Using Leeds Improvement Method to Improve the Process for Investigating Medication Incidents at Leeds Children’s Hospital​

Abstract

Background Medication incident investigations at Leeds Children’s Hospital were time consuming, inconsistent, and heavily influenced by a blame culture. Learning often failed to feed back to frontline staff, and investigations took on average over 60 days to finish and close. System level barriers including a blame culture, limited staff time, and governance structures prevented effective escalation.

Aim To streamline the medication incident investigation process, reduce waste, strengthen learning, and embed a system based, psychologically safe approach to improvement across the Medicines Management & Pharmacy Service (MMPS) and Leeds Children’s Hospital.

Methods A Leeds Improvement Method week-long improvement event deployed three PDSA cycles: Medication Safety Debrief to improve immediate awareness and multidisciplinary understanding of incidents. Trust‑wide learning integration by weaving improvement into governance frameworks to improve how insights flow back to frontline staff. Reducing blame culture through Human Factors and Just Culture principles, enabling staff to engage without fear and supporting a system‑wide learning mindset.

Results The redesigned process reduced investigation time with medication investigations being closed within two days of being submitted. There has been a wider multi- disciplinary approach with greater staff engagement and positive feedback from patients. The pilot wards have seen a notable reduction in medication incidents since the event which has been sustained for four months. However, limitations to the new process have occurred where incidents fall between two CSUs.

Conclusion System redesign of medication incident investigations supported by Human Factors and structured learning processes improved efficiency, enhanced psychological safety, and created a more reliable mechanism for learning across the Trust. Next steps in the learning are to expand testing to different specialties using a continuous improvement approach to scale and spread and link the process to the investigation of other harms.