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Keywords:

  • incident reporting;
  • interprofessional;
  • learning needs;
  • medication error;
  • patient safety

Abstract

Rationale, aims and objectives  Medication-related safety incidents are a source of concern to patients, policy makers and clinicians. The role of education in improving safety-critical practices in health care is poorly appreciated. This pilot study aimed to initiate collective discussion among professional groups of clinical staff about a range of medicine-related patient safety issues which were identified from a local incident reporting system. In engaging staff to collectively reflect on reported medication incidents we attempted to uncover a deeper understanding of local contextual issues and potential educational needs.

Methods  A mixed method study was conducted involving categorical analysis of 1058 medication incident reports (Phase 1) and the use of three mixed focus groups of clinical staff (Phase 2) in three acute hospitals in one locality in NHS Scotland.

Results  Focus group transcript analysis produced four main themes (e.g. the medical role) and 12 related sub-themes (e.g. pharmacological education and skill mix for administration of medicines) concerning medication-related practices and possible educational interventions.

Conclusions  While it is necessary to review reported incident data and disseminate the educational messages for the improvement of quality, this traditional risk management process is inadequate on its own. Reporting systems can be enhanced by collective examination of reported information about medicines by local clinical teams. We identified a strong message from the focus groups for learning about each other and from each other, and that the method piloted may be an important inter-professional mechanism for improvement.