bringing&together&medica/on&safety,&human& factors&and ... · dr yogini...
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Bringing&together&Medica/on&Safety,&Human&Factors&and&Improvement&Science&to&achieve&
“medica/on&without&harm”
Dr#Yogini#Jani#Director#Centre#for#Medicines#Op5misa5on#Research#&#Educa5on#
Consultant#Pharmacist#&#Health#Founda5on#Improvement#Science#Fellow,##
London#UK#
#
Dr Yogini Jani Consultant Pharmacist & Health Foundation Improvement Science Fellow, Director CMORE
Medication without harm: WHO’s 3rd Global Patient Safety Challenge
ISoP, 18th Annual General Meeting, November 2018, Geneva
Similar sounding names: risky or not? Yogini Jani
Patient involvement in adverse drug reaction detection & reporting
Rakhi Karwa & Merci Maina Medication without harm: is there a role for improvement science?
Yogini Jani, Rakhi Karwa & Merci Maina
RISKY OR NOT?
Similar sounding names in medications safety:
https://www.mentimeter.com/s/b1a3a38dbf2d6bfc64e7ab506caba15c/37505b527b2c
Go to www.menti.com and use the code 81 27 99
Human Factors
People and their behaviour
! environmental
! organisational and job factors
! individual characteristics
Human Factors
• mental workload
• distractions
• the physical environment
• physical demands
• device/product design
• teamwork
• process design
https://journals.sagepub.com/doi/pdf/10.1518/001872006776412199
….to “develop, establish and promote international standards with respect to biological, pharmaceutical and similar products.”
Similar sounding names…. Beneficial?
• to ascertain if there was an association between medication suffixes and pharmacological function amongst different health professions
• to determine if there was an association between level of experience and ability to match a medication suffix to pharmacological function
Method
• Acute care hospital organization • Specialist service
• Series of real & fictitious drugs • Confounder drugs included
Vigilomycin is a…..
Go to www.menti.com and use the code 81 27 99
Example
Match Mismatch
Atorvastatin was prescribed for her respiratory infection Clarithromycin was prescribed for her respiratory infection Cymbastatin was prescribed for her respiratory infection Neflecthromycin was prescribed for her respiratory infection
Please identify if these statements contain a correct match of medicine with condition or a mismatch:
Confounder Fictional drug Correct Fictional drug
Correct
Confounder
Results
Profession Number Ward-based staff 72
Pharmacy 26 Nursing 36
Medicine 10 Specialist pharmacy teams 102
R2 = 1 " 100% of the data’s variability can be accounted for.
Top 4 best answered questions
Statement Correct answer
% correct (ward based)
% correct (specialist)
Cymbastatin was prescribed for her respiratory infection
Mismatch 100 98 Levothyroxine was prescribed for her thyroid problems
Match 97 100 Minocillin was prescribed for the angina that the patient developed
Mismatch 96.5 100 Salmeterol was suggested for her asthma problems Match 100 100
Bottom 4 best answered questions
Statement Correct answer
% correct (ward based)
% correct (specialist)
Fluxicam was prescribed to reduce the swelling of her ankle.
Match 32.4 58 Delroxacin was given for his stomach infection as he couldn’t go to work.
Match 44.4 63.8 Meloxicam was prescribed to reduce the swelling of her ankle.
Match 48.5 72 Tenoxicam was given for arthritis, to make her feel better.
Match 50 95.6
….to “develop, establish and promote international standards with respect to biological, pharmaceutical and similar products.”
Preventable adverse drug events: causes and contributory factors
Clarity & Legibility Abbreviations
! Units and micrograms Calculations Knowledge
! Patient specific
! Drug specific Handovers/ communication
! Intra and inter care settings
US$42 billion
Causes ! Weak systems ! Human factors
4 areas • Patients and public • Medicines • Healthcare professionals • Systems and practices
https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf