This was this morning’s headline news in the press and on TV and radio. So given that this is a mainstream operations management issue, I thought I’d look into it. It raises some interesting points.
I started by trying to find the ‘Report’ from which these news stories originated (always go to the original source). I could not. This is because the stories are based on a pre-released speech that Jeremy Hunt, the Health Secretary, is going to make today. Apparently (according to the EEPRU’s website) the report is called “Prevalence and economic burden of medication errors in the NHS England“. The EEPRU (Policy Research Unit in Economic Evaluation of Health & Care Interventions) is a joint research centre of the University of Sheffield and University of York. They worked with University of Manchester to undertake the research into medication errors. As far as I can tell the report is not yet in the public domain. All the EEPRU website has is one short paragraph. The University of Manchester website says much the same as the news story and provides a link to the ‘Report’, which turns out to be simply a link to the EEPRU website. This is because “The report, funded by the UK Department of Health Policy Research Programme, will be unveiled at the World Patient Safety Science and Technology Summit”. And it turns out this event is taking place right now in London and it is where Jeremy Hunt will be making his speech.
What is the public domain is a report commissioned by the Department of Health and Social Care entitled “The Report of the Short Life Working Group on reducing medication-related harm“. This report has none of the statistics in it reported in the new stories, but it does make 15 recommendations designed to address medication errors. Here they are*:
- “Improved shared decision making so that patients and carers are encouraged to ask questions about their medications and health and care professionals actively support patients and carers in making decisions jointly, including when to stop medication.
- Work closely with NHS Digital and others to improve information for patients and families, and improve access to inpatient medication information.
- Encourage and support patients and families to raise any concerns about their medication.
- Improved shared care between health and care professionals; with increased knowledge and support.
- Professional regulators must ensure adequate training in safe and effective medicines use is embedded in undergraduate training, and professional leadership bodies, working with professional regulators must ensure continuing professional development adequately reflects safe and effective medicines use too.
- Professional regulators and professional leadership bodies should also encourage reporting and learning from medication errors.
- Work with industry and MHRA to produce more patient friendly packaging and labelling.
- Work with pharmacy dispensing computer system suppliers to ensure that labelling contributes to safer use of medicines and does not hinder, for example by labels being stuck over packaging or by using unfamiliar language.
- Build on work to identify and increase awareness of ‘look alike sound alike’ drugs and develop solutions to prevent these being introduced.
- The accelerated roll-out and optimisation of hospital e-prescribing and medicines administration systems.
- The roll-out of proven interventions in primary care such as PINCER.
- The development of a prioritised and comprehensive suite of metrics on medication error aimed at improvement.
- Development of a repository of good practice to share learning.
- New research on medication error should be encouraged and directed down the best avenue to facilitate positive change.
- A programme on medication safety and error should be established, in line with the domains and early priorities set out by WHO”.
So it seems the data on the scale and significance of the problem is being revealed at the same time as the steps deemed necessary overcome the problem. Neat. This has not stopped the media from trying to identify a single cause for this error rate – in most cases the funding of the NHS.
And the OM issues… where do I start? Six sigma? Empowerment without training? Lean? Organisational learning? It seems that the Short Life Working Group have never read anything on error-free quality management or spoken to anyone working in industry with expertise in this field. Heaven help us all!
*I am advised that I “may re-use the text of this document (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence”.