Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015...
Transcript of Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015...
![Page 1: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/1.jpg)
Shining a light on
Medication Safety
Steve Williams
Consultant Pharmacist in Medicine
& Medication Safety
Honorary Clinical Lecturer,
Manchester Pharmacy School
11th Sept 2015
![Page 2: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/2.jpg)
Outline of session
– Explain current patient safety and medication
safety landscape
– Consider possible future direction of travel for
patient and medication safety beyond 2015
– Make you think about how UKMI and all MI
pharmacists can collaborate to move towards the
aim of zero (preventable) patient deaths due to
medicines in the future
![Page 3: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/3.jpg)
How would you define Patient Safety and
Medication Safety?
![Page 4: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/4.jpg)
![Page 5: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/5.jpg)
![Page 6: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/6.jpg)
“Understanding how to make healthcare safer is hard
and actually making care safer is harder still.
Healthcare is the largest industry in the world and
extraordinarily diverse in terms of the activities
involved and the manner of its delivery. We are
faced with hugely intractable, multifaceted
problems which are deeply embedded within our
healthcare systems. Understanding and creating
safety is a challenge equal to understanding the
biological systems that medicine seeks to influence.”
Charles Vincent: The essentials of patient safety
2012 http://www.wiley.com/legacy/wileychi/vincent/index.html
![Page 7: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/7.jpg)
Current patient and medication
safety landscape
![Page 8: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/8.jpg)
NHS England response to Francis and
Berwick reports
![Page 9: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/9.jpg)
![Page 10: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/10.jpg)
NHS England and MHRA
collaboration on
Medication Safety
1. NHS England focus on
error (no harm, low,
moderate, serious harm,
SIs, Never Events)
2. MHRA focus on counterfeit
/ defective medicines or
devices , “classic” ADRs
and where medication /
device error leads to harm
![Page 11: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/11.jpg)
Medication Safety Officers (MSOs): March 2015
Unknown 1
CCG 72
Community Interest Company 8
Community pharmacy sector 21
Independent 1
NHS Acute Large 39
NHS Acute Medium 47
NHS Acute Small 25
NHS Acute Specialist 18
NHS Acute Teaching 30
NHS Ambulance Trust 8
NHS Community Trusts 16
NHS England Area Team 14
NHS Mental Health Trust 49
Other Independent Sector 19
Social Care Enterprise 1
(blank)
Grand Total 369
![Page 12: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/12.jpg)
MSOs already making an impact?
![Page 13: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/13.jpg)
MSOs: National focus
1. Web Events monthly & dedicated events supported by Specialised Pharmacy Services (SPS) & MHRA
2. Sharing learning from serious incidents3. UKMI literature observatory 4. Community Pharmacy, CCG & MH dedicated web
events5. Resources on www.patientsafetyfirst.nhs.uk
![Page 14: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/14.jpg)
MSOs: local focus
1. Local learning from PSIs
2. Implement national messages locally
3. Improve the frequency and quality of reporting
4. Link with own Safety/ Quality leads and
Directors of Pharmacy, Nursing and Medicine
to improve medication safety and be able to
prove it
5. Conduit between NHS England/MHRA and
practice for medication safety issues
![Page 15: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/15.jpg)
NHS England response to Francis and
Berwick reports
![Page 16: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/16.jpg)
Patient Safety Data on ‘My NHS’ website
![Page 17: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/17.jpg)
![Page 18: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/18.jpg)
NHS England response to Francis and
Berwick reports
![Page 19: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/19.jpg)
Never Events List 2015/16
– Now only 14 (25 in 2014/15)
– Never Event must:
-Be wholly preventable, where guidance or
safety recommendations are available at a
national level, that provide strong systemic
protective barriers that have been
implemented by all healthcare providers
-Have the potential to cause serious patient
harm or death
-Have occurred in the past, for example
through reports to (NRLS)
-Be easily recognised and clearly defined
![Page 20: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/20.jpg)
What is meant by strong systemic protective
barriers?
– Successful, reliable and comprehensive
safeguards or remedies e.g. a uniquely
designed connector to prevent administration
of a medicine via the incorrect route for which
the importance, rationale and good practice
use is known to, fully understood by, and
robustly sustained throughout the system
from suppliers, procurers, requisitioners,
training units, and front line
staff alike
![Page 21: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/21.jpg)
![Page 22: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/22.jpg)
![Page 23: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/23.jpg)
Physical barrier: Better picture of
bins where can only place certain
types of waste
![Page 24: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/24.jpg)
Never Events List 2015/16
– Following medicine Never Events removed:
• Opioid overdose of an opioid/opiate naïve
patient
• Wrong gas administered
• Failure to monitor and respond to oxygen
saturation
• Wrongly manufactured high risk injectable
medication
![Page 25: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/25.jpg)
Never Events List 2015/16
– Wrongly manufactured high risk injectable
medication NE removed from the list as the
strong systemic protective barriers that are
required e.g. national availability and use of
ready to administer products in clinical areas
– Requires a national plan for 2016/17
![Page 26: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/26.jpg)
![Page 27: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/27.jpg)
![Page 28: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/28.jpg)
![Page 29: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/29.jpg)
NHS England response to Francis and
Berwick reports
![Page 30: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/30.jpg)
![Page 31: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/31.jpg)
![Page 32: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/32.jpg)
![Page 33: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/33.jpg)
![Page 34: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/34.jpg)
![Page 35: Shining a light on Medication Safety - UKMi€¦ · Medication Safety Officers (MSOs): March 2015 Unknown 1 CCG 72 Community Interest Company 8 Community pharmacy sector 21 Independent](https://reader035.fdocuments.us/reader035/viewer/2022070719/5edf25a5ad6a402d666a7f6d/html5/thumbnails/35.jpg)
NHS England response to Francis and
Berwick reports