Safety recommendation
It is recommended that the Royal College of Physicians, in collaboration with the Royal Pharmaceutical Society, British Pharmacological Society, Royal College of General Practitioners, Royal College of Paediatrics and Child Health, NHS Improvement, the professional bodies for the professions regulated by the Health and Care Professions Council, Royal College of Nursing and Royal College of Midwives, provide leadership in recommending the postgraduate learning needs and activities to standardise professional development in medicines safety processes.
Response:
The Royal College of Physicians has coordinated a joint working group with other professional bodies to jointly develop and deliver work related to Medication Safety.
Members of the working group include Royal College of Physicians, Royal Pharmaceutical Society, British Pharmacological Society, Royal College of Nursing, Royal College of General Practitioners, Royal College of Paediatrics and Child Health, Health Education England, NHS Improvement and NHS England.
Through this group and in part informed by your report we recognise that interprofessional learning activities are required to address many of the patient safety issues that may be encompassed in practice and that are illustrated by the report and findings.
Over the next 12 months we aim to:
- Review the literature and evidence on medication safety and inter-professional workplace-based learning.
- Explore current best practice in this area, building on the work of Health Education England in Wessex and including the EPIFFANY programme.
- Develop a new model of inter-professional training to improve patient safety.
- Test pilots of the workplace-based training and activities in practice.
- Recommend how to spread this practice across the NHS.
Response received on 8 July 2019.
Training video
We've worked with Manchester University NHS Foundation Trust to produce a training video and teaching aid based on the reference event in this investigation.
The aim of the training video is to increase awareness of inadvertent administration of wrong route medication errors and how to prevent them.
The video contains a reconstruction of an event where a nine-year old child was wrongly administered an oral liquid drug into a vein during a planned renal biopsy. This is followed by a simulation of a current process, which aims to prevent these errors from happening.
The video is accompanied by a supplementary teaching aid.