Medication

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Medication

• Geraldine Yates
• Pharmacist Inspector

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Introduction

• Who am I?
• What Im not going to do
• What I hope to do
• What I want you to do

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Why now?

• 5 errors in 5 months leading to hospitalisation
• Concern as to how to share the learning

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What is a drug error?

• An unintended incident that could have or did
  lead to harm for one or more patients - NPSA

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Medication safety incidents

• Missed doses
• Wrong dose under dose overdose
• Wrong drug
• Wrong person
• Wrong time

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Common errors

• Missed doses
• 7/24 in 2 months
• Wrong person
• 6/24 in 2 months
• Over dose
• 4/24 in 24 months
• Wrong drug
• 3/24 in 2 months

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Common causes or errors

• Use of agency staff
• Busy, cluttered, noisy environment
• Medication not available
• MAR charts

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Domiciliary Care Issues

• Lack of information
• Clients ask carers to purchase medicines with
  weekly shop
• Medicines not in original dispensed container
• Monitored dosage systems

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Causes in Surrey

• Major incidents related to
• New residents
• New drugs
• End of life

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Incidents in last 2 months

• Secondary dispensing
• Medication left unattended
• Medication not given
• Wrong insulin selected

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How can we reduce risk?

• Ensure 5 rights
• Staff to be trained and competent
• Only administer medicines that are properly
  labelled
• If unsure dont give, check
• Promote self administration

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How are errors viewed in your homes?

• Do you have an open no blame culture?
• What are your procedures for dealing with errors?
• Do you audit and reflect on errors?
• Are your procedures really clear?
• How do you share your learning?

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Open fair organisationsA Systems Approach
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Myths

• The Perfection Myth
• If people try hard they will not make mistakes
• The Punishment Myth
• If we punish people when they make mistakes they
  will make fewer of them

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• The best people can and do make mistakes
• Dont just blame the individual look at what is
  wrong with the system
• Is what you are asking people to do reasonable /
  achievable?

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Measures of success

• An increase in reporting with a decrease in
  severity
• A high reporting rate openness not a bad service

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Further information

• The Administration and Control of Medicines in
  Care Homes and Childrens Services RPSBG
• Building a safer NHS for patients (improving
  medication safety) www.dh.gov.uk
• National Patient Safety Agency www.npsa.nhs.uk