1. Medication incidents and safety alerts
Carina Livingstone
Subject Matter Expert
Kent Surrey Sussex Patient Safety Collaborative

2. Why report?
Share information, learn key lessons, previous tragedies are not repeated
Francis Report (2013) – patients must be protected from avoidable harm
NICE Medicines Optimisation (2015) – use multiple methods to identify patient safety incidents

4. Medicine safety Alerts
Older NPSA Alerts on critical medicines
- Insulin 2010
- Methotrexate 2006
- Lithium 2009
- Oral anticoagulants 2007
All organisations report compliance..
But errors are still happening

5. Kent Surrey Sussex 2014/15 KSS totals 2014/15 No Harm Low Moderate
Severe
Death
Grand Total
Methotrexate 66 3 1 70
Insulin
967
156 35 2
1160

6. Examples - methotrexate
Example - Medway
Trimethoprim interaction with Methotrexate injection.  The injection was being prescribed by secondary care and it wasn’t recorded on the patient’s notes hence the interaction didn’t come up on the system.  It also then transpired that the interaction alert was not coming up on the Vision system.
Example - Surrey
We’ve had at least 2 patients turn up in A&E who have been prescribed trimethoprim by their GP while on methotrexate.
Example - Sussex
A patient was prescribed methotrexate for a rheumatology condition at a dose of 10mg weekly and it was explained that this would be four tablets taken once each week. The community pharmacy issued these as 10mg tablets labelled as one tablet to be taken each week. The patient inadvertently took four of these tablets as a single dose before noticing the directions on the pack. The patient went to A&E immediately and received rescue medication.

7. Can we learn more?

8. Patient safety alerts Aim:
Patient safety alerts on critical medicines are implemented across all healthcare organisations in KSS in a quality assured way
Use best practice examples from within and outside KSS
Cross-sector application
Patients help ensure their own safety
Improve and assure consistent implementation

9. Can we learn more?

10. Carina Livingstone
kssahsn.net