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Using the example of medication safety, this paper aims to explore the impact of three managerial interventions (adverse incident reporting, ward‐level support by pharmacists, and a medication safety subcommittee) on different professional communities situated in the English National Health Service (NHS).

Semi‐structured interviews were conducted with clinical and managerial staff from two English NHS acute trusts, supplemented with meeting observations and documentary analysis.

Attitudes toward managerial intervention differ by professional community (between doctors, nurses and pharmacists) according to their existing norms of safety and perceptions of formal governance processes.

The heterogeneity of social norms across different professional communities and medical specialties has implications for the design of organisational learning mechanisms in the field of patient safety.

The paper shows that theorisation of professional “resistance” to managerialism privileges the study of doctors' reactions to management with the consequent neglect of the perceptions of other professional communities.

The purpose of this paper is to illustrate the use of Lean Six Sigma (LSS) and its associated tools to reduce dispensing errors in an inpatient pharmacy of a teaching hospital in Thailand.

The action research methodology was used to illustrate the implementation of Lean Six Sigma through the collaboration between the researcher and participants. The project team followed the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) methodology and applied its tools in various phases of the methodology.

The number of dispensing errors decreased from 6 to 2 incidents per 20,000 inpatient days per month between April 2018 and August 2019 representing a 66.66% reduction. The project has improved the dispensing process performance resulting in dispensing error reduction and improved patient safety. The communication channels between the hospital pharmacy and the pharmacy technicians have also been improved.

This study was conducted in an inpatient pharmacy of a teaching hospital in Thailand. Therefore, the findings from this study cannot be generalized beyond the specific setting. However, the findings are applicable in the case of similar contexts and/or situations.

This is the first study that employs a continuous improvement methodology for the purpose of improving the dispensing process and the quality of care in a hospital. This study contributes to an understanding of how the application of action research can save patients' lives, improve patient safety and increase work satisfaction in the pharmacy service.

Medication reconciliation is integral to every hospital. Approximately 60 percent of all hospital medication errors occur at admission, intra‐hospital transfer or discharge. Effectively and consistently performing medication reconciliation at care‐interfaces continues to be a challenge. Tan Tock Seng Hospital (TTSH) averages 4,700 admissions monthly. Many patients are elderly (>65 years old) at risk from poly‐pharmacy. As part of a medication safety initiative, pharmacy staff started a medication reconciliation service in 2007, which expanded to include all patients in October 2009. This article aims to describe the TTSH medication reconciliation system and to highlight common medication errors occurring following incomplete medication reconciliation.

Where possible, patients admitted into TTSH are seen by pharmacy staff within 24 hours of admission. A form was created to document their medications, which is filed into the case sheets for referencing purposes. Any discrepancies in medicines are brought to doctors' attention. Patients are also counseled about changes to their medications. Errors picked up were captured in an Excel database.

The most common medication error was prescribers missing out medications. The second commonest was recording different doses and regimens. The reason was mainly due to doctors transcribing medications inaccurately.

This is a descriptive study and no statistical tests were carried out. Data entry was done by different pharmacy staff, and not a dedicated person; hence, data might be under‐reported.

The findings demonstrate the importance of medication reconciliation on admission. Accurate medication reconciliation can help to reduce transcription errors and improve service quality.

The article highlights medication reconciliation's importance and has implications for healthcare professionals in all countries.

The aim of this paper is to enhance the effectiveness of pharmacovigilance programs that provide information about medical products to benefit consumers, aid health care professional’s decision-making and improve community health. This research sought to determine whether distinct segments of consumers can be identified for prescription drug safety social marketing and communication activities and if these segments would respond differently to information about prescription drug products.

Theories of risk information-seeking behavior were used to develop questions for respondents in an online survey panel. Latent class analyses identified clusters that were similar in their ability to accurately interpret risks and benefits, preferred sources of health information, medication use and other related factors. Multinomial logistic regression models identified demographic and psychographic differences across the segments. Logistic and linear regression models were then used to compare each segment’s responses to a specific drug safety information product.

The 1,244 respondents were clustered into four segments: not engaged (12 per cent), low-involvement users (29 per cent), careful users (50 per cent) and social information seekers (9 per cent). These segments were distinguished by perceived seeking control, self-appraisal of skill, information insufficiency, self-efficacy, information competency and health literacy. Sources of health information and health-seeking behaviors were also different across the four segments. Significant differences were found among the segments in their comprehension and perceived utility of the content and their intentions to take relevant actions.

From an array of potential behavioral influences, adults can be segmented by risk information-seeking constructs and related behaviors. These segments respond differently to drug safety information. Use of the personas developed in this work can help pharmacovigilance programs around the world develop more relevant and tailored social marketing products, services and content.

A social marketing approach using empirically tested theoretical constructs can be useful for drug safety or pharmacovigilance programs. The results were used to create personas that quickly convey relevant information to drug safety program managers and staff.

Patient safety is gaining prominence in health professional curricula. Patient safety must be complemented by teaching and skill development in practice settings. The purpose of this paper is to explore how experienced pharmacists identify, prioritize and communicate adverse drug effects to patients.

A focus group discussion was conducted with cardiology pharmacy specialists working in a Doha hospital, Qatar. The topic guide sought to explore participants’ views, experiences and approaches to educating patients regarding specific cardiovascular therapy safety and tolerability. Discussions were audio-recorded and transcribed verbatim. Data were coded and organized around identified themes and sub-themes. Working theories were developed by the three authors based on relevant topic characteristics associated with the means in which pharmacists prioritize and choose adverse effect information to communicate to patients.

Nine pharmacists participated in the discussion. The specific adverse effects prioritized were consistent with the reported highest prevalence. Concepts and connections to three main themes described how pharmacists further tailored patient counseling: potential adverse effects and their perceived importance; patient encounter; and cultural factors. Pharmacists relied on initial patient dialogue to judge an individual’s needs and capabilities to digest safety information, and drew heavily upon experience with other counseling encounters to further prioritize this information, processes dependent upon development and accessing exemplar cases.

The findings underscore practical experience as a critical instructional element of undergraduate health professional patient safety curricula and for developing associated clinical reasoning.

The purpose of this paper is to investigate violations against work standards associated with using a new health information technology (HIT) system. Relevant recommendations for implementing HIT in rural hospitals are provided and discussed to achieve meaningful use.

An observational study is conducted to map medication administration process while using a HIT system in a rural hospital. Follow-up focus groups are held to determine and verify potential adverse factors related to using the HIT system while passing drugs to patients.

A detailed task analysis demonstrated several violations, such as only relying on the barcode scanning system to match up with patient and drugs could potentially result in the medical staff forgetting to provide drug information verbally before administering drugs. There was also a lack of regulated and clear work procedure in using the new HIT system. In addition, the computer system controls and displays could not be adjusted so as to satisfy the users’ expectations. Nurses prepared medications and documentation in an environment that was prone to interruptions.

Recommendations for implementing a HIT system in rural healthcare facilities can be categorized into five areas: people, tasks, tools, environment, and organization. Detailed remedial measures are provided for achieving continuous process improvements at resource-limited healthcare facilities in rural areas.

Medication management is a complex process, at high risk of error with life threatening consequences. The focus should be on devising strategies to avoid errors and make the process self-reliable by ensuring prevention of errors and/or error detection at subsequent stages. The purpose of this paper is to use failure mode effect analysis (FMEA), a systematic proactive tool, to identify the likelihood and the causes for the process to fail at various steps and prioritise them to devise risk reduction strategies to improve patient safety.

The study was designed as an observational analytical study of medication management process in the inpatient area of a multi-speciality hospital in Gurgaon, Haryana, India. A team was made to study the complex process of medication management in the hospital. FMEA tool was used. Corrective actions were developed based on the prioritised failure modes which were implemented and monitored.

The percentage distribution of medication errors as per the observation made by the team was found to be maximum of transcription errors (37 per cent) followed by administration errors (29 per cent) indicating the need to identify the causes and effects of their occurrence. In all, 11 failure modes were identified out of which major five were prioritised based on the risk priority number (RPN). The process was repeated after corrective actions were taken which resulted in about 40 per cent (average) and around 60 per cent reduction in the RPN of prioritised failure modes.

FMEA is a time consuming process and requires a multidisciplinary team which has good understanding of the process being analysed. FMEA only helps in identifying the possibilities of a process to fail, it does not eliminate them, additional efforts are required to develop action plans and implement them. Frank discussion and agreement among the team members is required not only for successfully conducing FMEA but also for implementing the corrective actions.

FMEA is an effective proactive risk-assessment tool and is a continuous process which can be continued in phases. The corrective actions taken resulted in reduction in RPN, subjected to further evaluation and usage by others depending on the facility type.

The application of the tool helped the hospital in identifying failures in medication management process, thereby prioritising and correcting them leading to improvement.

Since the publication of the report “To Err Is Human: Building a Safer Health System” by the US Institute of Medicine in 2000, much has changed with regard to patient safety. Many of the more recent initiatives to improve patient safety target the behavior of health care staff (e.g., training, double-checking procedures, and standard operating procedures). System-based interventions have so far received less attention, even though they produce more substantial improvements, being less dependent on individuals’ behavior. One type of system-based intervention that can benefit patient safety involves improvements to hospital design. Given that people’s working environments affect their behavior, good design at a systemic level not only enables staff to work more efficiently; it can also prevent errors and mishaps, which can have serious consequences for patients. While an increasing number of studies have demonstrated the effect of hospital design on patient safety, this knowledge is not easily accessible to clinicians, practitioners, risk managers, and other decision-makers, such as designers and architects of health care facilities. This is why the Swiss Patient Safety Foundation launched its project, “More Patient Safety by Design: Systemic Approaches for Hospitals,” which is presented in this chapter.

The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study.

In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility.

Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013).

Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

The purpose of this paper is to study a medication distribution technology's (MDT) impact on medication errors reported in public nursing homes in Québec Province.

The work was carried out in six nursing homes (800 patients). Medication error data were collected from nursing staff through a voluntary reporting process before and after MDT was implemented. The errors were analysed using: totals errors; medication error type; severity and patient consequences. A statistical analysis verified whether there was a significant difference between the variables before and after introducing MDT.

The results show that the MDT detected medication errors. The authors' analysis also indicates that errors are detected more rapidly resulting in less severe consequences for patients.

MDT is a step towards safer and more efficient medication processes. Our findings should convince healthcare administrators to implement technology such as electronic prescriber or bar code medication administration systems to improve medication processes and to provide better healthcare to patients.

Few studies have been carried out in long-term healthcare facilities such as nursing homes. The authors' study extends what is known about MDT's impact on medication errors in nursing homes.