ME5532: HUMAN FACTORS AND MEDICATION SAFETY (2024-2025)

Advanced Clinical Practitioners make a positive contribution to patient safety, but it is recognised that the benefits of the role are not fully realised. ACPs can be viewed as a ‘complex intervention’ which can have impact across the care system in which they operate. Understanding this is challenging – the ACP role is relatively new, so much of the ‘performance’ data is drawn from novice practitioners. ACPs themselves recognise that they need ongoing education and training to support their professional development. Related to this is that there appears to be a strong implicit assumption that the ACP role is primarily about ‘medical substitution’ rather than a role with the potential to transform services by bringing a different skills mix to the team.

ACPs have been shown to make a strong contribution to medication safety. Medicines review and reconciliation by ACPs has been shown to reduce medication errors, and their support for patients in terms of lifestyle management can reduce the need for medication. This role could be further enhanced by increasing CPD for ACPs in both medication safety and incident reporting and investigation. This aligns with the World Health Organization’s 3rd Global Patient Safety Challenge, Medication without Harm.

Medication safety emerges from a complex prescribing environment. Human Factors specialists  recognise as an issue the gap that exists between ‘work-as-imagined’ (what we think healthcare staff do, based on what is captured in ‘official’ procedures and processes) and ‘work-as-done’ (what really happens in practice). ‘Work-as-done’ reflects adaptations that are made by staff which are necessary if desired outcomes are to be achieved despite the variable demands of health and social care systems.

Many of these demands are familiar to staff – they include things like the high demand for care, under-staffing, fatigue, distractions and the cognitive burden imposed by challenging medication-related tasks. However, other demands are less obvious: many of the safety controls in medication pathways are social and/or administrative. Such controls are weak – they rely on the behaviour of people within the system. However, they are often necessary because of poor design of the tools and technologies used by prescribers.

‘Safe and effective’ are words that are frequently used by regulators to describe the expected performance of healthcare professionals. However, what is almost universally lacking is practical guidance to support the development and maintenance of safety competencies. Human Factors, as a person-centred safety science, has much to offer when it comes to supporting health care practitioners in developing practical safety skills and competencies. The course content will provide a thorough introduction to the core Human Factors principles of systems thinking and user-centred design. Students will have the opportunity to apply Human Factors frameworks, methods and tools to practical real-life medication safety problems. There will also be an opportunity to learn how systems-thinking principles can underpin better procedure design, and there will be a specific focus on how a Human Factors approach can support more effective incident reporting and learning, with the final assessment taking the format of a report of an incident investigation.

Information on contact teaching time is available from the course guide.

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