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Junior Doctor Led and Owned Patient Safety– Medication Error Reduction in an acute tertiary neurosciences ward

Engaging the junior doctor workforce in implementing/ sustaining culture change and learning/ feedback among peers in a safe, facilitated environment.

The problem

A number of changes had been implemented in the Trust over a period of 10 years – with electronic prescribing, merger of wards, redesigned workforce, increased turnover, all having a direct impact on medication errors. Junior doctors feel that they are “picked on” when errors are fed back to them.

Aims

To identify causes of medication errors in the clinical setting. To engage junior doctor workforce in identifying, designing and implementing change. To find ways of feedback that is constructive and inclusive/non-threatening.

Making the case for change

The change focussed on a different method of feedback of errors to prescribers. Since October 2012, a 10 minute discussion of all prescribing errors reported over seven days, has been incorporated into an already existing weekly meeting of the junior doctors. As part of EQUIP project a junior doctor led on this piece of work.

 The causes of errors are analysed, and strategies for avoiding future errors are discussed as a group and the following ideas have been implemented in stages. There are six ideas that have been proposed. This discussion generates a 'message of the week' on safe prescribing, which is emailed to all the staff. Leadership for the meeting rotates between the neurology registrars, so there is group buy-in to the project; some as part of EQUIP. A top list of common errors printed and updated with laminated cards every six months. A file of commonly used medication available for doctors. A hands on induction (scenario based) at time of start and more direct supervision for the first few weeks of new doctors starting. Safe prescriber award to the junior doctor at the end of rotation.

Your improvement

The number of prescribing errors per week changed from an average 4.2% of all prescribing to 0.4% of all prescribing over a 12 month period. 

A survey and verbal feedback from junior doctors indicated that they feel less stressed and more involved in the safety culture.

Learning and next steps

Safety projects need a “culture” change in terms of acceptance. Although leadership and innovation are key, buy in and ownership of frontline staff is key in sustaining this change. A system of incorporating medication error reporting and learning in to everyday practice makes this sustainable.  This model needs sharing with other areas within the Trust and revisited periodically to study its relevance in an ever changing NHS.

Quality assurance/MHRA Registration

This project was undertaken under the Quality Safety Team at Great Ormond Street Hospital and won the BMJ Patient Safety Award for 2014.