{
  "abstract": "Background Our quality team were working to improve medicines management safety through thematic reviews of patient safety events in adult and children’s services. In the Spring of 2024 an increase in these events on the adult inpatient unit and particularly an increase in the number of events reaching patients caused concern. There were no severe harm events but the nature of events and the potential for them to cause harm triggered an acceleration of the improvement process with a further thematic review and an externally commissioned rapid response review done alongside each other.Aims To reduce the number of medication-related patient safety events across all our adults and children’s services.To reduce the number of medication-related patient safety events which reach a patient.To reduce harm from medication-related patient safety events.Method All medication-related patient safety events were investigated individually with actions and learning as needed. Drug room CCTV viewed to support learning from patient safety events. Three thematic reviews of patient safety events relating to medications across adult and children’s services completed: August 2022-July 2023; July 2023-January 2024; January 2024- June 2024.Rapid response review of medicines management across the organisation in the summer of 2024 taking a Care Quality Commission style approach completed. Use of systems engineering initiative for patient safety (SEIPS) framework (NHS England. SEIPS quick reference guide and work system explorer. [Vers.1]. 2022) to look widely at potential system and process changes to improve patient safety.Results Improvements and changes made through this work have resulted in:A sustained reduction in the total number of medication patient safety events.A shift towards no and low harm events.Less medication errors reaching patients.Conclusion Through a multifaceted review of medications management and medicines-related patient safety events across the organisation we have been able to reduce both the numbers of events and the levels of harm to patients.",
  "authors": [
    {
      "affiliations": [
        "Havens Hospices, Southend, UK"
      ],
      "name": "Rachael Marchant"
    },
    {
      "affiliations": [
        "Havens Hospices, Southend, UK"
      ],
      "name": "Louise McKay"
    },
    {
      "affiliations": [
        "Havens Hospices, Southend, UK"
      ],
      "name": "Rachel Johnson"
    },
    {
      "affiliations": [
        "Havens Hospices, Southend, UK"
      ],
      "name": "Carol Chambers"
    }
  ],
  "title": "P-92 Using quality improvement and learning from patient safety events to improve safety of medicines management in hospice and community settings",
  "uid": "dd642b8f-9061-5e5f-b7da-6b4aab14ebb2"
}