Bringing&together&Medica/on&Safety,&Human&Factors&and&Improvement&Science&to&achieve&

“medica/on&without&harm”

Dr#Yogini#Jani#Director#Centre#for#Medicines#Op5misa5on#Research#&#Educa5on#

Consultant#Pharmacist#&#Health#Founda5on#Improvement#Science#Fellow,##

London#UK#

#

Dr Yogini Jani Consultant Pharmacist & Health Foundation Improvement Science Fellow, Director CMORE

Medication without harm: WHO’s 3rd Global Patient Safety Challenge

ISoP, 18th Annual General Meeting, November 2018, Geneva

Similar sounding names: risky or not? Yogini Jani

Patient involvement in adverse drug reaction detection & reporting

Rakhi Karwa & Merci Maina Medication without harm: is there a role for improvement science?

Yogini Jani, Rakhi Karwa & Merci Maina

RISKY OR NOT?

Similar sounding names in medications safety:

https://www.mentimeter.com/s/b1a3a38dbf2d6bfc64e7ab506caba15c/37505b527b2c

Go to www.menti.com and use the code 81 27 99

Human Factors

People and their behaviour

!  environmental

!  organisational and job factors

!  individual characteristics

Human Factors

•  mental workload

•  distractions

•  the physical environment

•  physical demands

•  device/product design

•  teamwork

•  process design

https://journals.sagepub.com/doi/pdf/10.1518/001872006776412199

….to “develop, establish and promote international standards with respect to biological, pharmaceutical and similar products.”

Similar sounding names…. Beneficial?

•  to ascertain if there was an association between medication suffixes and pharmacological function amongst different health professions

•  to determine if there was an association between level of experience and ability to match a medication suffix to pharmacological function

Method

•  Acute care hospital organization •  Specialist service

•  Series of real & fictitious drugs •  Confounder drugs included

Vigilomycin is a…..

Go to www.menti.com and use the code 81 27 99

Example

Match Mismatch

Atorvastatin was prescribed for her respiratory infection Clarithromycin was prescribed for her respiratory infection Cymbastatin was prescribed for her respiratory infection Neflecthromycin was prescribed for her respiratory infection

Please identify if these statements contain a correct match of medicine with condition or a mismatch:

Confounder Fictional drug Correct Fictional drug

Correct

Confounder

Results

Profession Number Ward-based staff 72

Pharmacy 26 Nursing 36

Medicine 10 Specialist pharmacy teams 102

R2 = 1 " 100% of the data’s variability can be accounted for.

Top 4 best answered questions

Statement Correct answer

% correct (ward based)

% correct (specialist)

Cymbastatin was prescribed for her respiratory infection

Mismatch 100 98 Levothyroxine was prescribed for her thyroid problems

Match 97 100 Minocillin was prescribed for the angina that the patient developed

Mismatch 96.5 100 Salmeterol was suggested for her asthma problems Match 100 100

Bottom 4 best answered questions

Statement Correct answer

% correct (ward based)

% correct (specialist)

Fluxicam was prescribed to reduce the swelling of her ankle.

Match 32.4 58 Delroxacin was given for his stomach infection as he couldn’t go to work.

Match 44.4 63.8 Meloxicam was prescribed to reduce the swelling of her ankle.

Match 48.5 72 Tenoxicam was given for arthritis, to make her feel better.

Match 50 95.6

….to “develop, establish and promote international standards with respect to biological, pharmaceutical and similar products.”

Preventable adverse drug events: causes and contributory factors

Clarity & Legibility Abbreviations

!  Units and micrograms Calculations Knowledge

!  Patient specific

! Drug specific Handovers/ communication

!  Intra and inter care settings

US$42 billion

Causes !  Weak systems !  Human factors

4 areas •  Patients and public •  Medicines •  Healthcare professionals •  Systems and practices

https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf