Dr K Lynette James
Honorary Senior Research Fellow
- Main Hospital Building, University Hospital of Wales, Heath Park, Cardiff, CF14 4XN
- Welsh speaking
I am the all Wales Consultant Pharmacist for Acute Care and Medication Safety. I work as a clinical academic pharmacist actively delivering pharmaceutical services to patients within hospital in a local University Health Board. I am also the National Clinical Lead for Medicines Safety advising the Chief Pharmaceutical Officer and colleagues at Welsh Government on the safe use of medicines, thereby informing and contributing to the development of National policy.
I am an active researcher undertaking research in all aspects of medicines safety. I am particularly interested in the impact of human factors, psychology and technology on medication errors. I have published widely on medication error research methodology, the nature and causes of medication errors and interventions to reduce medication errors. Recently I have focussed on the use of research to ensure that policy and practice is informed and supported by a robust evidence base, authoring technical documents and patient safety alerts for Government.
Central to my leadership role is providing support, development and training to healthcare professionals on medicines safety and risk management. I contribute to the education and training of undergraduate pharmacy and medical students and post-graduate pharmacists. In my clinical practice, I support and contribute to the delivery of practice-based education and assessment of doctors, nurses and pharmacists. Furthermore, I provide leadership to all healthcare professionals in medicines safety and research to a variety of national committees including the All Wales Medicines Safety Network, All Wales Prescribing Advisory Group, Yellow Card Centre Wales Advisory group.
Feb 2019: Level 7 Certificate in Executive Coaching and Mentoring, Institute of Leadership and Management.
May 2017: Level 5 Diploma in Management and Leadership, Institute of Leadership and Management
May 2017: National Vocational Qualification Level 5 Diploma in Management and Leadership, City and Guilds
Dec 2016: OCR Level 5 Diploma in Management and Leadership
May 2010: Postgraduate Certificate in Academic Practice - Merit, King’s College London
May 2009: Doctor of Philosophy for the thesis entitled “Dispensing Errors in Hospital Pharmacy:Incidence, Causes and Impact of Automation.” (Examiners: Professor David Cousins, Head of Medicines Safety, National Patient Safety Agency and Professor Nick Barber, Professor of Pharmacy Practice, London School of Pharmacy), King’s College London, University of London.
July 2004: Master of Pharmacy - First Class Honours, Welsh School of Pharmacy, University of Wales Cardiff.
March 2018: Member of Institute of Leadership and Management
March 2018: Fellow of the Royal Society of Medicine
March 2018: Member of Institute of Health Promotion and Education
August 2017: Member of the Q Community, Health Foundation
August 2010: Fellow of the Higher Education Academy
March 2009: Member of the UK Clinical Pharmacy Association
July 2005: Member of the Royal Pharmaceutical Society (RPS) of Great Britain
March 2010: Member of the General Pharmaceutical Council (GPhC)
Oct 2014 - present
All Wales Consultant Pharmacist – Acute Care & Medication Safety, Welsh Government and Cardiff and Vale University Heath Board.
Jan 2011 – Aug 2014:
Lecturer in Pharmacy Practice, University of Bath
Oct 2008 – Dec 2010:
Research Fellow Medication Safety, King’s College London & King’s Health Partners (Guy’s and St Thomas’ King’s College Hospital and South London and Maudsley NHS Foundation Trusts)
July 2005 – present:
Oct 2005 – Oct 2007:
Pharmacy practice demonstrator, King’s College London.
July – Sept 2005:
Research pharmacist, Cardiff and Vale NHS Trust
July 2004 – July 2005:
Pre-registration pharmacy graduate, Morriston Hospital Swansea
Four nations medication safety leads.
NHS Improvement and Wales Medication Safety Officer network.
Chair of NHS Wales Medication Safety Network
Member of the Welsh Government National Quality and Safety Forum.
Member of the Welsh Government Quality Triggers group.
Member of the Welsh Government Medication, Administration, Recording, Review and Storage review panel.
Member of the Medicines Healthcare and Regulatory Products, Yellow Card Centre Wales group.
Member of the Welsh Government Committee on the World Health Organisation Campaign to reduce medication errors.
Member of the All Wales Medicines Strategy Group, All Wales Prescribing Advisory Committee.
Member of the National Prescribing Indicator Committee for the All Wales Medicines Strategy Group.
Member of NHS Wales Informatics Service Hospital Medicines Management Board.
Member of the MHRA Yellow Card Centre Wales Advisory Committee.
Member of the All Wales Medicines Information Operational Group of the Chief Pharmacists Group.
Executive member of all Wales Quality and Patient Safety sub-group of the Welsh Chief Pharmacists Committee.
UK Consultant Pharmacists Group.
Member of the Pharmacy Research Strategy Implementation Group
All Wales Consultant Nurse, Midwife and Allied Healthcare Professionals Group.
Health Foundation Q community.
- Welsh Government Chief Optometric Conference. (March 2020). Let’s See SI: Reporting and Learning.
- Improvement Cymru Medication Safety Masterclass. (November 2019). Medication Safety in Wales – Key Facts and Figure.
- Improvement Cymru Pharmacy in Practice Community of Practice. (September 2019). Welsh Medicines Safety Programme.
- Chief Pharmacists for Wales Symposium (May 2019). Welsh Medicines Safety Programme – Let’s See Action.
- Royal Pharmaceutical Society Wales.(November 2018). Medicines Safety Conference. Safety Culture.
- Welsh Government Delivery Unit Conference. (November 2018). A Medicines Safety Carol. Past Present and Future.
- Welsh Government Delivery Unit Conference. (November 2016). Medicines Related NHS Wales Patient Safety Notices and Alerts. From Conception to Implementation.
- National NHS Pharmaceutical Quality Assurance and Technical Services Symposium (November 2018). Errors in the Preparation of Injectable Medicines.
- Welsh Government National Quality and Patient Safety Forum. (October 2018). The Medicines Cold Chain.
- NHS Wales. (September 2018). Paediatric Medication Error Prevention Study Day. Situational Awareness. Role in Medication Errors.
- Royal Pharmaceutical Society Scotland National Symposium. (August 2015). Nuts and bolts of dispensing.
- Royal Pharmaceutical Society North Wales Local Practice Forum (March 2015). Nuts and bolts of dispensing.
- Welsh Pharmaceutical Committee (Welsh Assembly Government Advisory Group). (February 2015). Medication safety.
- Royal Pharmaceutical Society Joint Hywel Dda and Bro Morgannwg Local Practice Forum. (February 2015). Nuts and bolts of dispensing.
- Royal Pharmaceutical Society Joint Cwm Taf and Cardiff and Vale Local Practice Forum (January 2015). Nuts and bolts of dispensing.
- UK Clinical Pharmacy Association Autumn Symposium. (November 2014). Errors in the Preparation of Injectable Medicines in the Pharmacy Environment.
- NHS Pharmaceutical Quality Assurance and Technical Services Symposium (24th -25th September 2013). Getting it right – learning from our errors.
- South West of England Chief Pharmacists Meeting (April 2012). Prescribing and dispensing errors: does the method of prescribing make a difference?
- Great Western Local Practice Forum (October 2011). Being an academic research pharmacist.
- South West QIPP, Medication Safety Stream. (15th March 2011). Causes of medication errors.
- RPS Pre-registration Tutors Meeting. (October 2010). Competence and understanding of pharmacists, pre-registration pharmacy graduates and pharmacists at accuracy checking dispensed medicines.
- British Pharmaceutical Conference. Quality and safety: old values, new vision (6-7th September 2009). Managing the risks of dispensing errors in pharmacy.
- UK Clinical Pharmacists Association (15-17th May 2009). Managing the risks of dispensing errors – workforce planning for automated and manual dispensing systems.
- South West of England Chief Pharmacists Meeting (23rd April 2009). Managing the risks of dispensing.
- Royal Pharmaceutical Society of Great Britain Workload Pressure Symposium (28th-29th April 2009). Role conflict: occupational stressors vs. patient safety. Effect of workload and pharmacy staff stress on prevented dispensing incidents in hospitals with manual and automated dispensing systems.
- Welsh Chief Pharmacists Meeting (29th January 2009). Managing the risks of dispensing errors in hospital pharmacy.
I have extensive experience of teaching and assessment having worked previously as a full-time lecturer. I have a Postgraduate Certificate in Academic Practice and I am a Fellow of the Higher Education Academy. In my current role, I deliver teaching on medication safety to undergraduate pharmacy and medical students. As a practitioner, I support and undertake practice-based assessments of pre-registration pharmacists, undergraduate and qualified doctors and nurses
My research is primarily concerned with understanding and mitigating the risks of patient harm from medication errors, particularly in the secondary care setting. The contribution of my research has been to:
- Evaluate the incidence and type of medication errors, including prescribing, dispensing, preparation and administration errors
- Determine the impact of human psychology on medication errors
- Understand patient, socio-technical and organisational factors influencing medication errors
- Evaluate interventions to ensure the safe use of medicines and reduce patient harm, particularly the use of technological solutions such as automated dispensing systems and electronic prescribing and administration systems.
- Anto, B., James, K. L., Barlow, D., Brinklow, N., Oborne, A., Whittlesea, C.(2013) Exploratory study to identify the process used by pharmacy staff to verify the accuracy of dispensed medicines. Int J Pharm Pract; 21: 233-242
- James K. L., Barlow D., Bithell A., Hiom S., Lord S., Pollard M., Roberts D., Way C., Whittlesea C. (2013). The impact of automation on workload and dispensing errors in a hospital pharmacy. Int J Pharm Pract; 21: 92-104
- James K. L., Barlow D., Bithell A., Hiom S., Lord S.,Oakley P., Pollard M., Roberts D., Way C., Whittlesea C. (2013). The impact of automation on pharmacy staff experience of workplace stressors. Int J Pharm Pract; 21, 105-116
- James, K. L., Barlow, D., Bithell, A., Burfield, R., Hiom, S. et al. (2011) Measuring dispensary workload: a comparison of event recording and direct time technique. Int J Pharm Pract 19, 264-275
- James, K. L. (2011). Are trainee pharmacists and qualified pharmacists competent at accuracy checking dispensed medicines? HERN-J; 2: 17-28
- James, K. L., Barlow, D., Burfield, R., Hiom, S., Roberts, D., Whittlesea, C. (2011). Unprevented or prevented dispensing incidents: which outcome to use in dispensing error research? Int J Pharm Pract; 19: 36-50
- James, K. L., Davies, J. G., Kinchin, I., Patel, J. P., Whittlesea, C. (2010). Understanding vs. competency. The case of accuracy checking dispensed medicines in pharmacy. Adv Health Sci Ed (published online 12th May 2010, DOI: 10.1007/s10459-010-9234-7)
- James, K. L., Barlow, D., McArtney, R., Hiom, S., Roberts, D., Whittlesea, C. (2009). Incidence, type and causes of dispensing errors: a review of the literature. Int J Pharm Pract; 17: 9-30.
- James, K. L., Barlow, D., Hiom, S., Roberts, D., Whittlesea, C. (2008). The development and use of the critical incident technique in evaluating the causes of dispensing incidents. Int J Pharm Pract; 16: 239-249
- James, K. L., Barlow, D., Burfield, R., Hiom, S., Roberts, D., Whittlesea, C. (2008). Analysis of unprevented dispensing incidents in Welsh NHS hospitals 2003-2004. Int J Pharm Pract; 16: 175-188.
- James K. L. (2015) Chapter 3: Dispensing Medication. In: Franklin B & Tully M (Eds). Safety in Medication Use. London: CRC Press
- Reynolds, M., James, K. L., Westbrook, J. I. (2015) Chapter 21: Innovations in Dispensing. In: Franklin B & Tully M (Eds). Safety in Medication Use. London: CRC Press.
- James, K. L. (2013). Assessing the Impact of Automated Dispensing. Hospital Pharmacy Europe; 69: 43-45
- James, K. L., Barlow, D., Hiom, S., Roberts, D., Whittlesea, C. (2007). Tackling dispensing errors – learning from the Welsh risk programme. Hospital Pharmacist; 14(9): 278
National Policy and Guidance
- Royal Pharmaceutical Society (2018). Professional Guidance on the Safe and Secure Handling of Medicines.
- Welsh Government and NHS Wales. (2017). PSN007/April 2017. Risk of death or serious harm from accidental ingestion of potassium permanganate.
- Welsh Government and NHS Wales. (2017). PSN006/January 2017. Risk of death and severe harm form errors with injectable phenytoin.
- Welsh Government and NHS Wales. (2017). PSA007/January 2017. Restricted use of open systems for injectables.
- Welsh Government and NHS Wales. (2016). PSA 005/ July 2016. Minimising the risk of medication errors with high strength, fixed combination and biosimilar insulin products.
- Welsh Government and NHS Wales. (2016). PSA 004/July 2016. Ensuring the safe administration of insulin.
- Welsh Government and NHS Wales. (2016). PSN 032/ May 2016. Risk of patient harm from an interaction between miconazole and coumarin anticoagulants.
- Welsh Government and NHS Wales. (2016). PSN 007/ April 2016. Risk of patient safety incidents resulting from errors in the British National Formulary for Children 2015-2016 and British National Formulary 70.
- Welsh Government and NHS Wales. (2016). PSN 028/ February 2016. Medicines reconciliation – reducing the risk of serious harm.
- Welsh Government and NHS Wales. (2016). PSN 027/ February 2016. Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus.
- Welsh Government and NHS Wales. (2016). PSN 025/ February 2016. Risk of death or severe harm due to inadvertent injection of skin preparation solution.
- Welsh Government and NHS Wales. (2015). PSN 022/December 2015. Risk of harm from the inappropriate use and disposal of fentanyl patches.
- Welsh Government and NHS Wales. (2015). PSN 020/ October 2015. Minimising the risk of omitted and delayed medicines from patients receiving homecare services.
- Welsh Government and NHS Wales. (2015). PSN 014/ July 2015. Residual anaesthetic drugs in cannulae and intravenous lines.
- Welsh Government and NHS Wales. (2015). PSN 010/ May 2015. Failure to act on known contraindications to low molecular weight heparins.
- Welsh Government and NHS Wales. (2014). PSN 005/ December 2014. Risk of distress and death from inappropriate doses of naloxone in patients on long-term opioid/opiate treatment.
- National Patient Safety Agency. (2007). Design for patient safety. A guide to the design of the dispensing environment.
- National Patient Safety Agency. (2007). Design for patient safety. A guide to the design of dispensed medicines.
- 2020-2021. Health and Care Research Wales. NHS Research Time Award.(Chief Investigator).
- 2013-2014. UK Clinical Pharmacy Association Clinical Research Grant. Errors in the Preparation of Injectable Medicines in the Pharmacy Environment. (Chief investigator).
- 2013 -2014. Pharmacy Research UK. The Role of the Multidisciplinary Team and its Effects on the Clinical Roles of Community Pharmacists. (Co-applicant).
- 2012-2013.Higher Education Academy Teaching Development Grant – Individual Grant Scheme. (2012). E-learning for Accuracy Checking: Can IT improve pharmacy students’ competence and understanding of accuracy checking dispensed medicines? (Chief investigator).
- 2008-2010. Royal Pharmaceutical Society of Great Britain, Pharmacy Practice Research Trust, Galen Award (2008). Role Conflict: Occupational Stressors vs. Patient Safety. Effect of Workload and Pharmacy Staff Stress on Dispensing Errors in a Hospital Pre and Post-Automation. (Chief investigator).
- 2007-2008. Welsh Government Pharmacy Practice Development Scheme. The Effect of Workload and Pharmacy Staff Stress on Dispensing Incidents in Hospitals with Manual and Automated Dispensing Systems. (Co-applicant & principal investigator)
- 2005-2006. Welsh Government Pharmacy Practice Development Scheme. Welsh Dispensing Error Risk Reduction Programme. (Co-applicant & principal investigator).
I supervise undergraduate, Masters and doctoral research students undertaking health services research in medicines and patient safety