Background Within healthcare, good clinical governance processes within all aspects of medicines management are essential for safe and effective care. The focus of enquiry was driven by the organisation being consistently an outlier within the Hospice UK medication related benchmarking exercise. This piece of work aimed at critically challenging the data with a very clear emphasis on patient related harm incidents. A cornerstone of the discipline is continuous improvement and patient safety is based on learning from errors and adverse events.

Method Medicine related incidents within the hospice incident reporting system were reviewed for the entirety of 2020. The Hospice UK definition of a ‘Medication-related patient safety incident’ was used along with the risk matrix of the actual incident itself.

Results In 2020, a total of 86 medicines related incidents were reported.

Level 0 Level 1 Level 2 Level 3

29   33   19   5

All 86 Incidents were reviewed by the Hospice Pharmacist initially using the Hospice UK metrics and then subsequently reviewed by the Medical Director. 42 (49%) Vantage Sentinel reports were discounted as they were not considered a ‘Medication- related patient harm incidents’.

44 incidents, i.e. 51% of the reported errors, were actual medication-related patient safety incidents.

Level 0 Level 1 Level 2 Level 3

7   15   17   5

Out of the 44 medication-related patient safety incidents, 18 (41%) were graded correctly and 26 (59%) required re-grading.

Conclusions The need for standardised operational definitions of incidents is critical, both to those reporting and those investigating. Education and prompts within the incident reporting system, have helped employees differentiate what a medication incident is, what a patient safety incident is and what a medication-related patient harm incident is. The organisation convened a pre-meeting called Mini- MOG (Medicines Optimisation Group), which sought to bring multi-professional hospice representation with the aim of consensus with grading but also scrutiny with the investigation. This has led to the organisation being able to prioritise and to share the learning in the spirit of continuous improvement.