Medication Safety in ABMU Health Board

Roger Williams

Head of Pharmacy Acute Services

June 2014

Aims of presentation

To consider:

1. Governance arrangements to provide assurances for medication safety

National

Local

2. Medication safety performance indicators

3. Omitted and missed doses

Medication safety

Evidence from national data:

50% medicines are not taken as prescribed

1 in 20 hospital admissions are as a result of adverse drug reactions

1 in 10 hospital prescriptions contain an error in prescribing

Medication safety is everybody’s business Need to ensure that the quality and safety agenda is

embedded in the organisation (Andrews May, 2014)

Patient safety and experience in relation to medicines must be a multidisciplinary activity

Complexity of patient’s healthcare needs requires the collective knowledge and skills of many professions – each makes it’s contribution to the “collective” pool

Pharmacy Hospital Standards Professional standards for hospital pharmacy services:

optimising patient outcomes from medicines (Royal Pharmaceutical Society: 2014)

Provide a framework to support Chief Pharmacists to improve

services to deliver safer and better quality of care. Ten standards divided into three domains Patient experience Safe and effective use of medicines Delivering the service

Standard 6: Safe and effective use of medicines “The Chief Pharmacist leads on promoting open and

transparent culture in which medication safety has a high profile”

Systems in place to ensure timely response to MHRA and other alerts

A multidisciplinary group reviews medication errors and systems failures – to improve practice and safety

Shared learning is reported at board level on a regular basis

Omitted and delayed doses are monitored and investigated

Reporting of medication incidents – changing national arrangements Medication incidents are reported by the National Reporting

and Learning System (NRLS)

Analysis of NRLS incidents have previously been communicated through from the former National Patient Safety Agency (NPSA)

In England, analysis is now co-ordinated by the new National Patient Safety Alerting System - an integrated reporting route for medication incidents by NHS England and the MHRA

Why is change needed to improve the governance of medication error reporting and learning? Incident reports are not always reviewed locally to check

quality and to initiate action

Senior managers in healthcare organisations need to be aware of important patient safety issues and have assurances that reporting and learning systems in their organisations are effective

Need to improve two way communication routes with the MHRA when further analysis required for specific incidents

Medication Safety Officer In England, medication safety officers have been appointed for

each organisation.

Post is responsible for:

improvements in reporting and implementation of local and national medication safety initiatives

supporting the work programme of the medication safety committee

Process for reporting medication incidents

Position in Wales Further to discussions with safety leads in England, support for

inclusion of representatives from Wales onto the medication safety network has been agreed

Wales has been asked to nominate one representative from each Health Board and a single national lead who will co-ordinate with the Senior Head of Patient Safety in NHS England

The local position Medication safety group in place

Role and responsibility of group to be updated in response to changing national picture

Appointment of a medication safety officer for ABM is required

Committee’s main responsibilities to be refocused

Key activities of Medication Safety Committee Improving reporting and learning of medication error incidents

in the organisation;

Analysing data, audits etc to identify, prioritise and address medication risks to minimise harm to patients

Supporting the implementation of external patient safety guidance from NHS England, MHRA, NICE and other organisations

Co-ordinating education and training support to improve the quality of medication error incident reports and safe medication practices

Key Performance Indicators for Medication Safety:

Medication Safety Key Performance Indicators Welsh Government’s National Quality Delivery plan –

Achieving Excellence describes the need for Q&S indicators

All Wales group developing a national set of medication safety indicators

Work based on the Medication Safety Thermometer tool

Indicators developed to reflect areas where most risk occurs

All Wales Patient Thermometer % patients with a documented allergy

status

% patients with a documented VTE risk assessment on the chart

% patients with meds reconciliation started within 24hrs of admission

% patients with an unintentional missed dose within last 24hrs

Proportion of missed doses by reason

Proportion of patients who missed a dose of a high risk/critical time medicine

Critical medicines (safety thermometer) Antibiotics

Anticoagulants

Insulin

Opioids

Other locally agreed critical medicines

Fundamentals of Care

ABMU Pilot – Feb 2014 83 charts were audited across 5 sites (10 wards) on a Tuesday in February 2014.

* Prescribers request 2 Patient off ward 3 No access 4 Patient refused

5 Drug not available 6 See notes Blank

Missed doses and the Mid Staffordshire Enquiry Omitted doses identified as the most significant issue in

relation to medicines management

Report recommended frequent checks to ensure all patients receive what they have been prescribed and need, particularly when they are moved from one clinical area to another (Francis, 2013)

Care Setting Clinical Outcome of Incident Reports Total

Death Severe Harm

Moderate Harm

Low Harm

No Harm

Acute/general hospital 27 68 975 4,430 13,027 18,527

Community nursing, medical & therapy service (inc. Community Hospital)

67 239 1,211 1,517

Mental Health Service 33 150 1,156 1,339

Total 27 68 1,075 4,819 15,394 21,383

Table 1 below shows the clinical outcomes of incident reports of omitted or delayed medicine reported to the RLS between 29 September 2006 and 30 June 2009.

Review of evidence of harm

ABMU Missed Dose Audit 2013/14 Between November 2013 and February 2014 hospital

pharmacies on the five acute sites undertook an audit on missed doses.

On each ward that currently receives a medicines management service, all drug charts were audited.

Data was collected on the following:

Total number of prescribed doses

Total number of missed doses

Where doses were missed, the reason was documented:

* Prescribers request 2 Patient off ward 3 No access 4 Patient refused

5 Drug not available 6 See notes Blank

ABMU Missed Dose Audit 2013/14

Trusted to Care: June Andrews’ report.

Identified failings in administration of medicines to patients.

Recommendation 8:

The Board should adopt a “zero tolerance” approach to the improper administration of sedation and medicines for all clinical staff,

“A mass education project is needed….. where staff are reconnected with their personal professional responsibilities and hospital policy”

Discussion 1. Record Keeping

Nursing and Midwifery Council Code of Conduct:

“you must make a clear accurate & immediate record of all medicines administered, intentionally withheld or refused by the patient ensuring the signature is clear and legible …. In addition … where medication is not given the reason for not doing so must be recorded…” (NMC, 2010).

Discussion 2. Refused medicines (code = 4)

Patients have a right to refuse medication, but staff should ensure they understand the implications of doing so – where to document and accountability.

Case Study Using the 4 medical wards in Neath as an example:

2: Patient off ward 3: No access 4a: Patient refused

5: Drug not available 6: See notes Blank 4b: Patient refused

(laxatives/painkillers/dietetic products

Proportion of refused doses that were laxatives/painkillers/ dietetic products

Discussion 3. Drug unavailable (code = 5) Accurate recording so understood by other multidisciplinary

team members.

Patients are almost twice as likely to miss a first dose because it was unavailable than later doses.

Timing of first doses of antimicrobials may be critical.

Need to understand the reasons:

e.g. cannot find on ward, not in pharmacy out of hours cupboard, why not contact on-call pharmacist.

If not urgent has this been documented?

Summary and action points Raise the profile of medication safety in the organisation

the role of the medication safety officer and links with patient safety England.

Review the role and responsibilities of the medication safety group

Introduce regular reporting of medicine safety KPIs and ensure action plans implemented

Focus on initially:

Missed doses

VTE risk assessment

Thank you