design and learning centre - the impact of medicines errors · 2019-11-15 · dispensing errors...

The Impact of Medicines Errors

PRESENTED BY

Judith Manners MRPharmS, DipClinPharm

Pharmacist Director - Opus

Pharmacists

Provide medicines training for the care sector and schools

Have trained over 100,000 people

Face to face courses,

e-learning, distance learning workbooks

Audits

Policies

Advice and support

Who we are!

www.opuspharmserve.com [email protected]©Copyright 2019 Opus Pharmacy Services Ltd. All rights reserved.

Medication Errors-The Stats

o 88.7m are minor (little or no potential to cause harm)

o 9.9m moderate (potential to cause moderate harm)

o 0.4m severe (potential to cause severe harm)

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237.4 millionIn England per year- there are medicines errors

99 millionIn care homes errors (41.7%)

Source: EEPRU - Prevalence and economic burden of medication errors in the NHS in England


Types of Medicines Errors

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Prescribing

Monitoring

Dispensing

Administration

Ordering and record-

keeping

Medicines Errors


Prescribing Errors

• Prescribing errors - most likely to cause moderate harm

• Around 400,000 people live in England’s 17,000 nursing and residential homes

• 1 in 7 residents aged 85 or over

• Often have 1 or more long term condition

• On average, care home residents prescribed 7 medicines a day

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Source: NHS England (https://www.england.nhs.uk/2019/05/army-of-nhs-experts-to-tackle-over-medication/)

https://www.england.nhs.uk/2019/05/army-of-nhs-experts-to-tackle-over-medication/


• Dispensing errors account for 17.5% of errors that have

the potential to cause moderate or severe harm

• Reporting of patient safety incidents by pharmacies

increased by almost a third (Jan-March 2019)

• Incidents reported as ‘wrong strength’ involved:

o metformin tablets SR 500mg and 1000mg (21%)

o metformin tablets 500mg and 850mg (11%)

• Wrong formulation (11%) involved a number of

inhalation preparations being dispensed incorrectly in

place of dry powder, breath actuated and/or nasal

spray, and vice versa

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Source: April 2019, National Pharmacy Association Medication Safety Officer Q1 Report

Dispensing Errors (1)


LASA (Look-alike Sound –alike)

• In England 2017 - 1.1 billion prescriptions dispensed

• Over 70M were for LASA medicines

• Highest risk due to occurrence and magnitude of harm

7Source: Community Pharmacy Patient Safety Group 2019

Amlodipine

Allopurinol

Azathioprine

Carbamazepine

Prednisolone

Amitriptyline

Atenolol

Azithromycin

Carbimazole

Propranolol

and

and

and

and

and


LASA (Look-alike Sound –alike)

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Administration Errors

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Most administration errors (71.1%) occur in care homes

Forgetting to give the medicine

Giving the medicine to the wrong person

Giving the wrong dose

Giving the medicine at the wrong time

Giving the wrong medicine

Giving the medicine twice

Giving out of date medicine

Forgetting to sign


Why do People Make Errors?

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Why Do People Make Medicines Errors?

• Care staff don’t set out to harm people

• A number of factors combine, making it more likely for a mistake to be made

• Need to understand:

o What these factors are

o When they are likely to occur

o Ways to overcome them

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MINIMISING RISK


Factor 1-Human Behaviour Factor

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Knowledge-based behaviours

Rule-based behaviours

Skill-based behaviours

This model links the type of error with how much experience someone may have with a task and therefore

how automatic it may feel when they carry it out


Occur when the rules learnt and usually used for similar scenarios no longer appear helpful for that scenario

Knowledge-Based Working Errors

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EXAMPLE: Fridge storage for medicines when person goes on holiday

ERROR OUTCOME:

Medicine is stored at the wrong temperature and may not be effective


Rule-Based Working Errors

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Occur when situations are different to what you assume

EXAMPLE: Someone’s medicine is not in the usual place

ERROR OUTCOME:

Person misses their medication which could have consequences


Skills-Based Working Errors

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• Are often slips and lapses• Person is working on autopilot• Unconscious competence

EXAMPLE 1:

No-one signs for medicine given on 1st 2 days of MAR sheet, day 3-no one signs

ERROR OUTCOME 1:

Person may receive double dose or no dose at all

EXAMPLE 2:

Medication is given early to a person and not recorded. Usual dose then given at breakfast

ERROR OUTCOME 2:

Person receives double dose


Action Points

• Look for these behaviours in your staff

• Address them

• Staff awareness of potential risk areas

• Encourage self-monitoring as well as alerting other members of staff

• Active decisions need to be made each time

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Understand behaviours

Ensure staff know correct procedures

Encourage staff to recognise when they’re working on auto-pilot

• Active decisions need to be made each time


Factor 2- Complacency in the Workplace

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Staff need to assess each situation individually with regard to medicines administration

Don’t rely on other team members (think of the airline industry!)

Strike a balance between enjoyable work environment with a supportive team structure and staff taking responsibility for their own actions


Action Points

• Always work as a team but don’t rely on others

• Take responsibility for every part of their own role

• Take pride in their role

• Understand the importance and consequences of their role

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Managers should encourage staff to:


Factor 3- Inadequate Auditing of Errors and Incidents

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What is it that you’re auditing?

Will this audit provide meaningful outcomes?

Does this audit provide any useful information or am I just form filling or box ticking?


Successful Auditing

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Audit

Risk based approach to frequency of audits

Learning from audits

Use audits to highlight greatness, not as a negative tool


Action Points

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Design an audit tool that works for you - continually review

Adopt a “no blame” culture

Ensure staff feel able to discuss the errors they have made

Look for trends-same time of day-same person-same medicine?

Near misses

Lessons Learnt Exercise-gather data and evaluate

Provide key learning points for staff


Factor 4-Confusing Internal Medicines Handling Processes

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Are staff aware of correct procedure to follow??

Do they know where to find the information??

Is the procedure easy to follow??Has a previous mistake lead to a more complicated procedure being developed which is more confusing??


Action Points

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Make sure you have clear procedures-easy to follow-easy to understand

Create a training programme based around your procedures

Competency assess staff

Monitor

Get an outside perspective e.g. external audit

Prevention is better than cure!


What does good leadership in medication look like?

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Manager knows what their role is

Staff know what to expect

Manager is available

Staff can report a concern in a way that is encouraged and that they know will be taken seriously


Strong foundations

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Medication policy- and procedures

Staff training

Competency assessed

Know when to report

Know what to do when things go wrong


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design and learning centre - the impact of medicines errors · 2019-11-15 · dispensing errors...

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