Thread by @MarkOneinFour

Welcome to the next session at #quality2021 (internationalforum.bmj.com/europe/) "Optimising the medication pathway: Meeting the WHO 2022 target of 50% fewer medication errors and clearing patient backlogs through automation". It runs through to 14.15GMT. Thanks for joining me

This is the abstract for the session. Basic summary: using automation to reduce medication errors internationalforum.bmj.com/europe/2021/03… #quality2021

Kirran Walsh of BMJ is introducing our session. First up: Rachel A. Elliott, Professor of Health Economics at the Manchester Centre for Health Economics; United Kingdom. Elliot is setting the scene in terms of economic impact of medication errors #quality2021

(Sorry, Kieran Walsh!) #quality2021

Elliott is saying the cost of medication errors for the NHS is large, as is the harm errors cause. Over a third of those over 65 discharged from hospital suffered some medication related harm within 8 weeks. Says we need to focus on what we can prevent #quality2021

John Dean, Clinical Lead for Quality Improvement and Patient Safety at the Royal College of Physicians, Deputy Medical Director of East Lancashire Hospitals, NHS Trust is up now. Is asking to think about patient pathways. #quality2021

Dean says that patients come to hospital with medications, then pass through many stages of treatment. At all stages medication may change, as might their health. All of these stages and changes alter medication prescribed/needed/ responded to. #quality2021

Dean says that there needs to timely provision of medications, monitoring. In hospital, the routines of a patient's life are changed, which impacts on their use of medication: the patient loses control. There are high risk medicines, high risk busy departments #quality2021

Dean says that medication errors may happen at one stage of a patient's pathway but be detected at another. We know that much unnoticed deterioration happens because another patient is in more need of attention. Says we need a system approach to system errors #quality2021

Now up: Johan Hellings, CEO AZ Delta and Senior Lecturer Patient Safety, Hasselt University; Belgium. Helling says right medication, right dose, right time in right structure is the goal. Says an electronic patient record is the answer to preventing errors #Quality2021

Helling says a future for integrated patient records systems is good. Automated pharmacy meets intelligent records which can keep track of interactions, changes. The aim of automated pharmacy is to reduce error in fast moving situations #quality2021

Helling says we need to close the loop of automation by scanning patient identity by a barcode and medication before doses are given. Helling says that we are all human, so we also need to train and listen to staff. You can't do this without motivated professionals #quality2021

Helling is stressing that technology needs people to implement it in health settings and that the technology and people need to work together to implement activity to reduce medication errors #quality2021

Up now: Anders Westermark, MD Project Lead of Safe and Efficient Pharmaceuticals Chain, Uppsala University Hospital; Sweden. Says you should start where you get your hands dirty when implementing in his experience. They started with automated prescribing cabinets #quality2021

'Start little but get your hands dirty quick' says Anders Westermark. Says it's important to do a stakeholder analysis very early. Change can't happen if you don't have the support and insight of staff on the ground #quality2021

Westermark says it's a myth healthcare is an area that easily accepts change. It is in fact risk adverse, but for good reasons. Also says that it's a myth patient and staff interests are opposed. Staff want to feel competent. Want support and right to ask questions #quality2021

Westermark says we often approach staff with wrong priorities when trying to do automation or tech. They want to do their job better, not save money or increase overall efficiency. Aligning change with their questions and concerns #quality2021

Up now, speaking about zero medication error targets is Mike Fairbourn, Patient Safety Chair at the Association of British HealthTech Industries, VP and General Manager at BD; United Kingdom and Ireland. Says their company has been in the business for over 100 years #quality2021

Fairbourn asks 'what problems are we trying to solve thinking of the future of the hospital where medication errors can be eliminated?' #quality2021

Fairborn says hospitals face four issues in relation to medication management:

-drug shortages
-medication waste (pharmacists don't know what happens to meds dispensed
-time stress on staff around medication (calling pharmacy etc)
-the cost of errors

#Quality2021

Fairbourn says that health professionals do an awful lot of manual work to knit together systems that aren't connected. A lot of ringing, checking, searching for medication. Says that automation can smooth this workflow by linking the bits of the system #quality2021

John Dean says we need a human centred design approach to making these new systems: understanding people in places and situations then taking an active design approach. Information needs to be able to travel both inside and outside hospital #quality2021

John Dean says we need electronic monitoring and decision aids. Says that we need teams that can act when things go wrong and also to promote more going right. Says both feedback and learning loops are needed so that things that go wrong can be solved systematically #quality2021

Dean says that local people need to design the solutions and also decide what level of error can be absorbed. Westermark says solution in automation can both cut into failure but also into success. Need human factor which can adapt and improvise. #quality2021

Westermark says that technology doesn't make so many mistakes but can't improvise ang humans make more mistakes but can. Also says 'don't blame workplace culture' as this just shows you haven't understood people and context #quality2021

Westermark is stressing the need to map and model the ways in which work actually happens. This allows you to trial changes. Says you should have an information model, use cases (with exceptions) a model of requirements and both a prototype and an evaluation model #quality2021

Hellings is saying that Covid-19 impact in their hospital was overwhelming, but it was also a time of developing a new spirit of cooperation between primary care and secondary care around covid screening and vaccination. Hospitals don't need to be the centre of care #quality2021

Hellings says that integration between primary and secondary care is an important way to reduce error. This is an argument for electronic records following the person, not be walled in a set of separate systems. Says the pandemic might be a trigger for this change #Quality2021

Hellings says that research doesn't get implemented in fragmented systems. Integrated care will provide us new perspective on medication safety, he says #quality2021

Fairbourn says the NHS is currently driving toward integrated systems, which says *should* breakdown gaps between silos and budgets. Says procurement needs to be a full value-based decision looking at impact over time. Makes the case for a less risk averse approach #quality2021

Fairbourn says the NHS and industry needs to turn up in a different way, looking at less short term goals, looking more at long term relationships. He's also arguing against the 'one product to rule them all' approach where tech is bought as an all-in service #quality2021

Fairbourn is also the first person so far to allude to the issue of data sharing as potentially problematic, as this weeks events in the UK have shown. Interoperability and the sharing of data needs people to be understand what's happening and why #quality2021

Elliott is saying that a needs driven, rather than a technology first approach is music to her ears but says this all a big ask at a time of constrained budgets and growing demands. Value based offer not only acquisition cost offer needs measurement, she says #quality2021

Elliott says if we are measuring the reduction of error in medications, it's important to work out ways to measure if we are actually making a difference. We need to know which errors are damaging to patients. The ones we can measure might not be important #quality2021

Elliott is saying we need to link errors to what actually happens to the patient. Some errors may make little difference to the patient. Elliott is stressing the need to know what the outcomes of reducing particular errors is predicted to be if we want to invest #quality2021

Elliott points out that the aim from the WHO is to reduce the harms created by medication errors, not to simply reduce the errors themselves. This is a strong point, focusing on purposes not on products. You can reduce lots of errors and change little for patients #quality2021

Elliott gives the example of administering a drug at slightly the wrong time between doses. The impact of this is very different from the wrong medication or no medication #quality2021

A question about cybersecurity concerns from the chat. Fairbourn says cybersecurity is a priority for his company. Westermark says that in their work implementing solutions, their team developed a checklist for considerations #quality2021

A question about closed loop medication, where bedside dispensing feeds back into records. Westermark says if staff need lots of training in a solution, you're probably on the wrong track #quality2021

A question about standardising software nationally to reduce training needs. John Dean says this isn't the right track. Suggests that there could be collaboration around interfaces and perhaps national standards. Says we need a common language in medication systems #quality2021

Dean says that primary and secondary care don't have the same language about medication. Says that software might actually be standard, but local implementation introduces differences. Dean not keen on one massive roll out of standardised tech #quality2021

Westermark being asked about amount of time it took for clinicians to become familar with new technology. He says when they did e-prescribing there was a long curve, but that was because the tools didn't fit the workflow. Also says 'don't do elearning for training' #quality2021

Westermark says clinicians aren't that interested in tech. Don't keep explaining more and more to them in the hope they'll finally get it. Train clinicians to train other clinicians. Always ask 'am I overfilling the cup? If so, stop pouring' keep it simple #quality2021

'If people aren't getting it, you might need to rethink what *it* is' is the flavour of Westermark's view. #Quality2021

Another question: 'how do you build a compelling business case in a system where there are other equally compelling business cases?' Hellings says you need to know what you are trying to measure and trying to change: safety, efficiency, patient safety #quality2021

Another question: 'how do you break the taboo about medication error?' Hellings says you need a just culture to do this, of change not blame. Dean: front line staff need to work collaboratively, interaction across structures: ward, pharmacy, beyond to do right thing #Quality2021

A final question: 'I've been hearing this discussion for years. How can we disrupt to accelerate change?' Elliott saying we need to focus on what we want to change not on the shiny things of tech. We need to focus on harm, on the value of error reduction #quality2021

Elliott says we need to be practical: 'what do we know works?' She says we must stop talking in generalities. We need to know why we want to reduce errors. A strong argument against solutionism in health, there! #quality2021

Westermark says 'the second costs are connect to patient harms, the work reducing errors will accelerate'. And that's the end of the session! An interesting one where I take away that asking 'what's the point of this improvement? remains imperative #quality2021

And that's it for this bit of live tweeting from #quality2021. I'll be back with you at 16.30GMT to live tweet from a session called "The Role of Leadership in People Wellbeing: Addressing Front Line Burnout Through Culture and a Systems Approach". See you then!