Protecting patients-now and in the future

Linda Matthew

Senior Pharmacist

National Patient Safety Agency

The changing face of chemotherapy

• IV Oral (now)

• Secondary care Primary care (the future)

Increasing risk

Modern health care is complex • Increased volume of work• Older and sicker patients• Complex, new drugs, interventions & technology• Cost constraints – efficiency• Workforce pressures• Changing expectations• Changing shape of service delivery

Public confidence

Managing the risks in current serviceconfigurations

• Information is key• Proactive risk management • Reactive risk management

BOPA position statement (2004)

• Standards – Manual of Cancer Standards (or equiv)• Patient remain under care of a specialist• Policy & procedures- IV and oral• Risk assess the hazards of oral medications• Prescribing & dispensing standards -same for IV/oral• Education of patients• Effective communication across care interfaces• Prescribing and dispensing should be responsibility of

hospital team

Oral chemotherapy-patient safety incident data

• What does data on incidents reported to the National Reporting & Learning System (NRLS) tell us?

National Reporting & Learning System (NRLS)

NHS Trusts

PractitionersStaff

Patients

Carers

NPSA

Healthcare Commission

MHRA

NHS Complaints

NHS Litigation Authority

Feedback

International

Collaboration

Australia

USA

Europe

Standardised reporting

Medication report – March 07

Medication Report – March 2007

7 Key areas for action• Increase reporting & learning from medication

incidents• Implement the safer medication practice

recommendations• Improve staff skills & competence

Medication Report – March 2007

7 key areas for action• Minimise dosing errors• Ensure medicines are not omitted• Ensure the correct medicines are given to the correct

patient• Document patients’ medicine allergy status

NRLS- All incident types v medicationJan 06 to March 07

50601 52261

60987

51375

6310759619

49684

65141

71643

63820

71901

47881

74963

53823

94554

4548 5007 3399 5368 5337 5162 5683 6291 5849 62313944

6559 48198523

4537

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07

Month / Year

Nu

mb

er

Total no. of incidents to NRLS Total no. of Medication incidents

Linear (Total no. of incidents to NRLS ) Linear (Total no. of Medication incidents)

NRLS Medication Incidents – reported by care sector

0% 10% 20% 30% 40% 50% 60% 70% 80%

Acute

Community Services

Mental Health

GP's

CommunityPharmacy

0ther

NRLS data Nov 03 – July 07

Search terms• Oral, chemotherapy • 26 individually named drugs• 3+ years of data from > 600 organisations

(>250 acute sector organisations)

Degree of harm caused

Stage in the process

Medication Error Types

Top 6 drugs reported

Key notes

Recommendations

Proactive management of risks;• review local systems (BOPA position statement

2004)

Reactive management of risks;• Increase reporting of patient safety incidents • Review reports to identify local risk trends • Analyse incidents to identify system weaknesses• Take action to improve systems

The changing face of chemotherapy DiagnoseSecondary care

Monitor Prescribe

Administer IV Dispense

The changing face of chemotherapy

Secondary care Diagnose

Primary care Monitor Prescribe

Self administer Dispense

Managing the risks of the future service configurations

• Information is key• Define/map out the system• Proactively assess the risks• Use incident and other data/info to inform the process

Example – NPSA alert no 18 anticoagulant therapy & services

Process• Search for related safety data• Map anticoagulant therapy services in the NHS• Assess the risks in each part of the treatment

process (using SWIFT)• Identify solutions to reduce the risks

Alert 18 Risk assessment

Related safety data- NHSLA data – published claims and reports- NPSA NRLS data- Published audits & reports- Case reports

Alert 18 Risk assessment- findings

- Inadequate training & work competences- Inadequate clinical audit and failure to act on results- Poor documentation- Prescribing issues (errors, interacting medications…)

Alert 18 Risk assessment- findings contd.

- Poor communication across the interface- Insufficient support for patients & staff- Insufficient monitoring - Inadequate safety checks at repeat prescribing

Alert 18 – safer practice solutions

• Ensure competency of staff • Ensure policies & procedures in place • Audit services• Provide verbal and written information for patients at

commencement and thro’ treatment• Prescribers and pharmacists to supply repeat prescriptions

using safe systems of practice & only when safe to do so• Implement safety precautions when co-prescribing interacting

drugs• Standardise the range of products available to avoid error

Generic risks

• Lack of knowledge and expertise • Poor communication between sectors• Poor monitoring • Poor patient information and education• Inadequate documentation• Lack of standardisation

The challenges

• Loss of control or a sharing of responsibility?• Increasing complexity

- longer care pathway- more stakeholders• Different cultures (and politics)• Longer chains of communication• Different ways of working - re-designing the system

The challenges - contd.

• Policy changes to meet future system needs (Community pharmacy services)

• Resource transfers• Providing information for patients• On-going monitoring• Inadequate/unreliable systems

Potential solutions

• Technology

Specialised design of e-prescription

E-transfer of prescriptions

Sharing of patient e-record (hospital, GP, pharmacy)

On-line availability of protocol information

Potential solutions

• Skills and competence

Secondary sector expertise in primary care

Consultant Oncology Pharmacists

Pharmacist led monitoring clinics

Enhanced role for specialist pharmacy technicians

Summary

The future presents both risk and opportunity• Information is key- Incident reporting• Learning from incidents – reactive• Learning from others – proactive

• Windows of opportunity for role enhancement

Thank you