Reporting ‘near misses’ will help improve systems

No health environment can be 100 per cent safe and free from risk but recording errors helps the Trust improve patient safety, a spokeperson told the paper.

The local health authority issued the statement in response to a report in last week’s Sentinel which revealed that hundreds of Western Trust (WHSCT) patients narrowly avoided harm during a one week period in November 2009 when 264 ‘near misses’ were recorded as having occurred in the administration of medicines at Ward level.

A spokesperson for the Trust said it collects and reviews information on medication incidents (including near misses) to allow it to educate staff, correct systems and share the learning from an error so that a future event will not occur. This provides the basis for identifying medicines related risk.

Last week the Sentinel revealed how minutes of the Trust’s Acute Governance Committee meeting in March 2010 stated: “A one-week snapshot identified 264 ‘near misses.’ This has been discussed at the Drugs and Therapeutics Committee and a series of sessions are planned with Medical Education Leads to discuss key themes.”

In response the Trust stated: “The clinical pharmacy team in Altnagelvin and Erne Hospitals documented all interventions that they made over a one week period in November 2009 which is the one-week snapshot noted in the minutes of the Acute Governance Meeting of 9 March 2010.

“The aim of this was to identify areas for reducing the potential for medication errors. This process resulted in 252 incidents, including near misses, being recorded across the two hospital sites.

“Incidents were identified at an early stage and the appropriate action was taken in relation to the prescribed medication.”

The Trust spokesperson said reporting such incidents allowed it “to share the learning from them with medical and nursing staff and to correct systems so that the potential for future errors is reduced.”

“Such a process is good practice and in line with the DHSSPS’s ‘Safety First: A framework for Sustainable Improvement in the HPSS’.

“This policy underlines the importance of reporting incidents including near misses as contributing to an informed safety culture within health care which the Western Trust is committed to,” the spokesperson said.

The focus on this one week period occurred at the same time as the release of the results of General Medical Council (GMC) research which had been commissioned to explore the causes of prescribing errors made by junior doctors.

The GMC report stressed that very few prescribing errors caused harm to patients because almost all were intercepted and corrected before reaching them (‘near misses’).

The intervention of nurses, senior doctors and, in particular, pharmacists was vital in picking up errors before impacting upon patients.

In a statement the Trust advised the Sentinel: “Medical, nursing and pharmacy staff receive training on safe medication practice. “The regional medicines governance team which includes the Western Trust, provides training to all final year medical, nursing and pharmacy students at Queens University Belfast and the University of Ulster.

“This one day workshop includes a lecture to all students on the principles and theory behind errors and input on high risk medicines; safe administration of medicines; taking a medication history; and allergy.”

Training is also provided across WHSCT for foundation year doctors at induction - this goes through key medicines guidelines/policies in the Trust, how to complete a hospital prescription and identifies key points to take into account to ensure safer prescribing.

Medicine prescription charts have also been developed to aid decision making with high risk medicines e.g. insulin, gentamicin, warfarin, whilst there is also a regional steer to standardise prescription charts across Northern Ireland. This will aid familiarity of processes by staff who rotate around hospitals.

The Trust also has a ‘Medicines Governance Working Group’ which includes senior medical, nursing, pharmacy and risk management representation.

The Trust says: “No health and social care environment will ever be absolutely safe and without risk, however, more can always be done to improve the safety and quality of care provided.

“The Western Trust actively encourages the reporting of all types of incidents. It is essential that the organization has such a reporting culture which is in the best interest of improving patient safety and care.”