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experience. Medication errors are the most common Whilst the number of reported medication incidents has
type of incident reported in most hospitals in the UK. increased since appointment to the role of Medication
We want to reduce the number of medication errors Safety Officer in 2014/15, the actual harm attributed to
happening in Alder Hey for 3 main reasons: incidents has dramatically reduced as demonstrated in
Table 2. This is reflective of an improved safety culture
• Medication errors can harm patients. The majority of
and willingness to report incidents openly, including
the errors which have happened in Alder Hey have
those that don’t reach the patient.
not caused harm to patients but a small number have
caused harm or might have caused harm if they had
Graph shows the number of incidents that resulted in
not been discovered before reaching a patient.
harm. This has decreased from 128 in 2014/15 to 32 in
• Medication errors can increase the length of time a 2017/18 (75% improvement), including zero incidents
patient stays in hospital or increase the cost of their causing moderate, severe harm or death.
stay because more tests, investigations or treatments
are needed. This fantastic outcome far exceeds our Sign up to
Safety 3 year target for reducing harm from medication.
• Being involved in a medication error can be a very
difficult experience for patients, their families and the
staff involved. Number of Incidents of Harm from
Medication Incidents
Medication errors are reported on the Trust’s incident
reporting system (Ulysses). Individual errors are
140
immediately triggered to the manager in the area where
the error happened plus other appropriate individuals. 120

The Medication Safety Committee (MSC) (a subgroup 100
of the Drug and Therapeutics Committee) review
monthly summaries and identify trends in reporting. 80
60
The Trust’s Weekly Meeting of Harm reviews incidents
that have caused harm to patients in the previous week,
40
this includes medication incidents.
20
The Clinical Quality Steering Group review overall
trends in medication error reporting. 0
2014/15 2015/16 2016/17 2017/18
Graph shows ongoing increase in reporting of
medication incidents. This has increased from a 2014/15 2016/17
baseline in 2014/15 from 703 incidents to 1209 in
2015/16 2017/18
2017/18 (a 72% increase in reporting).

Total Number of Medication Incidents Reported Improvements

This section lists the improvements developed to
1500
reduce the number of medication errors reaching
patients and causing harm over the past three years:
• Improved the quality of incident report data by
1000
implementing a more consistent approach to follow
up and ensuring minimum data is completed prior to
incidents being uploaded to the National Reporting
and Learning System.
500
• The implementation of the MERP (Medication
Error Reporting Program) grading structure for
classification of harm caused by a medication error.
0
2014/15 2015/16 2016/17 2017/18 This provides a much more objective method of
assessment.
2014/15 2016/17

2015/16 2017/18

Alder Hey Children’s NHS Foundation Trust 130 Annual Report & Accounts 2017/18