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Going beyond blame: reporting NHS medication errors in nursing home residents with diabetes

  • Frank Milligan
    ,
  • Roger Gadsby
    ,
  • Maisoon Ghaleb
    ,
  • Philip Ivory
    ,
  • Colette McKeaveney
    ,
  • Kathryn Newton
Research Output: Contribution to journal Article Peer-review

Sustainable Development Goals

  • SDG 3 - Good Health and Well-being
    SDG 3 Good Health and Well

Abstract

It is widely accepted in literature on patient safety that an open culture — one that seeks to understand the multiple reasons for error — is required to promote incident reporting and maximise learning for system improvement.1 In the attempt to deliver the research described here we encountered a culture of blame. Such a culture leads to low levels of medication error reporting with regard to NHS systems supplying the nursing home setting. This article explores the problem of this low level of reporting being detrimental to future learning on NHS medication errors.2 The study we undertook, ‘Root causes of medication errors in nursing home residents with diabetes: enhancing safety in NHS medicines management’, was funded by the Research for Patient Benefit (RfPB) programme. It focused on residents with diabetes in nursing homes, as defined by the Care Quality Commission (CQC),3 and involved consenting homes in Bedfordshire and Hertfordshire. Nursing homes were selected because medication delivery processes are slightly different from residential care home provision, although the incident reporting systems are similar. The aim of the study was to gather data on NHS errors, and report on and analyse them for learning purposes and solution development. The comments made here relate to the data collection process. The final research findings will be summarised in future publications.

Publication Information

Output type

Research Output: Contribution to journal Article Peer-review

Original language

English

Pages from-to (Number of pages)

Pages 372-373

Journal (Volume, Issue Number)

British Journal of General Practice (Volume 65, Issue 636)

Publication milestones

  • Published - 01/07/2015

Publication status

Published - 01/07/2015

ISSN

0960-1643

External Publication IDs

  • handle.net: 10547/622910
  • Scopus: 84937710483

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