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

Delivering a Healthy WA How many clinical incidents are reported in WA in a year?

Delivering a Healthy WA Types of medication Incidents

Delivering a Healthy WA Top 10 Medications involved in incidents

Delivering a Healthy WA Why did the error occur?

Delivering a Healthy WA 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

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 prescription The process The patient The people The place

Delivering a Healthy WA NPS E-Learning

Delivering a Healthy WA 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.