Patient Safety Federation Reducing Drug Errors

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Patient Safety FederationReducing Drug Errors

• Sheila Paul Chief Operating Officer
• Isle of Wight NHS PCT

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Reducing Drug Errors

• An Organisation with a Memory
• Building a safer NHS for patients Improving
  Medication Safety
• A Spoonful of Sugar Medicines Management in NHS
  Hospitals
• National Patient Safety Agency (NPSA)

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Reducing Drug Errors
A medication error is any preventable event that
may cause or lead to inappropriate medication use
or patient harm while the medication is in the
control of health professional, patient or
consumer
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Reducing Drug Errors

• Medicines do good and cause harm
• Leape et al - for South Central
• 29,600 adverse drug events
• 296 fatal
• 66,600 additional bed days
• 44.4m additional costs
• Medication errors are the greatest single source
  of preventable errors

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Reducing Drug Errors

• Effective medicines management achieves
• Improved patient safety
• Reduced length of stay
• Delivering 18 week wait target
• Rapid discharge
• Minimised re-admissions
• Prevention of admissions

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Reducing Drug Errors

• Process (prescribing, dispensing, administration)
• Risks in specific patient groups
• Risks in specific medicines groups
• Organisation/environmental management

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Reducing Drug Errors

• Causes
• 33 linked to look alike / sound alike names
• 23 high workload / low staffing
• 20 inexperienced staff
• 14 transcription errors (data entry)

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Reducing Drug Errors

• Development of medicines management metrics
  workshop
• October 1, St Marys Hospital (IW)
• For primary and secondary care pharmacy leads
• For more information contact gillian.honeywell_at_iow
  .nhs.uk