Medication Safety Landscape – What have we achieved and what’s next? Dr David Cousins Senior Head Safe Medication Practice and Medical Devices.

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Presentation transcript:

Medication Safety Landscape – What have we achieved and what’s next? Dr David Cousins Senior Head Safe Medication Practice and Medical Devices

National Reporting & Learning System NHS Trusts Practitioners Staff Patients Carers NRLS CQC MHRA NHS Complaints NHS Litigation Authority Research Feedback International Collaboration Standardised reporting

Air Safety Reports: Volume & Risk 0.0% 0.5% 1.0% 1.5% Year 2.0% 2.5% 3.0% Total % High Risk

National Reporting and Learning System (NRLS) in England and Wales medication incident reports Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – Types of incidents Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – who is reporting incidents? Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – Types of harm Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – Ratio of serious harm / all

NRLS – Stage of process Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – Error category Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – Critical medicines Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

DH – Never events – medication practice Wrong prepared high risk injectable medicine Maladministration of potassium containing solutions Wrong route administration of oral/enteral products Intravenous administration of epidural injections/infusions Maladministration of insulin products Overdose of midazolam during conscious sedation Opioid overdose in opioid naive patents Inappropriate administration of daily oral methotrexate Wrong gas administered

NHS Outcomes framework

Domain 5 Patient Safety

Known drug allergy Reconciliation Omitted doses Anticoagulants Opioids Sedatives Insulin

Patient Safety Collaborative

Safety is no accident!