‘Reducing Needless Medication Errors’

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Reducing Needless Medication Errors

• Gillian Honeywell, Chief Pharmacist, NHS Isle of
  Wight
• Clare Howard, Pharmaceutical Adviser, SHA

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Medication Errors do happen..
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Reported incident types in England April 2008 to
March 2009
Medication 86,287
NPSA Patient Safety Incidents in the NHS 2009
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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

• 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 12 2007
  available from http/www.npsa.nhs.uk/corporate/news
  /guidance-to-improve-mrdicines-reconciliation/

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Metrics

• Metric 1 Means of ensuring patient receive oral
  anticoagulation therapy within safe parameters
  (INR gt5 gt8)
• Metric 2 Medicines reconciliation safer
  admission to hospital and ensuring that patients
  medicines are reconciled within 24 hours of
  admission
• Metric 3 Allergies A means of ensure that
  patients allergy status is recorded on
  prescription charts
• Metric 4 SCIP 2 - Promoting the safer use of
  injectable medicines
• Metric 5 Reduce the number of  preventable NSAID
  related harms
• Metric 6 Reduction of harm from omitted and
  delayed medicines in hospital
• Metric 7 Reduce the number of insulin dosage
  errors caused by inappropriate use of
  abbreviations

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Metric 1 INRgt5 INR gt8

Oxford Radcliffe Hospitals
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Metric 2 Medicines Reconciliation
Implementation of 7 Day Working
Target line
Implementation of Green Bag Scheme
Staff vacancies
NHS Isle of Wight
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Green Bag Scheme

• 20,000 Pump Prime PSF
• Improves Medicines reconciliation by supporting
  the safe transfer of patients medicines between
  care settings
• Scheme has been rolled out throughout the South
  Central region
• Collaboration with 2 other regions on tendering
  process is currently underway to achieve best
  value for money

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Metric 3 Allergy Status
Target line
New prescription chart
New doctors- improved induction on allergy status
Increased intervention effort by pharmacists
New doctors
Berkshire Healthcare NHSFoundation Trust
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Metric 4 Safer Use of Injectable Medicines SCIP2
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

• Chief Pharmacists signed up to implement within
  agreed timescales
• Practical How to guides produced for each
  product (see Workstream stand)
• Progress assessed by purchasing data,
  questionnaire liaison with manufacturing unit

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Next steps Moving on from a culture of
measuring and benchmarking to action

• PDSA cycle for current metrics sharing of good
  practice
• Medicines Management training to provide a
  standardised training kit for all involved in
  medicines management
• Work is underway on following metrics
• NSAIDS related harms
• Omitted delayed medicines in hospital
• Reducing the number of insulin dosage errors
  caused by inappropriate use of abbreviations
• NNME workstream annual conference on the 12th
  13th May 2011 Isle of Wight Moving on from a
  culture of measuring and benchmarking to action

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PSF to QIPP?

• Medicines are the most frequently used healthcare
  intervention 12 billion (11) of overall NHS
  budget (South Central 777 million)
• Avoidable medication errors costs the NHS in
  England 750million (South Central 58million)1

• NPSA Patient Safety Observatory Safety in doses
  medication safety incidents in the NHS

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Safety Metrics QIPP

• What is the economic impact of improving safety
  in the areas selected?
• Initially, we set out to reduce medication
  related incidents by 20 which could (crudely)
  indicate savings of roughly 12 million per year.
• Does it add up? Can we QIPP the patient safety
  agenda? With medication errors we think we can

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Next steps

• Some of the assumptions need to be tested
  locally..
• Costs and Meds Rec rates before and after green
  bags?
• How many INR gt 8 result in an admission?
• What does it cost your Trust to treat a drug
  induced bleed?
• Can we determine the cost of omitted doses?
• How many admissions per year by Trust for insulin
  induced hypoglycaemia?
• Will cost avoidance fall on deaf ears?

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• For more information on the
• Reducing Needless Medication Errors Workstream
  
• please see the Patient Safety Federation website
  www.patientsafetyfederation.uk
• or contact
• Fiona Eccleston- Project Manager
• Fiona.eccleston_at_iow.nhs.uk