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News, Updates and Presentations for todays Medication Errors Conference

The National Medication Safety Programme

Prof Ashok Soni CBE LPN Pharmacy Chair NHS England and Vice President International Pharmacy Federation

Ashok was appointed as a member of the NHS Future Forum to review the Health & Social Care Bill and the appropriateness of elements of that Bill. Ash was a member of the Clinical Advice and Leadership work stream in the first phase. In the second phase he jointly led the work stream on 'The NHS's Role in the Public's Health'. In the third phase, he was involved in the review of the NHS Constitution. Ash is a Fellow of The Royal Pharmaceutical Society and a Fellow of the RPS Faculty and Honorary Fellow of The UCL School of Pharmacy. He was awarded an OBE in the New Year’s Honours 2015 for services to pharmacy and the NHS. He is a Council and Executive member of the National Association of Primary Care and the Local Professional Network Chair for pharmacy for NHS England for London. He has received honorary doctorates from Portsmouth University, Bradford University and Kingston University and is a visiting professor for Huddersfield University. 

Ashok looked at working with patients and the public to reduce medication errors, saying we can; improve shared decision making including when to stop medication, improve information for patients and families, encourage patients and families to raise concerns about their medication. He went on to look at systems and practice to reduce medication errors including:

  • accelerated roll out of hospital eprescribing and medicines administration systems 
  • proven interventions in primary care such as PINCER
  • development of a prioritised and comprehensive suite of metrics  
  • new systems linking patient data in primary care to hospital admissions
  • new research on medication errors to be encouraged

Shaun Kinghorn a service user shared his lived experience of lifelong anticagulation with warfarin.  He said; "patients have an important role in maintaining their safety" "it's reassuring to hear NHS Improvement say "patients should be encouraged and empowered to become 'vigilant stakeholders' in safety".  Shaun said; "poor communication is often the cause of a lot of medcation safety incidents" "as a patient you are incredibly vigilant, one of the things that makes me feel safe is a shared conversation".  Shaun also said; "it's important to be signposted towards resources that make sense and help me to maintain my safety...help me understand how I can keep myself safe". 

Managing and investigating a Medication incident

Mike O'Connell Legal Services Practitioner   

  • managing a medication incident (an overview of the NHS England Serious Incident Framework, identifying the 4 key stages of investigation, and how to write the report, plus practical experience and tips, together with an update on the NHS Patient Safety strategy)
  • supporting staff who make a medication error (practical tips); 
  • principles of effective incident investigation (as per the NHS Serious Incident Framework);
  • effectively communicating the learning from medication errors and safety alerts to frontline staff (practical examples, upcoming changes, plus the work of the Healthcare Safety Investigation Branch). 

Full PowerPoint Presentation

Reducing Medication Errors in Practice: Where to prioritise medication error reduction programmes.

James Hooley Pharmacist, Medicines Safety & Clinical Governance and Medicines Dafety Officer University Hospitals of Derby & Burton NHS Foundation Trust

James has 16 years’ experience working as a pharmacist in acute NHS Trusts. Following clinical rotational roles, James led pharmacy services to Surgery and Anaesthetics Divisions at both Derby Teaching Hospitals, and later, Nottingham University Hospitals NHS Trust. These roles provided opportunities for safety and improvement work (e.g. Drug Error Reduction Software; Purchasing for Safety) and chairing trust-wide committees for Medicines Management and Medical Gases. 

James is now Medication Safety Officer for UHDB, an organisation formed following the merger of Derby & Burton Hospitals in 2018, and contributes to the East Midlands and the Derbyshire Medicines Safety Networks. 

Full PowerPoint Presentation