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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

Medication Safety Landscape – What have we achieved and what’s next?

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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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Page 1: Medication Safety Landscape – What have we achieved and what’s next?

Medication Safety Landscape – What have we achieved and what’s next?

Dr David CousinsSenior HeadSafe Medication Practice and Medical Devices

Page 2: Medication Safety Landscape – What have we achieved and what’s next?

20012000

Page 3: Medication Safety Landscape – What have we achieved and what’s next?

National Reporting & Learning System

NHS Trusts

PractitionersStaff

PatientsCarers

NRLS

CQCMHRA

NHS ComplaintsNHS Litigation Authority

Research

Feedback

InternationalCollaborationS

tandardised reporting

Page 4: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 5: Medication Safety Landscape – What have we achieved and what’s next?
Page 6: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 7: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 8: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 9: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 10: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 11: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 12: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 13: Medication Safety Landscape – What have we achieved and what’s next?

NRLS – Types of incidents

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

Page 14: Medication Safety Landscape – What have we achieved and what’s next?

NRLS – who is reporting incidents?

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

Page 15: Medication Safety Landscape – What have we achieved and what’s next?

NRLS – Types of harm

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

Page 16: Medication Safety Landscape – What have we achieved and what’s next?

NRLS – Ratio of serious harm / all

Page 17: Medication Safety Landscape – What have we achieved and what’s next?

NRLS – Stage of process

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

Page 18: Medication Safety Landscape – What have we achieved and what’s next?

NRLS – Error category

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

Page 19: Medication Safety Landscape – What have we achieved and what’s next?

NRLS – Critical medicines

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

Page 20: Medication Safety Landscape – What have we achieved and what’s next?

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

Page 21: Medication Safety Landscape – What have we achieved and what’s next?

NHS Outcomes framework

Page 22: Medication Safety Landscape – What have we achieved and what’s next?

Domain 5 Patient Safety

Page 23: Medication Safety Landscape – What have we achieved and what’s next?

• Known drug allergy• Reconciliation• Omitted doses• Anticoagulants• Opioids• Sedatives• Insulin

Page 24: Medication Safety Landscape – What have we achieved and what’s next?
Page 25: Medication Safety Landscape – What have we achieved and what’s next?

Patient Safety Collaborative

Page 26: Medication Safety Landscape – What have we achieved and what’s next?
Page 27: Medication Safety Landscape – What have we achieved and what’s next?

Safety is no accident!