1. Pilot Data Over 50% of reports not coded
Large number of fields missing
Large amount of data unusable
Only 1 out of 20 Trusts involved in pilot – small number in each category
BUT – Learning still possible.

3. Potassium Chloride - 31 Alerts/Reports Received
Inappropriate admission
processes
Wrong drug 1
Incomplete prescription 3
Delay in administering of drug 2 10
Wrong dose 1
Lack of medical support 2
Error in infusion rate 2
Equipment error 2 8
Misidentification of results

4. Solutions Suicide prevention
Medication errors – e.g. Potassium Chloride

5. Solutions Suicide prevention
Misidentification
Equipment
Communications
Cross infection
Patient involvement
Suicide prevention
Medication errors – e.g. Potassium Chloride

6. 5 Steps to Safer Health Care
Speak up if you have any questions or concerns
Keep a list of all the medicines you take
Make sure you get the results of any test or procedure – ask what they mean for your care
Talk with your doctor and health care team about your opinions if you need hospital care
Make sure you understand what will happen if you need surgery

7. Closing Thoughts Uncharted territory – we are all pioneers
Not about counting reports – about identifying vulnerabilities
Prevention not punishment
Cultural change takes time
Safety is the foundation on which the quality of care for the patient is built.