delivering a healthy wa minimising medication errors: a new approach to medication safety watag...
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Delivering a Healthy WA
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)
Delivering a Healthy WA
• 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
An opportunity for a new approach……
Delivering a Healthy WA
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 errorsLook for ways to influence nursing behaviours / interprofessional culture to minimise risk / maximise medication safety
Delivering a Healthy WA
The Minimising Medication Errors SDLP
• 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
Promote awareness of 5 risk areas:
The prescriptionThe processThe patient The peopleThe place
Delivering a Healthy WA
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!
Delivering a Healthy WA
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.