Medication incidents and safety alerts Carina Livingstone Subject Matter Expert Kent Surrey Sussex Patient Safety Collaborative

Why report? Share information, learn key lessons, previous tragedies are not repeated Francis Report (2013) – patients must be protected from avoidable harm NICE Medicines Optimisation (2015) – use multiple methods to identify patient safety incidents

Medicine safety Alerts Older NPSA Alerts on critical medicines - Insulin 2010 - Methotrexate 2006 - Lithium 2009 - Oral anticoagulants 2007 All organisations report compliance.. But errors are still happening

Kent Surrey Sussex 2014/15 KSS totals 2014/15 No Harm Low Moderate Severe Death Grand Total Methotrexate 66 3 1 70 Insulin 967 156 35 2 1160

Examples - methotrexate Example - Medway Trimethoprim interaction with Methotrexate injection.  The injection was being prescribed by secondary care and it wasn’t recorded on the patient’s notes hence the interaction didn’t come up on the system.  It also then transpired that the interaction alert was not coming up on the Vision system. Example - Surrey We’ve had at least 2 patients turn up in A&E who have been prescribed trimethoprim by their GP while on methotrexate. Example - Sussex A patient was prescribed methotrexate for a rheumatology condition at a dose of 10mg weekly and it was explained that this would be four tablets taken once each week. The community pharmacy issued these as 10mg tablets labelled as one tablet to be taken each week. The patient inadvertently took four of these tablets as a single dose before noticing the directions on the pack. The patient went to A&E immediately and received rescue medication.

Can we learn more?

Patient safety alerts Aim: Patient safety alerts on critical medicines are implemented across all healthcare organisations in KSS in a quality assured way Use best practice examples from within and outside KSS Cross-sector application Patients help ensure their own safety Improve and assure consistent implementation

Can we learn more?

Carina Livingstone carina.livingstone@nhs.net kssahsn.net