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East & South East England Specialist Pharmacy Services
East of England, London, South Central & South East Coast
Medicines Use and Safety
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Seven Steps to Medication Safety:
Identifying and Reporting Medication Safety
Incidents
Bite-sized training
©East & South East England Specialist Pharmacy Services
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Learning Outcomes
• Define medication safety incidents and adverse drug reactions and
events
• Describe why reporting of medication safety incidents is important
• Identify where errors occur in the MR process and how this links to
incident reporting
• Identify incidents occurring as part of a case study
• Identify the prescription of insulin as abbreviated units as a Never
Event
• Describe the pros and cons of reporting incidents in the workplace
√ Practice aim: To identify and report incidents as expected as part of
the pharmacy team
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Incident vs ADR
ADR
A response to a drug
which is noxious.. and
occurs at doses used
[intentionally] for
prophylaxis, diagnosis
or therapy e.g. a ‘side
effect’
(World Health Organisation)
Example
of both?
A medication safety
incident
Any preventable event
that may lead to
inappropriate
medication use or
patient harm while
medication is in
control of health
professional, patient or
consumer
(NPSA)
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Why is it important to report them?
Research shows that:
“Trusts with significantly high levels of
incident reporting are more likely to
demonstrate other features of a strong
safety culture”
NPSA 2008
NHS providers are required to report
incidents
NHS Outcomes Framework
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Stage 1
Clerking by
Doctor
Meds Reconciliation (MR) Process Map
Stage 2
Selection of patients for MR
Stage 5
Listing and documenting
unintentional discrepancies
Stage 3
Sourcing the information
for use in the MR process
Stage 4
Comparing the sourced list(s) and patient
sourced information against the written
prescription: Identifying discrepancies
Stage 6
Referring unintentional discrepancies: For
doctor to make changes or to a
pharmacist or nurse for further
analysis/follow-up
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Real examples of things going wrong
GP prescription
PODs
Inpatient
prescription
Hospital disp item
in locker
Simvastatin 20mg
ON
Simvastatin 20mg
daily
Simvastatin 20mg
ON
Simvastatin 20mg
ON
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium chloride
1200mg BD
Betaxolol ED
---
---
---
Methotrexate
2.5mg weekly
Methotrexate
2.5mg weekly
Methotrexate
2.5mg daily
Methotrexate
2.5mg daily
Lisinopril 25mg OD Lisinopril 2.5mg OD Lisinopril 25mg OD
Lisinopril 2.5mg OD
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Real examples of things going wrong
GP prescription
PODs
Inpatient
prescription
Hospital disp item
in locker
Simvastatin 20mg
ON
Simvastatin 20mg
daily
Simvastatin 20mg
ON
Simvastatin 20mg
ON
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium chloride
1200mg BD
Betaxolol ED
---
---
---
Methotrexate
2.5mg weekly
Methotrexate
2.5mg weekly
Methotrexate
2.5mg daily
Methotrexate
2.5mg daily
Lisinopril 25mg OD Lisinopril 2.5mg OD Lisinopril 25mg OD
Lisinopril 2.5mg OD
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Real examples of things going wrong
GP prescription
PODs
Inpatient
prescription
Hospital disp item
in locker
Simvastatin 20mg
ON
Simvastatin 20mg
daily
Simvastatin 20mg
ON
Simvastatin 20mg
ON
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium chloride
1200mg BD
Betaxolol ED
---
---
---
Methotrexate
2.5mg weekly
Methotrexate
2.5mg weekly
Methotrexate
2.5mg daily
Methotrexate
2.5mg daily
Lisinopril 25mg OD Lisinopril 2.5mg OD Lisinopril 25mg OD
Lisinopril 2.5mg OD
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Real examples of things going wrong
GP prescription
PODs
Inpatient
prescription
Hospital disp item
in locker
Simvastatin 20mg
ON
Simvastatin 20mg
daily
Simvastatin 20mg
ON
Simvastatin 20mg
ON
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium chloride
1200mg BD
Betaxolol ED
---
---
---
Methotrexate
2.5mg weekly
Methotrexate
2.5mg weekly
Methotrexate
2.5mg daily
Methotrexate
2.5mg daily
Lisinopril 25mg OD Lisinopril 2.5mg OD Lisinopril 25mg OD
Lisinopril 2.5mg OD
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Real examples of things going wrong
GP prescription
PODs
Inpatient
prescription
Hospital disp item
in locker
Simvastatin 20mg
ON
Simvastatin 20mg
daily
Simvastatin 20mg
ON
Simvastatin 20mg
ON
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium valproate
1200mg BD
Sodium chloride
1200mg BD
Betaxolol ED
---
---
---
Methotrexate
2.5mg weekly
Methotrexate
2.5mg weekly
Methotrexate
2.5mg daily
Methotrexate
2.5mg daily
Lisinopril 25mg OD Lisinopril 2.5mg OD Lisinopril 25mg OD
Lisinopril 2.5mg OD
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Barriers and enablers for reporting
National drivers e.g. Outcomes Framework
Organisational or departmental strategy for
what to report
Roles need to be clear – who can report and
what
Time needed to report
Human factors
E.g. fear of reprisals, upsetting existing
relationships, making the organisation/division look
bad, public image concerns
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Evaluation
• Define medication safety incidents and adverse drug
reactions and events
• Describe why reporting of medication safety incident is
important
• Identify where errors occur in the MR process and how
this links to incident reporting
• Identify incidents occurring as part of a case study
• Identify the prescription of insulin as abbreviated units as
a Never Event
• Describe the pros and cons of reporting incidents in the
workplace
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Using this session for CPD
• By taking part in this session you will be able to record or
include what you have learnt as a CPD entry starting at
“Action”: For example you could:
– complete the further reading or practical next steps
and document this
– Document your participation in the session and
explain how you have applied this to your day to day
practice.
• This learning could identify further learning needs that
you can complete as Plan and Record CPD entries
starting at “reflection”
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Further Reading
Further information about reporting medication incidents
and other aspects of medication safety are available in
• An SPS Resource “Seven Steps to medication Safety: A
Development Resource for Pharmacists and Senior
Pharmacy Technicians. Download it here: NeLM link
• CPPE provide some modules on medication safety:
www.cppe.ac.uk
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