is the individual

• a patient safety incident cannot simply be linked to the actions of the individual.

• All incidents are also linked to the system in which the individuals were working.

• Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring.

System approach to the cause of error

Systems approach

• Poor organisational design sets people up to fail

• Focus on the system rather than the individual

• Change the system = improve safety

• considers all relevant factors ad design systems and strategies that maximise the frequency of things going right

Human factors

all factors that can influence people and their behaviour.

In a work context, human factors are the environmental, organisational and job factors and individual characteristics which influence behaviour at work.

Dirty dozen of human factors

1. Lack of communication

2. Complacency

3. Lack of knowledge

4. Distraction

5. Lack of teamwork

6. Fatigue

7. Lack of resources

8. Pressure

9. Lack of assertiveness

10. Stress

11. Lack of awareness

12. Norms - filling the gaps

A Systems Approach

• Review the organisation

  • Are processes simple and standardised?

  • Are failure identification and mitigation systems in place?

• Task analysis

  • How many interruptions are there during the working shift?

  • How complex are the tasks or instructions?

• Human factors audits

  • Noise levels, distractions, design of workspace, label format, work hours

• Train staff in human factors awareness

WHO human factor approaches

1. Avoid reliance on memory

   • e.g. sepsis screening tools

2. Make things visible

   • signs

3. Review and simplify processes

4. Standardise common processes and procedures

5. Routinely use checklists

6. Decrease the reliance on vigilance

SEIPS Framework

System Engineering Initiative for Patient Safety

• SEIPS is a framework for understanding outcomes within complex socio-technical systems

• acknowledges that work systems and processes constantly adapt

• can be used as a general problem-solving tool (eg to guide how we learn and improve following a patient safety incident, to conduct a horizon scan, and to inform system design).