Medication safety is about reducing harm caused by medicines without affecting the good they do. Strong clinical leadership is crucial for this work.
Medicines are everywhere in health care, from the bathroom cabinet to the operating theatre. The potential for medication-related harm is everywhere too. Simply giving fewer medicines is not always the answer as there can be as much harm caused by not giving medicines that should have been given. Not giving or taking medicines for fear of a bad outcome or, at the other extreme, becoming too tolerant and accepting of the harm caused by medicines are both possible approaches. The middle ground is to continue using medicines while actively looking for ways to reduce harm.
For example, morphine-like medicines routinely cause constipation. This harm features strongly in trigger tool data obtained from district health boards (DHBs) and in data from the Health Quality & Safety Commission’s opioid collaborative. Given available treatment options many cases of constipation should be either preventable or treatable.
At the other end of the spectrum, medication error can cause serious harm or death. There are multiple ways for consumers, health care workers and institutions to report medication-related adverse events and errors. The Commission aims to be a vital connection between individuals and organisations for learning from adverse events. Through our partnership with the sector we identify system changes to improve safety and quality.
Medication safety is not an issue that will disappear once all health care workers are using electronic systems for prescribing, dispensing and administering medicines. Nor is it an issue for clinical pharmacy alone. Key professions – nurses, pharmacists, midwives and doctors – must work collaboratively and take collective ownership. Too often events are followed up by one of the professional groups in isolation eg, it was an administration error therefore it was a nursing responsibility to sort out. A better approach is to have a multi-disciplinary review and consider that something about the storage, labelling or prescribing of the medicine may also contributed to the event.
There is a need for better governance within DHBs to make collective ownership easier and more transparent, and to make improving medication safety a strategic priority. Until this happens we are likely to achieve short term improvements in behaviour, rather than long term improvements through changes in culture and better integrated systems.
All individuals have a leadership role to identify potential harm and events and to improve the safety of systems, processes and behaviours. This involves acting when things aren’t going well, modelling through actions and words and speaking up for safety.
Effective clinical leaders will need influence at all levels, more than authority, to drive positive change. It is not the leader’s authority that motivates successful multidisciplinary teams or determines their impact; it is the leaders ability to influence and inspire.