title: Learning from the design, development and implementation of the Medication Safety Thermometer.
abstract: Approximately 10% of patients are harmed by healthcare, and of this harm 15% is thought to be medication related. Despite this, medication safety data used for improvement purposes are not often routinely collected by healthcare organizations over time.
  
  
  METHODS
  A need for a prospective medication safety measurement tool was identified.
  
  
  METHODS
  The aim was to develop a tool to allow measurement and aid improvement of medication safety over time. The methodology used for the National Health Service (NHS) Safety Thermometer was identified as an approach. The resulting tool was named the 'Medication Safety Thermometer'.
  
  
  METHODS
  The development of the Medication Safety Thermometer was facilitated by a multidisciplinary steering group using a Plan, Do, Study, Act (PDSA) method. Alpha and beta testing occurred over a period of 9 months. The tool was officially launched in October 2013 and continued to be improved until May 2016 using ongoing user feedback.
  
  
  RESULTS
  Feedback was gained through paper and online forms, and was discussed at regular steering group meetings. This resulted in 16 versions of the tool. The tool is now used nationally, with over 230 000 patients surveyed in over 100 NHS organizations. Data from these organizations are openly accessible on a dedicated website.
  
  
  CONCLUSIONS
  Measuring harm from medication errors is complex and requires steps to measure individual errors, triggers of harm and actual harm. PDSA methodology can be effectively used to develop measurement systems. Measurement at the point of care is beneficial and a multidisciplinary approach is vital.
authors.affiliation: Manchester Pharmacy School, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Oxford Road, Manchester, UK.
authors.forename: Paryaneh
authors.initials: P
authors.lastname: Rostami
authors.affiliation: Haelo, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK.
authors.forename: Maxine
authors.initials: M
authors.lastname: Power
authors.affiliation: Haelo, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK.
authors.forename: Abigail
authors.initials: A
authors.lastname: Harrison
authors.affiliation: Haelo, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK.
authors.forename: Kurt
authors.initials: K
authors.lastname: Bramfitt
authors.affiliation: Manchester Pharmacy School, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Oxford Road, Manchester, UK.|University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, UK.
authors.forename: Steve D
authors.initials: SD
authors.lastname: Williams
authors.affiliation: Pharmacy Department, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK.|UCL School of Pharmacy, Brunswick Square, London, UK.
authors.forename: Yogini
authors.initials: Y
authors.lastname: Jani
authors.affiliation: Manchester Pharmacy School, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Oxford Road, Manchester, UK.|NIHR Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Oxford Road, Greater Manchester, UK.
authors.forename: Darren M
authors.initials: DM
authors.lastname: Ashcroft
authors.affiliation: Manchester Pharmacy School, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Oxford Road, Manchester, UK.
authors.forename: Mary P
authors.initials: MP
authors.lastname: Tully
mesh_terms: D003153:Community Health Services / Q000458:organization & administration*; D003625:Data Collection; D004739:England; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation
keywords: PDSA; harm; measurement; medication errors