• Prescribing errors
  • Projects

Peer Support Project Leading to Decrease in Drug Errors

Implementation of a Peer Support System for decreasing drug errors on the paediatric ward of a DGH.

The problem

When a drug error is made, the person involved feels guilty, distraught, and feels like they have failed the system. Mistakes are human and will be made, however the importance is to minimise these as much as possible. The project aims to create a supportive and friendly environment to learn from these errors and ensure patient safety, as usually junior doctors are intimidated to share and learn from these experiences. Current practice is not optimal for minimising the rate of error and giving evidence of reducing drug errors.

Aims

 The aim is to reduce drug errors and, therefore, improve patient safety. We are aiming for a reduction of 10% initially in drug errors. To get to this aim, we encourage junior doctors to learn form the errors committed, and ensure that they have the appropriate training with prescribing. Another objective is to ensure the errors are dealt with in a supportive way in order to improve the learning experience and for it to be less intimidating. 

Making the case for change

All doctors are involved in the scheme, but it is essentially targeted at trainees as they are the main prescribers. Additionally, a decision has been made that, rather than by consultants, junior trainees will be informed by more senior peers (registrars). The registrars will be supported by consultants throughout. Consultants and trainees have all been informed of this process. Feedback from the junior doctors showed that this is an effective way of learning from errors, rather than feeling blamed and intimidated for them. It also encourages better sharing of information, and enabling others to learn as well. This is an ongoing learning process, as it allows the Trust to monitor good management of drug errors (by completing the RCPCH safe prescribing module). By reflecting on the process, it promotes "reflection on action" which has been shown to consolidate effective learning. 

Your improvement

This project is ongoing, it is at the start and we are currently working on implementing it. It will improve prescribing practice as will allow a supportive way for trainees to reflect. It is moving away from the blaming culture, and one always feels guilty when making a prescription error.  All junior trainees having made drug errors will redo the RCPCH online module of Safe Prescribing and email their completion certificate to their educational supervisor. They will also write a reflective entry in their eportfolio and decide whether to keep it private of share with education supervisor. It can be reviewed and discussed with a registrar. Consultant will engage the consultant body to encourage implementation of this process whenever attending. Pharmacists are currently noting all drug errors and presenting them in grand rounds. We will be asking them to count drug errors per week (doses) by the paediatric team, and are hoping to see a reduction of 10% in errors. 

Learning and next steps

The main challenges we have faced are under reported drug errors and engaging all members of the registrar group to be happy to inform the trainees and give supportive feedback. Our next step is to identify champions (junior doctors) who will be informed by pharmacists in order to minimise under reporting. We're also implementing 5 minutes in ground round of overview of drug errors anonymously to encourage learning from them. 

Quality assurance/MHRA Registration

This project has been approved by the paediatric department.