Patient Safety Homecare Incident Reporting The NUH Experience. See Mun WONG Medicines Homecare Pharmacist Nottingham University Hospitals NHS Trust

Transcription

1 Patient Safety Homecare Incident Reporting The NUH Experience See Mun WONG Medicines Homecare Pharmacist Nottingham University Hospitals NHS Trust

2 Why Report Homecare Incidents? Trust-wide incident reporting policy Hackett report from DoH RPS standards for homecare services Patient safety alert (NHS England) April 14 Shared learning with various stakeholders Performance monitoring

3 Clinical Indication Category Patient No. Contract Arrangement HIV (antiretrovirals) Low >500 Regional Contract Renal Transplant (immunosuppressants) Low >500 Regional Contract Cystic Fibrosis (Inhaled antibacterials) Low <50 Regional Contract Cystic Fibrosis (Inhaled mucolytics) Low Regional Contract Cystic Fibrosis (Ivacaftor) Low 10 Pharma Scheme Interstitial Lung Disease (Pirfenidone) Low <50 Pharma Scheme Multiple Sclerosis (Glatiramer, Interferons) Fingolimod Med Low >500 Pharma Schemes Immune Deficiency (Immunoglobulins) Med <50 Regional contract for s.c.; SLA for i.v. Parkinson s Disease (Duodopa) Med 1-5 Pharma Scheme Haemophilia (Clotting Factors) Med <50 National Contract Growth Deficiency (Somatropin) Med <30 Pharma Schemes Rheumatoid Arthritis Paeds (Anti-TNFs, Methotrexate, Anakinra) Med Regional Contract Anaemia (renal and haematology) (Aranesp & Eprex) Med >300 Regional Contract Crohn s Disease (adalimumab) Med <50 Pharma Scheme Hereditary angioedema (Icatibant) Med 1-10 Pharma Scheme Osteoporosis Teriparatide Med Pharma Scheme Alcura BUPA Calea Evolution Grifols Osteoporosis i.v. Zoledronic Acid High Trust SLA Chronic Iron Overload Desferrioxamine High 1-5 Regional Contract Breast Cancer (Trastuzumab and Persephone Trial) High <100 Regional Contract Healthcare at Home Cystic Fibrosis & OPAT (i.v. antibiotics) High Regional Contract Atypical Haemolytic Uraemia Syndrome (Eculizumab) High 1-5 Pharma Scheme Intestinal Failure (Parenteral Nutrition) High <100 National Contract

4 Types of Patient Safety Homecare Incidents Medication Errors Dispensing errors (e.g. incorrect drug, quantity) Service Failures Delivery issues delayed treatment, missed doses Nursing issues Ancillary/Equipment issues unable to administer drug Late prescription requests Patient errors Information Governance Delivery to a wrong address Communication Issues Helpline problems, miscommunication on dose/medication change Documentation Issues Misplaced prescriptions, incorrect use of homecare forms

5 How incidents were reported in the past Pharmacy homecare team logged incidents onto Datix and handled the incidents SOP to share with all clinical teams All NUH staff were encouraged to log homecare incidents with training provided Datix location option patient s home ; begin incident description with HOMECARE Summary to be reported to Trust s Medicines Safety Group 6 monthly

6 180 No of incidents reported % / / / No of patients 10% 2011/ / /2014

7 Challenges Confusion over what needs reporting Limitations on Datix Incident categories don t fit with homecare incidents Lack of mechanism to filter homecare incidents Homecare incidents skewed NUH internal incident data Patient awareness of incident reporting Homecare providers not notifying Trust of incidents within timeline Lack of governance control for pharma-funded services

8 Improved Homecare Incident Reporting Recommendations from the regional Medicines Safety Group Report actual or potential safety incidents Use individual Trusts existing incident codes e.g. for medication or medical devices Report PATIENT OUTCOME rather than only the root cause of an incident Reconfiguration of Datix Report directly against HOMECARE Directorate/Specialty: Homecare Homecare provider options Risk assessment and options appraisal

9 Data Analysis No. of Incidents by Therapy Area January - June % 0% 0% 8% 6% 2% 0% 4% 2% 6% 8% 0% 4% 2% 2% 17% 10% 2% 0% 0% CF inhaled CF IV Crohns Desferal Epo Fingolimod Haemophilia Herceptin HIV Icatibant Immunoglobulin MS Multiple OPAT Paediatric Renal Transplant Paediatric Rheumatology Pirfenidone Renal transplant Teriparatide Zolendronic Acid

10 60 Data Analysis Incidents by type January July Storage Prescription/Documentation issue 40 Medication(s) issue Information Governance 30 Incorrect Quantity Helpline/Customer services Duplicate Dispensing 20 Delivery Issue Communication Issue 10 Clinical Incident Ancillaries 0

11 Regional Homecare Group Summary of homecare incidents benchmarking Collate data regionally to monitor incident trends Date reported Datix Notify by Reference Category Brief Description Outcome Therapy Area Homecare Company 03/01/2014 XX Delivery Issues Failed delivery no harm - didn't miss doses Paed Rheum 10/01/2014 XX Ancillary/Equipment Issues Missing ancil (dermagesic spray) no harm - didn't miss doses Paed Rheum 10/01/2014 XX Medication(s) errors Short expiry of XXXX sent no harm - drug exchanged, no wastage Haemophilia 17/01/2014 XX Ancillary/Equipment Issues Missing ancil items & delivery not made to the requested address no harm - didn't miss doses Haemophilia 29/01/2014 XX Medication(s) errors MTX tablets incorrect qty x2pts no harm - didn't miss doses Paed Rheum 13/01/2014 XX Delivery Issues No delivery of XXX,? Missed doses no harm - missed a dose Crohn's

12 Further work to be addressed Improved patient communications complaints and incidents Better defined incident codes on Datix Review of incident data regionally and above (e.g. NRLS, CMU) Utilising incident data to improve patient safety How to map homecare incidents to NRLS Closer engagement with drug companies over pharma-funded homecare performance

13 Key suggestions to improve system Separate homecare incidents by reporting them against Homecare as a designated directorate Better clarity in terms of which incidents need reporting improves reporting consistency Recording homecare incidents on a spreadsheet to monitor trends

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