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
CCG
1
72
Community Interest Company
8
Community pharmacy sector
Independent
NHS Acute Large
NHS Acute Medium
NHS Acute Small
NHS Acute Specialist
NHS Acute Teaching
NHS Ambulance Trust
NHS Community Trusts
NHS England Area Team
NHS Mental Health Trust
Other Independent Sector
Social Care Enterprise
(blank)
Grand Total
21
1
39
47
25
18
30
8
16
14
49
19
1
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 incidents
3. UKMI literature observatory
4. Community Pharmacy, CCG & MH dedicated web
events
5. Resources on www.patientsafetyfirst.nhs.uk
MSOs: local focus
1.
2.
3.
4.
Local learning from PSIs
Implement national messages locally
Improve the frequency and quality of reporting
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