Healthcare safety investigators advocate that all professionals responsible for prescribing use an online learning programme developed by the University of Birmingham.
It would be beneficial for the SCRIPT eLearning programme to be mandatory for all prescribers and rolled out across the country, said the Healthcare Safety Investigation Branch (HSIB).
It is one of a raft of safety observations made by HSIB in its latest report, aimed at driving national improvements to reduce potentially fatal medication errors. The safety actions follow an investigation by the HSIB, launched after a nine-year old child was wrongly administered an oral liquid drug into a vein during a planned renal biopsy. The child stayed in hospital for monitoring and was discharged a day later with no adverse effects.
SCRIPT, developed by the University of Birmingham and OCB Media, was created in 2010 to encourage safe and effective prescribing among newly qualified doctors in response to a study in 2009 commissioned by the General Medical Council. This study found that trainee doctors prescribe with an error rate of eight to 10%.
Jamie Coleman, Professor of Clinical Pharmacology and Medical Education at the University of Birmingham, was one of the experts called upon to comment on the HSIB investigation and its findings.
Professor Coleman said: “We welcome the investigation by the HSIB and its recommendations, which addresses complex interrelated human factors that can be difficult to recognise in practice.
“Not only will we be examining safety actions to ensure that they are embedded into the undergraduate training of all healthcare professional courses at the University of Birmingham, we will also contribute to the national development of medicines safety processes given our extensive research activities in the area of medicines safety.”
Dr Sarah Pontefract, Lecturer in Clinical Pharmacy and Therapeutics at the University of Birmingham, was also invited to comment on the findings of the HSIB investigation and the recommendations.
Dr Pontefract said: “Administration of a medication via the wrong route is a never event in the National Health Service. This means that such errors are largely preventable if healthcare providers act to implement existing guidance or safety recommendations.
“We welcome the observation from the HSIB that it would be beneficial to roll out SCRIPT as a mandatory requirement for all prescribers. The SCRIPT eLearning programme, funded by Health Education England, delivers just-in-time education for the continuing professional development of healthcare professionals relating to prescribing and therapeutics.
“This is essential to ensure staff involved in the medication process remain up-to-date with changes in prescribing guidelines, safely alerts and legislation.”
Keith Conradi, HSIB Chief Investigator, said: “Our investigation highlighted how challenging it is to make improvements at a national level, due to the complex nature of safety processes and the number of human interactions needed to prevent errors from occurring.
“The case we looked at for the investigation demonstrated that whatever the level of harm, medication errors have a devastating impact on all those involved – patients, families and staff.
“We recognise all the good work already undertaken but there is more to be done. The recommendations set out in the report are focused on ensuring consistency in standards and training. We trust this collaborative and cohesive work at a national level will improve medicine safety processes across the system.”
Since its launch, further versions of the SCRIPT programme have been developed for foundation trainee dentists, paediatric trainee specialists, nurses, GP trainees, and non-medical prescribers. Each SCRIPT portfolio comprises a number of modules covering a wide range of crucial therapeutic topics. A module usually takes around 30–60 minutes to complete. All course materials have been authored by a team of expert healthcare professionals, and are reviewed and updated by the SCRIPT on a weekly basis to reflect changes in practice.