James Reason on BBC Radio 4 Part 2

Back in February I got very excited and wrote a post about a 2-programme BBC Radio 4 series presented by Prof James Reason. I have finally had chance to catch up with the second part of this programme – even though it aired on 5th March! Yes I have been that busy. I like being busy though so I am most definitely not complaining.  Before you read this, you may want to read my earlier post which introduces the programme.

The second installment, I am sad to report did not include pharmacists amongst the healthcare professionals invited to talk on the programme. I had hoped it might, but it is only a 30 minute programme and they really were going for the heads of the big NHS /NHS related services so, it is not surprising. Despite the lack of pharmacy input into the programme, it was still very interesting and there were lots of points that could easily apply to pharmacy practice.

Firstly Sir Liam Donaldson, Chairman of the National Patient Safety Agency commented on his own visit to the University of Michigan Health Centre who have been looking at the effects of an open policy to medical errors over the last decade (which was the focus of the previous episode of this programme). He said one thing he noticed that was very different was the training that was given to staff on how to talk to patients about the errors that had been made with their care. He also noted that the support that was provided to the patient and the family was much more than just an apology that they stayed without them throughout the whole process. In terms of our work into mental workload, the emphasis would definitely have to consider both how to train pharmacists to avoid errors, but also how to deal with them if they did happen (especially if they happened because of mental overload).

Next, a representative from the National Reporting and Learning Service talked about how the approach to errors has changed in UK healthcare over the last few years. How she felt that the daily reports (e.g. before staff started their shift on a ward) had changed to include a focus on situations or patient issues that had the potential to lead to errors being made. Again this could easily be applied to pharmacy practice (this may be especially useful for locum pharmacists).

By contrast Peter Walsh CEO of Action Against Medical accidents painted a much bleaker picture of our healthcare system today. He spoke about a case his organisation has been dealing with where the errors that had been made in a young man’s care was covered up. This young man died because of these errors, and at the time the family were made aware that some errors had been made but they were not given the full story and shockingly neither was the coroner. Peter Walsh said that cover-ups were still tolerated in our health system and that this needed to change. I agree with this, but for this to happen I think we need to implement Sir Donaldson’s observation that healthcare professionals need to be trained and supported in how to be open with patients when errors occur.

For me, it is so exciting that these programmes have been aired in the last couple of months. Pharmacy is making a huge step at the moment to changing the safety culture and for that to happen the NHS needs to be making that step too, because ultimately the pharmacy profession works within the culture of the other healthcare services and systems in the UK. The fact that this is being talked about now, gives me hope that healthcare as a whole is moving towards this change in culture…but we shall see what happens.


Student Study & Community Pharmacist Study Updates 14.03.2012

Image by Roger Hargreaves

Sorry for the lack of study updates recently, it has been a busy few weeks. It started with a weeks worth of media coverage of our community pharmacist study that we have just launched in various pharmacy publications – who would have known a project not even completed could create so much interest? For this Jane, Marjorie and I are so very grateful and very excited – we hope there is just as much interest next year when we have data to publish.

In between that I have been testing participants for the student study. We are now up to 40 students through the first experiment so we have almost hit our total for the first study (52). I am hoping we get our last few recruits soon because I cannot wait to look at our data. The database is looking so lovely and full – it’s odd, but to me it really is a thing of beauty. This is probably because I know how many hours of hard work has gone into filling the database and it’s amazing to see the slow but sure outcome of all our efforts.

With regards to the community pharmacist study, the big news is that we got ethics a couple of weeks ago and I have now sent out information about the study (as of today) to pharmacy chain CEOs and superintendent pharmacists, to ask their permission for me to do research with their organisation before I contact their local and regional pharmacy managers about it. The independent pharmacy and small pharmacy chain letters are in process too and I hope I will get them out tomorrow. So we are definitely on a roll.

In between that I have been doing a lot of demonstrating work – which is basically a teaching assistant role for university workshops. I love these sessions – even when I do the same session several times over with different groups of students. However, it does take me out of the lab for hours at a time, and/or away from my desk and so I have noticed that my research time has more than halved in the last few weeks. There are only a few more weeks left of teaching for me now until next October, so I am making the most of it because I really do enjoy working with the students.

In the odd moments of calm I have also been busy working with Jane and Marjorie and some of our other colleagues on papers and grant proposals.

How I have found time to do all this I just don’t know, in fact now I read this it is no wonder I have felt like a headless chicken the last few weeks. Ironically, my mental workload has been very high at times (mostly due to time pressure) and I have noticed myself missing things, doing things wrong or forgetting to do things. So it’s not only pharmacists that may be affected by mental workload, it may be researchers too!

So as you can see it has been an amazing few weeks, busy, but in the best of ways. I have yet to have time to listen to the second installment of the Prof James Reason medical errors BBC radio 4 programme that I wrote about here. I hope I get to listen to it by the end of the week and I will write about it then!

Outside the box: inside pharmacy


Yesterday I presented with my supervisor at the Outside the box: inside pharmacy conference in Bristol. It was aimed at pharmacists from the south west of the UK and is about fostering connections between difference disciplines of pharmacists, and building stronger networks in the local areas. My supervisor and I were lucky to be invited as conference delegates were limited to those who were members of the Royal Pharmaceutical Society.

Anyway I had the most amazing day, meeting so many inspiring pharmacists and pharmacy students. After one talk I was on the verge of re-training to become a pharmacist as the speaker gave a talk about what exciting times there were ahead for those in the pharmacy profession!

Anyway I was asked to present about the theory behind my research. I called the talk brain errors (which explains the photo above) and spent some time explaining how the way our brains work can lead us to make certain types of errors. It was perhaps the most nerve-wracking and difficult talk I have given so far in my career. Firstly I was worried that I wasn’t going to do the concepts I was talking about justice or explain them well enough. They are fairly straightforward, but quite abstract and I only had a 20 minute slot to outline them and how that might all relate back to dispensing errors. Plus I had to work hard to pitch it at the right level – i.e. for people who had never come across psychology theories before. However, I think most of my nerves were down this was the first time I had presented in front of a non-academic & 100% pharmacy audience and as they will be the key audience for my results when I have them, it was so important to me that they thought my rationale and the theories I was using were relevant. The talk was a big deal for my supervisor as well who has been trying to promote the role of psychologists within this field for many years. So we both felt we had a lot riding on our talks.

I think we sold it though. We were asked lots of questions afterwards about the theory and other people said they would be interested in hearing more – taking part in the research – or – most exciting doing some research in collaboration with us. I must not get my hopes up too soon, but that is the first time anyone has approached “little old me” and said I would love to work with you on a project related to this.

So we made some great contacts, and best of all, because some of the students at our University attended this conference, they got in touch afterwards and asked if they could take part in my study. Every time someone says they want to take part I get very excited – one participant closer to my goal, but also that is one more person that thinks my research is worth giving their time to. Hooray! The pace is starting to pick up now with the research so I am sure my updates are going to be much more frequent.

Presenting at the outside the box inside pharmacy conference (Photo credits to Dr Philip Rogers)

Day 1 of testing

Hooray! Day 1 of testing for the student pharmacist study has gone with success. Only 2 minor hiccups, so in my book that is a resounding success.

Me after a hard days work at uni!

This will be me in a few hours – as I am off to my favourite cocktail bar tonight – it wasn’t planned as a celebration for the first day of data collection going well, but I am sure I will elbow a toast to that in at some point. Anyway, before I head home to put on my fancy clothes and enjoy a cocktail or two – I shall tell you about the hiccups!

Hiccup 1: Not really a hiccup more par for the course when doing research with human participants. One participant cancelled around 10pm last night. Thankfully this person is super keen to take part but something urgent had cropped up that meant they couldn’t take part today but they are free next week so have agreed to come then. Phew!

Hiccup 2: A rather amusing hiccup really given the amount of time we spent trying to avoid this happening. Basically there were some unintended errors in our task items – but to get why this is an issue you need to know a little more about this student study.

The aim of my doctoral research is to find out what factors increase or decrease the likelihood that pharmacists will notice dispensing errors when they are asked to carry out a final check of some pre-dispensed items. So I get participants to come in and “do a final accuracy check” which is basically double check of 50 medications and medication labels against a set of corresponding prescriptions. The medications are real (as we have real stock for pharmacy students training purposes) and the labels and prescriptions are designed to mimic (look very similar) to those that they would see in real life practice.  At the beginning of the week – before I started testing participants, all these medications were dispensed and labelled (and “faux” prescriptions) were produced by a fabulous member of staff qualified and very experienced in the dispensing of medication. A certain percentage of the items have deliberate errors in – the participant’s main task is to spot these. Next I asked two other qualified and very experienced pharmacists in the department to check everything that had been dispensed to make sure there were no unintended dispensing errors in the task set. Well, clearly they didn’t notice much to the other pharmacists’ amusement. I am pleased though as it just reinforces in my mind that I am going along the right lines with my research –  we just can’t spot errors / problems / targets 100% of the time.

So all in all I think it was a good start. Tomorrow I test 5 more participants, fingers crossed we have ironed out all the kinks in the testing procedure and it all goes to plan tomorrow!

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