S Seven Steps to Medication Safety : Identifying and Reporting Medication Safety Incidents Bite-sized training P S East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Medicines Use and Safety ©East & South East England Specialist Pharmacy Services 1

S P S Learning Outcomes Define medication safety incidents and adverse drug reactions and events Describe why reporting of medication safety incidents is important Identify where errors occur in the MR process and how this links to incident reporting Identify incidents occurring as part of a case study Identify the prescription of insulin as abbreviated units as a Never Event Describe the pros and cons of reporting incidents in the workplace √Practice aim: To identify and report incidents as expected as part of the pharmacy team 2

S P S Incident vs ADR 3 ADR A response to a drug which is noxious.. and occurs at doses used [intentionally] for prophylaxis, diagnosis or therapy e.g. a ‘side effect’ (World Health Organisation) A medication safety incident Any preventable event that may lead to inappropriate medication use or patient harm while medication is in control of health professional, patient or consumer (NPSA) Example of both?

S P S Why is it important to report them? Research shows that: “Trusts with significantly high levels of incident reporting are more likely to demonstrate other features of a strong safety culture” NPSA 2008 NHS providers are required to report incidents NHS Outcomes Framework 4

S P S Stage 1 Clerking by Doctor Stage 2 Selection of patients for MR Stage 3 Sourcing the information for use in the MR process Stage 4 Comparing the sourced list(s) and patient sourced information against the written prescription: Identifying discrepancies Stage 5 Listing and documenting unintentional discrepancies Stage 6 Referring unintentional discrepancies: For doctor to make changes or to a pharmacist or nurse for further analysis/follow-up Meds Reconciliation (MR) Process Map 5

S Real examples of things going wrong GP prescriptionPODsInpatient prescription Hospital disp item in locker Simvastatin 20mg ON Simvastatin 20mg daily Simvastatin 20mg ON Sodium valproate 1200mg BD Sodium chloride 1200mg BD Betaxolol ED--- Methotrexate 2.5mg weekly Methotrexate 2.5mg daily Lisinopril 25mg ODLisinopril 2.5mg ODLisinopril 25mg ODLisinopril 2.5mg OD P S 6

S GP prescriptionPODsInpatient prescription Hospital disp item in locker Simvastatin 20mg ON Simvastatin 20mg daily Simvastatin 20mg ON Sodium valproate 1200mg BD Sodium chloride 1200mg BD Betaxolol ED--- Methotrexate 2.5mg weekly Methotrexate 2.5mg daily Lisinopril 25mg ODLisinopril 2.5mg ODLisinopril 25mg ODLisinopril 2.5mg OD P S 7 Real examples of things going wrong

S GP prescriptionPODsInpatient prescription Hospital disp item in locker Simvastatin 20mg ON Simvastatin 20mg daily Simvastatin 20mg ON Sodium valproate 1200mg BD Sodium chloride 1200mg BD Betaxolol ED--- Methotrexate 2.5mg weekly Methotrexate 2.5mg daily Lisinopril 25mg ODLisinopril 2.5mg ODLisinopril 25mg ODLisinopril 2.5mg OD P S 8 Real examples of things going wrong

S GP prescriptionPODsInpatient prescription Hospital disp item in locker Simvastatin 20mg ON Simvastatin 20mg daily Simvastatin 20mg ON Sodium valproate 1200mg BD Sodium chloride 1200mg BD Betaxolol ED--- Methotrexate 2.5mg weekly Methotrexate 2.5mg daily Lisinopril 25mg ODLisinopril 2.5mg ODLisinopril 25mg ODLisinopril 2.5mg OD P S 9 Real examples of things going wrong

S GP prescriptionPODsInpatient prescription Hospital disp item in locker Simvastatin 20mg ON Simvastatin 20mg daily Simvastatin 20mg ON Sodium valproate 1200mg BD Sodium chloride 1200mg BD Betaxolol ED--- Methotrexate 2.5mg weekly Methotrexate 2.5mg daily Lisinopril 25mg ODLisinopril 2.5mg ODLisinopril 25mg ODLisinopril 2.5mg OD P S 10 Real examples of things going wrong

S P S Barriers and enablers for reporting  National drivers e.g. Outcomes Framework  Organisational or departmental strategy for what to report  Roles need to be clear – who can report and what  Time needed to report  Human factors  E.g. fear of reprisals, upsetting existing relationships, making the organisation/division look bad, public image concerns 11

S P S Evaluation Define medication safety incidents and adverse drug reactions and events Describe why reporting of medication safety incident is important Identify where errors occur in the MR process and how this links to incident reporting Identify incidents occurring as part of a case study Identify the prescription of insulin as abbreviated units as a Never Event Describe the pros and cons of reporting incidents in the workplace 12

S P S Using this session for CPD By taking part in this session you will be able to record or include what you have learnt as a CPD entry starting at “Action”: For example you could: –complete the further reading or practical next steps and document this –Document your participation in the session and explain how you have applied this to your day to day practice. This learning could identify further learning needs that you can complete as Plan and Record CPD entries starting at “reflection” 13

S P S Further Reading Further information about reporting medication incidents and other aspects of medication safety are available in An SPS Resource “Seven Steps to medication Safety: A Development Resource for Pharmacists and Senior Pharmacy Technicians. Download it here: NeLM linkNeLM link CPPE provide some modules on medication safety: