Transcript Minimising Medication Errors- A New Direction in Learning [PDF

Minimising Medication Errors:
A new approach to medication safety
WATAG Seminar
Nick May
Staff Development Educator
Royal Perth Hospital
September 2013
Delivering a Healthy WA
New National Accreditation Standards
Medication Safety is
now a stand-alone
National Accreditation
Standard (Standard 4)
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An opportunity for a new
approach……
• Have we been designing resources to fix
the wrong problem?
• Goal: - Review education packages to
minimise medication errors
• Look for ways to influence nursing
behaviours / interprofessional culture to
maximise medication safety
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Office of Safety and Quality in Healthcare
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How many clinical incidents are reported in
WA in a year?
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Types of medication Incidents
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Top 10 Medications involved in incidents
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Why did the error occur?
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Critical question:
Have we been designing resources to fix
the wrong problem?
Goal: - Redesign education to address
factors most likely to result in medication
errors
Look for ways to influence nursing
behaviours / interprofessional culture to
minimise risk / maximise medication safety
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The Minimising Medication Errors SDLP
Promote awareness of 5
risk areas:
The prescription
The process
The patient
The people
The place
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• Promote environmental
awareness and reflective
practice
• Promote the role of the
Clinical Pharmacist
• Promote high standards
of collaborative practice
• Encourage
interprofessional use of
the NPS E-Learning
NPS E-Learning
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Other parallel strategies
• S.W.E.E.T.
• ‘Above and Below the Line’ – managing
behavioural risks collectively
• The Sweetest Ward Award
• Medication Safety Group
• Ward Initiatives / Divisional Initiatives
• And hopefully many more!
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Take home messages:
• Simply knowing is not the answer.
• If, as an organisation we are really serious about
reducing medication errors, we need to identify
and isolate actual behaviours that cause
medication errors and one by one, work
collectively and methodically to eliminate them
from the workplace.
Delivering a Healthy WA