Health professionals recognise the importance of pharmacist involvement in reducing harm, says speaker at SHPA’s Medicines Management Conference 2017
Kim Oates, Emeritus Professor at Sydney University, paediatrician and advisor to the Clinical Excellence Commission, believes pharmacists should be involved in patient prescribing to improve safety outcomes.
“Nearly half a million admissions each year with an adverse event are caused by the care health professionals have provided,” Professor Oates told delegates at the Medicines Management Conference in Sydney on Saturday morning.
In his talk entitled “Doing more to keep our patients safe”, Professor Oates said “medical graduates have a lot to learn about patient safety”.
He shared research that revealed first-year medical graduates made lots of prescribing mistakes, and second-year graduates were “even worse”.
“The thing is almost all errors were picked up by pharmacists before they could cause harm, so pharmacists are such a crucial part of the healthcare team,” Professor Oates told the crowd.
Errors rates are high in the hospital setting.
About 2-3% of all hospital admissions are medication related, he said.
“Once they get to hospital, up to 9% of errors are medication related, and once they get home from hospital, there are up to 2 errors per patient in the documentation and discharge summary.
“Some error traps to do with medications are pretty obvious, for example packaging problems, look-alike medicines.”
He shared seven key reasons for error in healthcare environments:
1. Not being aware of the situation
“There are plenty of people who say, ‘oh tried that before, nothing happens’,” said Professor Oates. “Leaders say, ‘how can we do it better?’ Never accept the status quo.”
“The more steps in the process, the more chance there is of error,” he says. “Some organisations tend to put in an extra step as a safeguard. But the best way to reduce errors is to simplify.”
4. Self reliance
5. Poor communication
“Communication errors are common in healthcare,” says Professor Oates. “Between healthcare professionals, professional groups, between the practitioner and the patient… We have to make sure we communicate clearly and concisely, and get feedback from the patient.”
6. Fatigue, pressure and workload
7. Distractions and interruptions
Professor Oates says there is a problem with healthcare culture, where people tend to feel reticent about reporting mistakes.
“The culture is difficult. Mistakes are still seen as a personal aberration – which is bad. If you have that view, by blaming errors or dismissing them, instead of saying, ‘What can we do, how can we use this error to make things better?’ If it’s that kind of culture, staff will be afraid and hide their errors.
“Management sometimes has their eye on the wrong ball and are too focused on punishing offenders.
“A blame culture and a reporting culture can’t co-exist.”
Professor Oates also suggested that pharmacists should be more involved in the prescribing process, as it would allow for less errors.
“Pharmacist prescribing – we need more of that!” he said. “Pharmacists know more about the medications being prescribed, so why shouldn’t we have that?
“The main game for senior leaders is making things safer for patients, that should be your main priority.”
Professor Oates’ four components of a safe healthcare culture:
- A reporting culture
- A flexible culture
- A learning culture
- A just culture