1. ‘No Needless Medication Errors’
Gillian Honeywell, Chief Pharmacist
NHS Isle of Wight
South Central

2. Medication Errors do happen..
Why was this workstream chosen?
South Central

3. Facts and figures
Medicines are the most frequently used healthcare intervention
97% of all hospital patients take a medicine
6% of hospital admissions are a direct result of problems with medicines including side effects1
Poor communication between care settings is responsible for up to 50% of all medication errors & up to 20% of adverse drug reactions that occur in hospital 2
Average DGH has 350 medication errors per day
NPSA: medication errors account for 9% total
Pharmacy in England Building on strengths – delivering the future, Department of Health. 2008
NICE/NPSA patient safety guidance to improve medicines reconciliation at hospital admission. National Patient Safety Agency. December available from http/
South Central

4. Project Plan
Project 1: Metrics: 3rd year: Improvement Methodology: Trust Quality Standard kpi’s and SHA monitoring
1: Means of ensuring patient receive oral anticoagulation therapy within safe parameters (INR >5 & >8)
2: Medicines reconciliation: safer admission to hospital: patients’ medicines are reconciled within 24 hours of admission
3: Allergies: A means of ensuring that patients allergy status is recorded on prescription charts
Project 2: Promoting the safer use of injectable medicines
Pre-filled syringes for high risk medicines: nursing time released to care
Risk assessments to reduce errors with injectables: collaborative procurement
What have we achieved?
All trusts now use this data as a measure of quality & safety
South Central

5. Project Plan Project 3: NSAID related harm
Baseline audit completed. Usage data reported 3 monthly, preparation for monthly prescription metric
Project 4: Reduction of harm from omitted and delayed medicines in hospital
Baseline audit for antibiotics completed. Single Trust audit for all drugs / doses completed. Preparation for monthly metric
Project 5: Reduce the number of errors and harms with insulin
Baseline audits completed. Preparation for monthly metric
Project 6: Standardised accessible Medicines Management Training
E-learning modules for all aspects of the medicines trail, for all professions.
What have we achieved?
All trusts now use this data as a measure of quality & safety
South Central

6. Metric 2: Medicines Reconciliation
Implementation of 7 Day Working
Target line
Implementation of Green Bag Scheme
Staff vacancies
NHS Isle of Wight
South Central

7. Green Bag Scheme £20,000 Pump Prime PSF
Medicines reconciliation supporting the safe transfer of patient’s medicines between care settings
QIPP and Waste Campaign
Recent audit in South Central: estimated saving of approx. £10 per patient admitted- from admissions data this equates to potential savings of £3.6million
A further £1.26m from MR safety cost- avoidance for 70% of these patients
South Central

8. Medicines Reconciliation
Percentage of Meds Rec Completed
(since 01 Apr 2011) %

9. Medicines Reconciliation
Acute Trusts in FY 2011 %

10. Medicines Reconciliation
Costs Avoided
Further Cost Avoidances

11. Isle of Wight Example
Cost avoidance
Min
Avg
Max
Med Rec 5 10
1. Estimated cost avoidance from medicines reconciliation within 24 hours of patient arrival (per patient).
2. HES data admission figures for 2010/11 and calculated uplift (3%) for 2011/12.
Trust (HES title)
2010/11
2011/12
Month average
5QT Isle of Wight NHS PCT
25911
26688
2224
3. Actual data collated by Trust – used to calculate % achieved
Trust
IoW
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Adult patients sampled
208
211
194
215
196
204
173
164
150
175
156
161
124
180
137
179
185
Med Rec completed 67 92
125
139
120
111 99 73 93
104
112
103 77
109
117
% Med Rec
32%
44%
64%
65%
71%
59%
60%
49%
53%
67%
70%
75%
57%
56%
61%
63%
4. Calculated avoidable and avoided costs (monthly average from 2 applied to % achieved from 3)
Trust
IoW
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
HES adult admission
2224
% Med Rec
32%
44%
64%
65%
71%
59%
60%
49%
53%
67%
70%
75%
57%
56%
61%
63%
Avoidable cost
7538
6272
3955
3931
3234
4579
3985
4407
5708
5211
3707
3384
2780
4757
4870
4349
4087
Costs avoided
3582
4849
7165
7189
7886
6541
7135
6713
5412
5910
7413
7736
8340
6363
6250
6771
7033
Therefore, using IoW data for 2011 :
£5 cost avoidance per patient x admissions = £113,340 total
Average of 61% medicines reconciliation achieved = £69,137 in cost avoidance achieved
with 39% further potential savings = £44,203 in avoidable costs

12. Dashboard
South Central

13. Safer Use of Injectable Medicines
Focus on practical implementation of targeted products identified by NPSA alert 20:
Dobutamine 250mg in 50ml vial
Morphine 1mg/ml & 2mg/ml – 50ml vial
Human soluble insulin 50 units in 50ml pre-filled syringe
Four work streams were funded by PSF :
Injectables: purchasing for safety
Assessing risk to operators from exposure to hazardous injectable medicines
Neonatal Injectables
Medicine package inserts
South Central

14. OUTCOMES
Less delay to start administration for emergency injections (Magnesium for eclampsia- 0.5h)
Ensure correct concentration (ward based preparation >10% out; Wheeler et al, 2008)
Reduced waste
Reduced rework (e.g. inadequate labelling)
Less risk of contamination
Eliminate human error
Standardise concentration (ICS standards)
Health & safety (needlestick injury, RSI)
Assistance with assurance (NHSLA, NPSA alerts)

15. QIPP OUTCOMES…£261k over 3 years
Cost of medicines:
Adenosine for cardiac cath labs (save £10k pa)
Morphine for PCA and continuous infusion (save £4k pa)
Suxamethonium and thiopentone for emergency caesarean section (also eliminate unsafe practice – save £3.5k pa)
Noradrenaline PFS – no UK instructions in ampoule pack
NHS manufacturing units tender
Process improved:
1,667 minutes nurses time per month released by introducing ready to use potassium syringes in adult critical care (approx. 20% band 5 = £5k)

16. IN PROGRESS
Established current use of NSAIDs and are developing metrics and methodology for QIPP
Medicines management e learning project published on Nelm
Missed doses in process of audit and analysis for potential for metrics
Number admissions hypoglycaemia evaluated for frequency and cost. Insulin in hospital. To identify areas for improvement and metrics
Injectables in the community
Dashboard
South Central

17. Challenges Linking quality with safety to tangible savings
Engaging with other professions
Moving forward to kpi’s and standards for safety
Communication, continuity and commitment
Dashboard
South Central

18. ‘Reducing Needless Medication Errors Workstream’
For more information on the
‘Reducing Needless Medication Errors Workstream’
please see the Patient Safety Federation website
or contact
Fiona Eccleston- Project Manager
South Central