Making medicines safer for patients (The Safe Medicines Pathway Toolkit) Patient Safety Federation Conference Sept 15 Jane Hough, Associate Director, NHS Specialist Pharmacy Service Triss Clark, PSF Programme Director & PSF Project Manager for SMP Safe Medicines Pathway

Content of the presentation Background Aim/Purpose Developments and Successes Challenges & Lessons Learnt Safe Medicines Pathway

Background to project starting No Needless Medication Error work-stream PSF held meetings with stakeholders Concern raised about large number of medication errors Safe Medicines Pathway conceived Safe Medicines Pathway

Aims 1.To simplify, standardise and make reliable some of the elements of the medicines pathway: such that the likelihood of errors occurring is reduced. 2.To share work through a Web-based tool kit. Safe Medicines Pathway

Purpose of the Project To understand the processes undertaken when information about patient’s medicines and the medicines themselves enter and leave the system. To test changes to the system in one organisation To work with other organisations in the PSF geography to test tools developed To share the experiences, learning and tools through a web-based tool-kit Safe Medicines Pathway

Who is respons ible for writing up the Drugs Clarity of Drugs Charts Timing of LTC Meds being written up Portering Collection and Distribution Use or Not of PODs Lockers Themes LTC Medicati on Omitted Medicatio n Omitted at Initial Visit Loss of Medic ation Delays in the writing of TTO’s Single Storage space for all Medicat ion on the Wards Safe Medicines Pathway Duplication of Medication Lack of Consistency in the use of technology i.e. iPADS New meds only given in certain departments Delay in Writing TTO’s Condition of Patient on admission Communication with GP’s/Community Pharmacists

Story Board No one had told her, she had started on new Medication Patient/family sometimes return to collect meds ? ? Some patients unaware of the medication they are taking Looked after his own meds at home. Did not need additional medication – had more supplies at home Patients eye drops not charted throughout stay. Lost somewhere along the pathway She was pleased with the medicine process – agreed it would be helpful to see the Community Pharmacist on discharge Pt sent home without own meds; meds thrown out by Nursing Staff Safe Medicines Pathway

Developments and Successes Data collection tools Interventions across prescribers, nursing and pharmacy Patient involvement Working with an FY2 Improvement in medicines reconciliation DART campaign (prescribing) SMP Website Safe Medicines Pathway

Interventions Safe Medicines Pathway

Challenges and Lessons learnt Team/Timescales Releasing staff and running a project on top of “day job” Complexity of the pathways Engagement and clarity of purpose Impact of the introduction of EPR Safe Medicines Pathway

Purposeful Observation People do not always do what they say they do People do not always do what they think they do People do not always do what you think they do People cannot always tell you what they need Things are not always as they seem ……. (adapted from IDEO) Safe Medicines Pathway

Thank you! Contact Details PSF Project Manager for SMP – Triss Clark Tel Project Lead - Jane Hough Safety/Improvement Expert – Dr Clare Crowley Tel Safe Medicines Pathway