Reducing Medication Errors: National Update Ahmed Ameer Medication Safety Officer Ahmed.Ameer@NHS.net Safer Medication Practice & Medical Devices Team 27 th January 2015
Agenda 1. Development of the National Medication Safety Network 2. Improving the number, quality, timeliness of reports maximizing local learning and actions 3. Improving adherence to the Patient Safety Alert on improving medication error incident reporting and learning 4. Developing the role of the medication safety officer
Improving Medication Safety CCG 71 NHS Mental Health Trust 48 NHS Acute Medium 42 NHS Acute Large 33 NHS Acute Teaching 30 NHS Acute Small 24 Community pharmacy sector 21 NHS Acute Specialist 19 NHS Community Trusts 16 Independent Sector 14 Other 14 NHS England Area Team 13 NHS Ambulance Trust 7 Total 352
MSO Responsibilities Active membership of the NHS Medication Safety Improvement Collaborative Manage medication incident reporting in the organisation. Review all medication incident reports to ensure data quality for local and national learning. Where necessary investigate and seek additional information from reporters. Authorise the release of medication error reports to the NRLS each week. Receive and respond to requests for more information concerning medication error incident reports from the patient safety team in NHS England and the MHRA. Support the dissemination of medication safety communications from NHS England and the MHRA throughout the organisation.
Vision NHS England Analysis MHRA Analysis MSO National Network Local Action Identifying Risk NRLS Reports Yellow Cards Knowledge Sharing Patient Safety Alerts Drug Safety Updates / Recalls Implementing Change 2-way relationship between MSO and Healthcare Professionals to implement actions. Supported by the local Medication Safety Committee
Risk Management Weekly review of NRLS severe and death medication incidents Lookout for trends of risky practice Collect intelligence from NRLS mini-scopes and MSOs insights / RCAs Share thoughts with MSO Network Develop actions for change
PSI reported to the NRLS for Dec 2014 Degree of Harm (PD09) Administration Advice Medication stage (MD01) Monitoring/ follow-up Other Dispensing/ Preparation Prescribing OTC medicine No Harm 1616 35 189 463 593 703 18 3617 Low 207 2 17 40 40 89 1 396 Moderate 40 6 9 10 23 88 Severe 2 3 1 6 Death 1 1 Total 1865 37 213 515 643 816 19 4108 Total
PSI reported to the NRLS for Dec 2014 Medication error type (MD02) Total Other 952 Omitted medicine / ingredient 821 Wrong / unclear dose or strength 471 Wrong drug / medicine 345 Wrong frequency 325 Wrong quantity 254 Mismatching between patient and medicine 171 Wrong storage 111 Wrong method of preparation / supply 89 Unknown 82 Wrong formulation 81 Contra-indication to the use of the medicine in relation to drugs or conditions 80 Patient allergic to treatment 78 Wrong / omitted / passed expiry date 71 Wrong route 62 Adverse drug reaction (when used as intended) 52 Wrong / transposed / omitted medicine label 50 Wrong / omitted verbal patient directions 8 Wrong / omitted patient information leaflet 5 Total 4108
Quality of Reporting NRLS Field Data Entered IN07 MD01 MD02 MD05 PD09 Time between incident date & reaching the NRLS Patient with past medical history of aortic valve replacement being treated for sepsis?cause with IV meropenem according to blood culture result which had shown serratia marcesens, treated as probable infective endocarditis as no other source identified although not fit for trans - oesophageal echocardiogram. Given aortic valve replacement was commenced on anticoagulation - warfarin. Following the weekend on the [date 1] INR was >10 : had not been repeated since [3 months later] when was 3.3 : patient reviewed no active bleeding, given 2mg oral vitamin K and INR [incident date] was 2.1 [incident date] patient became acutely unwell : reduced GCS and drowsy CT head showed bilateral intracranial haemorrhage, discussed with Walton reviewed by stroke team and treated conservatively.. Monitoring / follow-up of medicine use Adverse drug reaction (when used as intended) Warfarin Death 10 days 9
Timeliness of Reporting
Timeliness of Reporting
Feedback of Reporting One to one discussion about local incidents whenever possible Patient Safety First online portal for MSOs to share experience, ask for help/advice and communicate emerging risk. Monthly web events to discuss medication error reporting, data quality, risk management and new policies. Yearly national conferences / workshops
MSO Opportunities
MSO Opportunities Sign up to Safety s 3 year objective is to reduce avoidable harm by 50% and save 6,000 lives Patient Safety Collaborative Patient Safety Fellows New NRLS Safety Action for England (SAFE) Team
MSO Opportunities Measurement tool for improvement: Medication Reconciliation Allergy Status Medication Omission Harm from high risk medicines
Aspiration Improve quality of reports Showcase local learning MSOs take charge of the Network Bottom-up approach of risk management National Learning Local Actions
Conclusion Database of MSOs is continually growing Uptake of alert is welcomed by key players across pharmacy and other healthcare bodies Network is up and running since April 2014 Great opportunity for pharmacists to be involved and proactive in ensuring medication is utilised safely Finally, it s a learning curve for everybody to ensure patients are receiving harm free care
Get in touch David Gerrett - Senior Pharmacist David.Gerrett@nhs.net Ahmed Ameer Medication Safety Officer Ahmed.Ameer@nhs.net Isobel O Grady Medication Safety Officer Isobel.Ogrady@nhs.net