‘No Needless Medication Errors’

Gillian Honeywell, Chief Pharmacist

Fiona Eccleston, Project Manager

NHS Isle of Wight

South Central

Medication Errors do happen..

South Central

Facts and figures• Medicines are the most frequently used healthcare

intervention• 97% of all hospital patients take a medicine• 6% of hospital admissions are a direct result of problems

with medicines including side effects1

• Poor communication between care settings is responsible for up to 50% of all medication errors & up to 20% of adverse drug reactions that occur in hospital 2

• Average DGH has 350 medication errors per day• NPSA: medication errors account for 9% total

South Central

1. Pharmacy in England Building on strengths – delivering the future, Department of Health. 20082. NICE/NPSA patient safety guidance to improve medicines reconciliation at hospital admission. National Patient Safety Agency.

December 12 2007 available from http/www.npsa.nhs.uk/corporate/news/guidance-to-improve-mrdicines-reconciliation/

Project PlanProject 1: Metrics: 3rd year: Improvement Methodology: Trust Quality Standard kpi’s and SHA monitoring

1: Means of ensuring patient receive oral anticoagulation therapy within safe parameters (INR >5 & >8)

2: Medicines reconciliation: safer admission to hospital: patients’ medicines are reconciled within 24 hours of admission

3: Allergies: A means of ensuring that patients allergy status is recorded on prescription charts

Project 2: Promoting the safer use of injectable medicines Pre-filled syringes for high risk medicines: nursing time released to careRisk assessments to reduce errors with injectables: collaborative

procurement

South Central

Project PlanProject 3: NSAID related harm

Baseline audit completed. Usage data reported 3 monthly, preparation for monthly prescription metric

Project 4: Reduction of harm from omitted and delayed medicines in hospital

Baseline audit for antibiotics completed. Single Trust audit for all drugs / doses completed. Preparation for monthly metric

Project 5: Reduce the number of errors and harms with insulinBaseline audits completed. Preparation for monthly metric

Project 6: Standardised accessible Medicines Management Training

E-learning modules for all aspects of the medicines trail, for all professions.

South Central

Metric 2: Medicines Reconciliation

South Central

% of Adult Patients with Medicines Reconciliation Completed within 24 hrs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

J an-10 Feb-10 Mar-10 Apr-10 May-10 May(2) J un-10 J une(2) J ul-10 J ul (2) Aug-10 Sep-10 Oct-10 Nov-10 Dec-10

Staff vacancies

Implementation of Green Bag Scheme

NHS Isle of Wight

Target line

Implementation of 7 Day Working

Green Bag Scheme£20,000 Pump Prime PSF

Medicines reconciliation supporting the safe transfer of patient’s medicines between care settings

QIPP and Waste Campaign• Recent audit in South Central:

estimated saving of approx. £10 per patient admitted- from admissions data this equates to potential savings of £3.6million

• A further £1.26m from MR safety cost- avoidance for 70% of these patients

South Central

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

28-Mar-11 17-May-11 06-Jul-11 25-Aug-11 14-Oct-11 03-Dec-11

5QF Berkshire West PCT

5QT Isle of Wight NHS PCT

RBF-X Nuffield Orthopaedic Centre NHS Trust

RD7 Heatherwood and Wexham Park Hospitals NHSFoundation TrustRD8 Milton Keynes Hospital NHS Foundation Trust

RHM Southampton University Hospitals NHS Trust

RHU Portsmouth Hospitals NHS Trust

RN1-X Winchester and Eastleigh Healthcare NHSTrustRN5-X Basingstoke and North Hampshire NHSFoundation TrustRNU Oxford Health NHS Foundation Trust

RTH Oxford Radcliffe Hospitals NHS Trust

RW1 Hampshire Partnership NHS Foundation Trust

RWX Berkshire Healthcare NHS Foundation Trust

0 10 20 30

0-1011-2021-3031-4041-5051-6061-7071-8081-90

91-100

Frequency

Percentage of Meds Rec Completed(since 01 Apr 2011)

%

Medicines Reconciliation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

26/02/2011 17/04/2011 06/06/2011 26/07/2011 14/09/2011 03/11/2011 23/12/2011 11/02/2012

5QT Isle of Wight NHS PCT

RBF-X Nuffield Orthopaedic Centre NHS Trust

RD7 Heatherwood and Wexham Park Hospitals NHSFoundation Trust

RD8 Milton Keynes Hospital NHS Foundation Trust

RHM Southampton University Hospitals NHS Trust

RHU Portsmouth Hospitals NHS Trust

RN1-X Winchester and Eastleigh Healthcare NHSTrust

RN5-X Basingstoke and North Hampshire NHSFoundation Trust

RTH Oxford Radcliffe Hospitals NHS Trust

RXQ Buckinghamshire Healthcare NHS Trust

0 10 20 30

0-1011-2021-3031-4041-5051-6061-7071-8081-90

91-100

Frequency

Medicines ReconciliationAcute Trusts in FY 2011

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

South Central

Green Bag & Medicines Reconciliation

South Central

Input Green Bags

£20k

Output /deliveredAcross SCSHA*• £3.6m savings from medicines•£1.26m safety cost avoidance•Supports SC QIPP waste medicines campaign•Green bags & metrics being adopted nationally

*estimates of savings to secondary care (J.Hough)

NPSA /NICE

South Central

Safer Use of Injectable Medicines

• Dobutamine 250mg in 50ml vial

• Morphine 1mg/ml & 2mg/ml – 50ml vial

• Human soluble insulin 50 units in 50ml pre-filled syringe

Focus on practical implementation of targeted products identified by NPSA alert 20:

Four work streams were funded by PSF :Injectables: purchasing for safety

Assessing risk to operators from exposure to hazardous injectable medicines

Neonatal InjectablesMedicine package inserts

OUTCOMES

• Less delay to start administration for emergency injections (Magnesium for eclampsia- 0.5h)

• Ensure correct concentration (ward based preparation >10% out; Wheeler et al, 2008)

• Reduced waste • Reduced rework (e.g. inadequate labelling)• Less risk of contamination • Eliminate human error• Standardise concentration (ICS standards)• Health & safety (needlestick injury, RSI)• Assistance with assurance (NHSLA, NPSA alerts)

South Central Injectable Projects 3 year project

South Central

Input £152k

(4 workstreams)

Output /delivered•Risk assessment template for high risk injectable medicines•Risk assessment of ward based injectable medicines•Purchasing for safety policy – prefilled syringes (insulin, dobutamine, morphine)•£261k savings in consortium purchasing and released nurse time, (unquantified error reduction impact)•Review and standardisation of neonatal infusion practice

NPSA Alert 20 – ‘Promoting the safer use of injectable medicines’

South Central

IN PROGRESS• Established current use of NSAIDs and are

developing metrics and methodology for QIPP• Medicines management e learning project

published on Nelm• Missed doses in process of audit and analysis for

potential for metrics• Number admissions hypoglycaemia evaluated

for frequency and cost. Insulin in hospital. To identify areas for improvement and metrics

• Injectables in the community

Medicines Management Training Project

South Central

Input £15k

1st phase – scoping exercise(2nd phase £30k –

roll out)

Output /delivered•NHLSA Level 2-4 mandatory training (10 - 30% savings on insurance costs)• CQC mandatory • Identified gaps• Produced index of learning resources online published on Nelm

South Central

Challenges

• Linking quality with safety to tangible savings

• Engaging with other professions• Moving forward to kpi’s and standards for

safety• Communication, continuity and

commitment

South Central

For more information on the‘Reducing Needless Medication Errors

Workstream’

please see the Patient Safety Federation website www.patientsafetyfederation.uk

or contact

Fiona Eccleston- Project ManagerFiona.eccleston@iow.nhs.uk