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Medication Safety Landscape – What have we achieved and what’s next?. Dr David Cousins Senior Head Safe Medication Practice and Medical Devices. 2001. 2000. National Reporting & Learning System. Feedback. Standardised reporting. NRLS. International Collaboration. NHS Trusts. - PowerPoint PPT Presentation
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Medication Safety Landscape – What have we achieved and what’s next?
Dr David CousinsSenior HeadSafe Medication Practice and Medical Devices
20012000
National Reporting & Learning System
NHS Trusts
PractitionersStaff
PatientsCarers
NRLS
CQCMHRA
NHS ComplaintsNHS Litigation Authority
Research
Feedback
InternationalCollaborationS
tandardised reporting
Air Safety Reports: Volume & Risk
0100020003000400050006000700080009000
1994 1995 1996 1997 1998 1999
0.0%
0.5%
1.0%
1.5%
Year
2.0%
2.5%
3.0% Total % High Risk
Patient accident
Medication
Treatment, procedure
Implementation of care and ongoing monitoring / review
Access, admission, transfer, discharge (including missing patient)
Documentation (including records, identification)
Infrastructure (including staffing, facilities, environment)
Clinical assessment (including diagnosis, scans, tests, assessments)
Other
Consent, communication, confidentiality
Disruptive, aggressive behaviour
Self-harming behaviour
Medical device / equipment
Infection Control Incident
Patient abuse (by staff / third party)
0 5 10 15 20 25 30
Chart 2: Proportion of incidents by incident type and quarter, Jul 2011 - Jun 2012
Apr 2012 - Jun 2012Jan 2012 - Mar 2012Oct 2011 - Dec 2011Jul 2011 - Sep 2011
Percent
Acute / general hospital
Mental health service
Community nursing, medical and therapy service (incl. community hos-
pital)
Learning disabilities service
Community pharmacy
Ambulance service
General practice
Community and general dental service
Community optometry / optician service
0 10 20 30 40 50 60 70 80
Chart 3: Proportion of incidents by care setting and quarter, Jul 2011 - Jun 2012
Apr 2012 - Jun 2012Jan 2012 - Mar 2012Oct 2011 - Dec 2011Jul 2011 - Sep 2011
Percent
Patient accident
Treatment, procedure
Medication
Implementation of care and ongoing monitoring / review
Access, admission, transfer, discharge (including missing patient)
Documentation (including records, identification)
Infrastructure (including staffing, facilities, environment)
Clinical assessment (including diagnosis, scans, tests, assessments)
Consent, communication, confidentiality
Medical device / equipment
Other
Infection Control Incident
Disruptive, aggressive behaviour
Self-harming behaviour
Patient abuse (by staff / third party)
0 5 10 15 20 25 30
Chart 4: Proportion of incidents in acute / general hospital settings by quarter, Jul 2011 - Jun 2012
Apr 2012 - Jun 2012Jan 2012 - Mar 2012Oct 2011 - Dec 2011Jul 2011 - Sep 2011
Percent
Patient accident
Self-harming behaviour
Disruptive, aggressive behaviour
Access, admission, transfer, discharge (including missing patient)
Medication
Other
Infrastructure (including staffing, facilities, environment)
Documentation (including records, identification)
Patient abuse (by staff / third party)
Implementation of care and ongoing monitoring / review
Treatment, procedure
Consent, communication, confidentiality
Infection Control Incident
Clinical assessment (including diagnosis, scans, tests, assessments)
Medical device / equipment
0 5 10 15 20 25 30
Chart 6: Proportion of incidents in mental health settings by quarter, Jul 2011 - Jun 2012
Apr 2012 - Jun 2012Jan 2012 - Mar 2012Oct 2011 - Dec 2011Jul 2011 - Sep 2011
Percent
Patient accident
Implementation of care and ongoing monitoring / review
Medication
Treatment, procedure
Access, admission, transfer, discharge (including missing patient)
Other
Consent, communication, confidentiality
Documentation (including records, identification)
Clinical assessment (including diagnosis, scans, tests, assessments)
Infrastructure (including staffing, facilities, environment)
Medical device / equipment
Infection Control Incident
Self-harming behaviour
Disruptive, aggressive behaviour
Patient abuse (by staff / third party)
0 5 10 15 20 25 30 35
Chart 8: Proportion of incidents in community nursing settings by quarter, Jul 2011 - Jun 2012
Apr 2012 - Jun 2012Jan 2012 - Mar 2012Oct 2011 - Dec 2011Jul 2011 - Sep 2011
Percent
Medication
Documentation (including records, identification)
Implementation of care and ongoing monitoring / review
Clinical assessment (including diagnosis, scans, tests, assessments)
Access, admission, transfer, discharge (including missing patient)
Consent, communication, confidentiality
Treatment, procedure
Other
Patient accident
Infrastructure (including staffing, facilities, environment)
Infection Control Incident
Medical device / equipment
Self-harming behaviour
Disruptive, aggressive behaviour
Patient abuse (by staff / third party)
0 5 10 15 20 25
Chart 9: Proportion of incidents in general practice set-tings by quarter, Jul 2011 - Jun 2012
Apr 2012 - Jun 2012Jan 2012 - Mar 2012Oct 2011 - Dec 2011Jul 2011 - Sep 2011
Percent
National Reporting and Learning System (NRLS) in England and Wales medication incident reports 2005 - 10
Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012
NRLS – Types of incidents
Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012
NRLS – who is reporting incidents?
Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012
NRLS – Types of harm
Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012
NRLS – Ratio of serious harm / all
NRLS – Stage of process
Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012
NRLS – Error category
Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012
NRLS – Critical medicines
Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012
DH – Never events – medication practice• Wrong prepared high risk injectable medicine• Maladministration of potassium containing solutions• Wrong route administration of oral/enteral products• Intravenous administration of epidural injections/infusions• Maladministration of insulin products• Overdose of midazolam during conscious sedation • Opioid overdose in opioid naive patents• Inappropriate administration of daily oral methotrexate• Wrong gas administered
NHS Outcomes framework
Domain 5 Patient Safety
• Known drug allergy• Reconciliation• Omitted doses• Anticoagulants• Opioids• Sedatives• Insulin
Patient Safety Collaborative
Safety is no accident!
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