1. Reducing medication errors Key slides In association with National Patient Safety Agency (NPSA)

2. Why is patient safety important? First domain in NHS national standards 1, which describe the level of quality that healthcare organisations will be expected to meet Managing medicines safely is a key component Medication errors can cause unnecessary pain and harm to patients and can even lead to death Medication errors account for a substantial use of NHS resources 1. Standards for better health (updated). Dept of Health (2006) www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4086665

3. Definitions of safety Patient safety Patient safety is the freedom from accidental injury in healthcare Patient safety incident A patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare

4. Patient safety incidents involving medicines Source : Safety in doses. Medication safety incidents in the NHS. Fourth report from the patient safety observatory. National Patient Safety Agency (2007); London

5. Some holes due to active failures Other holes due to latent conditions Hazards Medication error DEFENCES, BARRIERS AND SAFEGUARDS James Reason 1990 Reason’s ‘Swiss cheese’ model

6. The medication process Prescribing - (ordering a given medicine and dose) Dispensing - (supplying medicines to individuals or to hospital wards) Preparation - (preparing a dose of medicine for administration ) Administration - (administering the dose of medicine by the appropriate route and method) Monitoring - (checking the administration and effect of a medicine) Reproduced with permission - NPSA

7. Forms of NPSA advice A Patient Safety Alert requires prompt action to address high-risk safety problems –Actions that can make anticoagulant therapy safer (2007) A Safer Practice Notice strongly advises implementing particular recommendations or solutions –National Patient Safety Agency alerts NHS to risks with high-dose morphine and diamorphine injections (2006) Patient Safety Information suggests issues or effective techniques that healthcare staff might consider to enhance safety –Vaccine incident — Review of a clinical incident in a PCT (2005) Rapid Response Reports are issued in response to issues arising through the National Learning and Reporting System –Risks of incorrect dosing of oral anti-cancer medicines — Jan 2008 RRR

8. History Obtain and document relevant history Prescribing Decide on medicine Prescribe medicine Transmission/ transcription Record keeping Prescription generation Medicine supply Ordering & preparation Interpret Dispense & clinical check Patient Patient understanding Concordance & compliance Monitoring Routine checks Interpret response Potential for medication errors

9. Seven steps to patient safety 1.Build a safety culture 2.Lead and support your staff 3.Integrate your risk management activity 4.Promote reporting 5.Involve patients and the public 6.Share safety lessons 7.Implement solutions to prevent harm http://www.npsa.nhs.uk/patientsafety/improvingpatientsafety/patient-safety-tools-and- guidance/7steps/

10. Seven key actions to improve medication safety 1.Increase reporting and learning from medication incidents 2.Implement NPSA safer medication practice recommendations 3.Improve staff skills and competences 4.Minimise dosing errors 5.Ensure medicines are not omitted 6.Ensure the correct medicines are given to the correct patients 7.Document patients’ medicine allergy status Source: Safety in doses. Medication safety incidents in the NHS. The fourth report from the patient safety observatory. NPSA (2007)Safety in doses. Medication safety incidents in the NHS. The fourth report from the patient safety observatory. NPSA (2007)

11. NPC materials may be downloaded/copied freely by people employed by the NHS in England for purposes that support NHS activities in England. Any person not employed by the NHS, or who is working for the NHS outside England, who wishes to download/copy NPC materials for purposes other than their personal use should seek permission first from the NPC. Email: copyright@npc.nhs.uk © Copyright 2007copyright@npc.nhs.uk