He explained that healthcare is intrinsically harmful. One in 10 people admitted to hospital is harmed unintentionally and there is a one in 300 chance of accidental death arising from errors in care. “So we are talking big numbers,” he said. “But between a third and a half of harms are foreseeable and avoidable.”
The 1,000 Lives Plus campaign is about running specific improvement programmes, Dr Wilson said. “We focus on patient engagement. We are trying to systematise the approach to doing things differently.”
He told the conference that medicines management can be chaotic at times. And by way of example he showed a graph summarising the “survival of the intention to get things right”. In his graph, the intention at the beginning of the medication process was 100 per cent but there were various stages in the process that resulted in a loss of that intention. For example, a medicine might be prescribed incorrectly, then the prescription might not be handed in for dispensing, or it might be dispensed inaccurately. Having received the medicine, patients might decide not to take it and even if they did it might not be effective. The survival of the prescriber’s intention, having passed through these various stages, could be as low as 5 per cent, Dr Wilson explained.
So where do we focus our efforts to improve this? Teamwork is the answer. But what is a team? “It is easy to think that a team is made of people just like you,” Dr Wilson said. “But such a team will not provide a multitude of knowledge and experience. You need to think about the process and base the team on that so that, rather than like-minded people, we will have a team that will look at the whole process.”
Dr Wilson said that pharmacists should talk to different people, and never assume that something is happening. For example, in one area 11 per cent of warfarin patients were not having their INRs tested because everyone assumed that someone else was doing it. Over 90 per cent of these patients did not have any requirement for INR testing written in their GP notes, yet some people who were not taking warfarin were having INR checks.
Dr Wilson said that harm is a solvable problem and that solutions must be outcomes-focused. “Teams must be based on the process,” he concluded.
By Graeme Smith
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