Introduction A trend identified that drug errors were happening due to complacency and a shortfall in nurses' capabilities in Medicines Management. The potentially serious consequences of this led to the introduction of a rolling medicines management programme.
Aim To create an effective Medicines Management system containing structure and guidance in order to ensure patients' safety and minimise the occurrence of drug errors.
Method Introduction of a yearly medicine management programme which includes:
▶ Training sessions – responsibility and accountabilities, update on drug calculation skills
▶ Annual drug calculation test
▶ Annual drug administration competency
▶ Annual syringe driver assessment
A scoring system for medication errors was implemented to ensure consistency in assessing the severity of the drug errors and determining the appropriate action to take.
Results The Medicines Management Policy and Procedure has been amended and awareness of good medicine management is embedded in the daily routine. The hospice encourages a supportive culture, involving staff in the process of investigation and the implementation of new ways of working. Medication errors and near misses are managed in a fair and supportive manner.
All staff successfully achieved the pass rate of 95% for their Drug Calculation Test. The number of incidences of drug errors has fallen by 50% within the last 12 month period.
The focus on this area has enabled trends to be identified, both general and individual, and remedial action taken to improve practice. Measures have also been taken to minimise risk.
Conclusion Awareness, communication, education and support are the main drivers for the reduction in drug errors. Staff feel more confident as their competencies have increased.
The implementation of an annual programme keeps medicine management on the radar and the programme is an effective and efficient investment to enhance patient safety.
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