Shining a light on

Medication Safety

Steve Williams

Consultant Pharmacist in Medicine

& Medication Safety

Honorary Clinical Lecturer,

Manchester Pharmacy School

11th Sept 2015

Outline of session

– Explain current patient safety and medication

safety landscape

– Consider possible future direction of travel for

patient and medication safety beyond 2015

– Make you think about how UKMI and all MI

pharmacists can collaborate to move towards the

aim of zero (preventable) patient deaths due to

medicines in the future

How would you define Patient Safety and

Medication Safety?

“Understanding how to make healthcare safer is hard

and actually making care safer is harder still.

Healthcare is the largest industry in the world and

extraordinarily diverse in terms of the activities

involved and the manner of its delivery. We are

faced with hugely intractable, multifaceted

problems which are deeply embedded within our

healthcare systems. Understanding and creating

safety is a challenge equal to understanding the

biological systems that medicine seeks to influence.”

Charles Vincent: The essentials of patient safety

2012 http://www.wiley.com/legacy/wileychi/vincent/index.html

Current patient and medication

safety landscape

NHS England response to Francis and

Berwick reports

NHS England and MHRA

collaboration on

Medication Safety

1. NHS England focus on

error (no harm, low,

moderate, serious harm,

SIs, Never Events)

2. MHRA focus on counterfeit

/ defective medicines or

devices , “classic” ADRs

and where medication /

device error leads to harm

Medication Safety Officers (MSOs): March 2015

Unknown 1

CCG 72

Community Interest Company 8

Community pharmacy sector 21

Independent 1

NHS Acute Large 39

NHS Acute Medium 47

NHS Acute Small 25

NHS Acute Specialist 18

NHS Acute Teaching 30

NHS Ambulance Trust 8

NHS Community Trusts 16

NHS England Area Team 14

NHS Mental Health Trust 49

Other Independent Sector 19

Social Care Enterprise 1

(blank)

Grand Total 369

MSOs already making an impact?

MSOs: National focus

1. Web Events monthly & dedicated events supported by Specialised Pharmacy Services (SPS) & MHRA

2. Sharing learning from serious incidents3. UKMI literature observatory 4. Community Pharmacy, CCG & MH dedicated web

events5. Resources on www.patientsafetyfirst.nhs.uk

MSOs: local focus

1. Local learning from PSIs

2. Implement national messages locally

3. Improve the frequency and quality of reporting

4. Link with own Safety/ Quality leads and

Directors of Pharmacy, Nursing and Medicine

to improve medication safety and be able to

prove it

5. Conduit between NHS England/MHRA and

practice for medication safety issues

NHS England response to Francis and

Berwick reports

Patient Safety Data on ‘My NHS’ website

NHS England response to Francis and

Berwick reports

Never Events List 2015/16

– Now only 14 (25 in 2014/15)

– Never Event must:

-Be wholly preventable, where guidance or

safety recommendations are available at a

national level, that provide strong systemic

protective barriers that have been

implemented by all healthcare providers

-Have the potential to cause serious patient

harm or death

-Have occurred in the past, for example

through reports to (NRLS)

-Be easily recognised and clearly defined

What is meant by strong systemic protective

barriers?

– Successful, reliable and comprehensive

safeguards or remedies e.g. a uniquely

designed connector to prevent administration

of a medicine via the incorrect route for which

the importance, rationale and good practice

use is known to, fully understood by, and

robustly sustained throughout the system

from suppliers, procurers, requisitioners,

training units, and front line

staff alike

Physical barrier: Better picture of

bins where can only place certain

types of waste

Never Events List 2015/16

– Following medicine Never Events removed:

• Opioid overdose of an opioid/opiate naïve

patient

• Wrong gas administered

• Failure to monitor and respond to oxygen

saturation

• Wrongly manufactured high risk injectable

medication

Never Events List 2015/16

– Wrongly manufactured high risk injectable

medication NE removed from the list as the

strong systemic protective barriers that are

required e.g. national availability and use of

ready to administer products in clinical areas

– Requires a national plan for 2016/17

NHS England response to Francis and

Berwick reports

NHS England response to Francis and

Berwick reports