Improving medicine management across the UK's children's hospice service
Submitting Institution
University of BradfordUnit of Assessment
Allied Health Professions, Dentistry, Nursing and PharmacySummary Impact Type
PoliticalResearch Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
University of Bradford research into medication error management has
directly impacted upon
policy and practice, informing changes to mitigate potential harm across
the 49 children's hospice
services in the UK. Implementation of a research-informed medicines
management toolkit co-produced
by the Bradford team and Children's Hospices UK (now Together for
Short Lives)
resulted in hospices identifying key vulnerabilities and using guidance
from the toolkit to make
significant service improvements. This impact of this research has
resulted in changes in both
practice and behaviour by strengthening systems for error reporting
including the analysis of
contributory factors — staff are now identifying more errors and near
misses, consequently leading
to a reduced risk to the children.
Underpinning research
The Bradford medicines management team included Gerry Armitage (Lecturer
2000-2005, Senior
University Teacher 2005-2007, Senior Lecturer 2008-2012, Professor
2012-present), Rob Newell
(Professor 2001-2011), Kay Marshall (Senior Lecturer 1997-2007, Professor
2007-2013), and Mrs
Jennifer Adams (Lecturer 2003-present). The research started in 2004 with
the award of a
Department of Health Research Development Award (2004-7) to Armitage, and
continues to the
present. Armitage conducted a programme of work investigating contributory
factors in medication
errors and strategies for increasing reporting and learning from errors
(1,2,3). There is a
considerable literature on the need to improve medical error reporting so
as to advance
organisational learning — a central imperative in improving patient
safety. Empirical work conducted
by Armitage, and supported by Newell and Wright involved: the documentary
analysis of 1250
incident reports; a systematic review of the contributory factors in
medication error, and 40 in-depth
interviews with a multi-disciplinary sample of practitioners who had been
involved in medication
errors. The research identified key vulnerabilities in the medicines
management pathway and ways
in which error reporting systems could be strengthened using design and
structure to enable more
effective analysis of causes and, in turn, increase organisational
learning. A novel medication error
reporting scheme with accompanying guidance was then designed. Following
this, the process of
error management was examined in a study with one of Armitage's external
PhD students
(Sirriyeh) in the adult hospice setting; several challenges were
identified, including the impact of
error on those involved and their managers, and the conceptualisation of
blame (4).
Following involvement in local improvement work on medication error
management with several
hospices in Northern England, Armitage & University of Bradford
researchers were invited by
Children's Hospices UK (now Together for Short Lives, TfSL) in
2010 to co-lead a further
Department of Health funded project to develop a medicines management
toolkit for use in
hospices (5). The children's hospice sector provides care to approximately
8000 children, many of
whom have complex needs and medication regimes. Drawing upon the above
underpinning
research, the toolkit focused on key areas of risk, applying the findings
to enable children's
hospices to identify key vulnerabilities in systems and processes. Content
included detailed advice
on: medicines regulation; requisite competencies; medicines reconciliation
and transcribing (where
accurate information about current medication is critical to reducing
discrepancies); non-medical
prescribing, and medication error reporting. The toolkit also offered an
evidence based format for
completing an error report, which was directly informed by the
underpinning research described
above.
References to the research
1. Armitage G. (2008) Double checking medicines: defence against error or
contributory factor?
Journal of Evaluation in Clinical Practice 14(4): 513-519.
2. Armitage G. (2009) Human error theory: relevance to nurse management.
Journal of Nursing
Management 17(2): 193-202.
3. Armitage G, Newell RJ, Wright J. (2010) Improving Drug Error
Reporting. Journal of
Evaluation in Clinical Practice 16(6): 1189-1197.
4. Sirriyeh R, Armitage G, Gardner PH, Lawton RJ. (2010) Medical Error:
perspectives from
Hospice Management. International Journal of Palliative Nursing
16(8): 377-386.
5. Adams J, Armitage G, Marshall K, Shah K. (2011) Medicines
Management: a Toolkit for
Children's Hospice Services. Children's Hospices UK. ISBN
9780954729691
Evidence of Quality
The research outputs were published in several leading journals: Journal
of Evaluation in Clinical
Practice — Impact factor: 1.5; ranking: 2012: 16/23, Medical
Informatics; 48/82, Health Care
Sciences & Services; Journal of Nursing Management — Impact
factor 1.4; ranking 17/101 Nursing
Social Science; 19/103 Nursing Science; 73/172 Management. The core
research (paper 3) was
peer reviewed by the Department of Health Research Development Award panel
and shortlisted
for an award. In addition the work on improving medication error reporting
received a Highly
Acclaimed (Runner-up) award in the National Bupa Foundation Patient Safety
Awards 2007.
Evidence of the quality of the research is also demonstrated by the award
of the following peer
reviewed and competitive research grants:
Armitage G, Doctoral Research Development Award, National
Institute for Health Research 2004-2007
£250,000
Blackburn M, Shah K, Armitage G, Marshall K, Adams J. 30 Million
Stars, Department of Health
2010 £30,000
Details of the impact
The research described above has achieved impact through: i) Adoption of
the medicines
management toolkit as national policy and good practice guidance; ii)
Adoption of best practice in
identifying error causation and error reporting by individual hospices. It
has had national reach,
being adopted across all children's hospices in England, Scotland and
Wales.
i) Adoption of the toolkit as policy and good practice guidance
In 2011, Together for Short Lives (TfSL) adopted the medicines management
toolkit as policy and
issued it to all its 49 member hospices across the UK. TfSL recommended it
to be used to review
internal systems and processes and as a good practice guide to improve
medicines management
across the sector, advance multi-disciplinary/cross agency working, and
make medicines safety a
priority. TfSL's then Director of Practice & Service Development,
advised all hospices in 2011 to
implement a review of systems and processes and to consider changes based
on the toolkit
guidance (a).
The toolkit, referred to as the CHUK medicines management toolkit, is
cited as one of two key
medicines management resources in a regional strategy for children's
hospices across London
(University of Kent /CHAL 2011) (b). At the time of this submission,
impact is continuing to build as
a University of Bradford team led by Armitage has been funded by TfSL to
evaluate the current
edition of the toolkit and prepare a second edition.
ii) Evidence of adoption of best practice
The Director of Care at TfSL has surveyed hospice leads to gather
evidence of the use and effects
of the medicines management toolkit and has reported that all hospices in
the network have
reviewed their approach to medicines management since the toolkit was
launched in 2011 (a)
Key changes made by hospices in response to the toolkit, and specifically
the guidance provided
for improving error management have resulted in better identification of
errors emanating both from
within the hospices and from local NHS Trusts. There have also been
improvements in taking
action following errors, thus mitigating the future risk to patients. A
number of examples, clearly
influenced by the Bradford research, are described below.
The East Anglia Children's Hospices (EACH) now routinely interrogate
medicines incidents every
quarter with clinical quality staff; they have instigated reflective
reviews of causation and action
taken at medicines management meetings three times per year and the
Director of Care at EACH
suggests that there are now systematic opportunities for learning (c).
Furthermore, their clinical
educators use the toolkit as a resource in their medicines management
training. At the Rainbow's
Hospice in Leicestershire, the Director of Care has adopted a reporting
scheme based on the
toolkit; the contributory factors framework is used to audit medication
incidents, and there has been
a rise in the number of near miss incidents, seen as a reflection of an
open and just safety culture
(d). The Director of Care has reported that, "I have used the form a
lot for auditing drug incidents and
it has been really helpful in changing some of our practice."
At the Welsh hospices (Hope House and Ty Gobaith) the reporting process
has similarly been
adopted and incidents are assessed by a quarterly, multi-disciplinary
medicines management
group; the number of reported incidents has increased, but not the number
of harm events. The
number of discrepancies identified during medicines reconciliation has
also increased. All reported
dispensing errors from referring NHS Trusts (the reporting rate of which
has also increased) are
shared with the Director of Pharmacy at the partnering NHS Trust. The
Director of Care at Welsh
Hospices has explained how medicines management is now "more
pro-active and organise"', and
that there is increased staff vigilance which has "empowered parents
to take greater ownership of
their children's medicines management" (e).
The Children's Hospice Association of Scotland (CHAS) made further
changes in response to both
the toolkit and the supporting research papers. Armitage was invited to
lead a study day for senior
staff (April 2012) which resulted in the implementation of a tailored
reporting tool as part of a new
`Medication Management Strategy' directly based on the principles
advocated in the Bradford
research (f). Secondly, following advice from the Bradford team, the first
pharmacist post within
CHAS was planned and established in 2012 to strengthen medicines
governance. The job
description and person specifications were written following consultation
with University of Bradford
staff (g), and the first of two pharmacists is now in post. CHAS have
built their medication
management strategy on the central principles of a human factors approach
as advocated in the
toolkit, with a particular focus on learning from error through their
clinical incident reporting scheme
(h).
Evidence of impact on error reporting systems and on hospice staff
culture comes from the report
of the regulator's (Healthcare Improvement Scotland) unannounced visit to
CHAS (February 2013)
which explicitly acknowledged a "strong culture of reporting
medication incidents, with staff being
encouraged to report openly and honestly". The report also commented
on how "management
was able to see the frequency and type of errors that were occurring and
that the new pharmacist
was involved in their review". Importantly, the regulator
complimented the reporting scheme which
was seen to be gathering more detail and using a `more robust method
of assessing possible
harm'. The regulator also noted the need for further improvement and
asked that staff continue to
audit medicines administration and related staff training (i). In summary,
the toolkit has made a
positive, demonstrable impact on safety attitudes, safety policy and
routine medicines
management across the UK children's hospice service.
Sources to corroborate the impact
a. Testimonial from the Director of Practice and Service Development at
Together for Short Lives.
b. Billings J, Jenkins L. A learning and development strategy for
hospices across London. 2011.
Centre for Health Services Studies, University of Kent/Childrens Hospices
Across London
(CHAL)
http://kar.kent.ac.uk/27698/1/CHAL_report_4th_april.pdf
c. E-mail from Director of Care at East Anglia's Children's Hospices
(EACH) to Director of
Practice and Service Development at Together for Short Lives detailing how
the
implementation of the management toolkit in East Anglia has affected
practice and training.
d. E-mail from the Director of Care, Rainbows Hospice for Children and
Young People detailing
their implementation and use of the Medicines Management Toolkit.
e. Paper by Director of Care for the Welsh Hospices documenting how they
have implemented
the use of the Medicines Management Toolkit and the transformational
effects this has had on
practice.
f. Children's Hospice Association Scotland Medication Management Strategy
2012 - 2016.
g. Job description and person specification for pharmacy post created by
Children's Hospice
Association Scotland written after consultation with University of
Bradford researchers.
h. Children's Hospice Association Scotland Clinical Incident Report Form
— Medication.
i. Health Improvement Scotland, Unannounced Inspection Report:
Independent Health Care.
Rachel House Children's Hospice, Kinross, April 2013. p13.