Transcript High quality care for all, now and for future generations

PRESCRIBING
AND RESEARCH
IN MEDICINES
MANAGEMENT:
“High quality care
for all, now and for
future generations”
Dr David Gerrett
Senior Pharmacist
NHS England Patient Safety
2000, >15 years ago!
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Our overriding aim is to embed a culture of safety in all NHS treatment,
whether in hospitals or in primary care. Ensuring that drug treatment is
safe is central to this strategy.
The rates of administration errors in primary care and community
healthcare settings are not known.
Department of Health (2004). Building a safer NHS for patients: Improving medication safety. A report by the Chief
Pharmaceutical Officer. London: Department of Health. Also available at:
www.doh.gov.uk/buildsafenhs/medicationsafety/medicationsafety.pdf (January 2004)
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Medication errors are incidents in which there has been an
error in the process of prescribing, dispensing, preparing,
administering, monitoring, or providing medicine advice,
regardless of whether any harm occurred. (NPSA 2007)
We also need to consider:
…latent errors (or latent conditions), refers to less apparent failures of
organisation or design that contributed to the occurrence of errors or
allowed them to cause harm
or Latent failure conditions describe the set of background
circumstances which eventually lead to an unsafe act.
National Patient Safety Agency. Safety in doses: medication safety
incidents in the NHS 2007 http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61392
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PSIs
Basic error types
Routine
Reasoned
Reckless & Malicious
Violations
Rule & Knowledge
Based errors
Intended
actions
Mistakes
Unsafe
acts
Skill based errors
Memory failures
Lapses
Unintended
actions
Skill based errors
Attentional failures
Slips
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Competence
Consciously incompetent
Assess
and learn
PSDA
Unconsciously incompetent
Learn
Consciously competent
Lapse
Practice
Unconsciously competent
The implications: we are all capable of error and things change
NPC. MeReC bulletin.2011;22(no1)
http://www.npc.nhs.uk/merec/mastery/mast3/resources/merec_bulletin_vol22_no1.pdf
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Medicines Optimisation Principles
Aim to understand
the patient’s
experience
Evidence based
choice of
medicines
Patientcentered
approach
Make medicines
optimisation part of
routine practice
Ensure medicines
use is as safe as
possible
All centred around
measurement/metrics and outcomes
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8
The goal of Medicines Optimisation
Medicines optimisation looks beyond the cost of medicines
to the value they deliver and recognises medicines as an
investment in patient outcomes.
The goal of MO is to help patients to:
• Improve their outcomes, including better monitoring and
metrics
• Have access to an evidence-based choice of medicine
• Improve adherence and take their medicines correctly
• Avoid taking unnecessary medicines
• Reduce wastage of medicines
• And improve medicines safety
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MO - the Dashboard
http://www.england.nhs.uk/2014/06/12/mo-dash/
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Proportion of Harm
Total number of medication incidents reporting harm
Total number of medication incidents
The new metric provides an indication of preventable harms occurring and a
surrogate measure of reporting culture
Better reporting and learning, especially of no harm incidents, will help to enable
action to minimise preventable harms from medicines
Takes specific information from the NRLS and presents it in the MO dashboard
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Use of safety Audit Software
within CCGs GP practices using PINCER
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Medical Device Safety Officer
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Supporting documents
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And coming up – implementation of….
Article 107a(5)of Directive 2001/83/EC outlines the key responsibilities of national
competent authorities (MHRA) in relation to the reporting of ADRs associated with
medication error:
• Member States shall ensure that reports of suspected adverse reactions
arising from an error associated with the use of a medicinal product that are
brought to their attention are made available to the Eudravigilance database
and to any authorities, bodies, organisations and/or institutions, responsible for
patient safety within that Member State. They shall also ensure that the
authorities responsible for medicinal products within that Member State are
informed of any suspected adverse reactions brought to the attention of any
other authority within that Member State. These reports shall be appropriately
identified in the forms referred to in Article 25 of Regulation (EC) No 726/2004.
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ADE’s, ADR’s and Medication Errors
No harm
Low harm
Things we don’t know
NHS E
Medication errors
THE FOCUS
Preventable (ADEs, ADRs and AEs)
NHS E
ADE’s
Potential
ADE’s
Non
preventable
(ADR, MHRA)
Intercepted
NHS E
Bates DW, Boyle DL, Vander Vliet MB, Schneida J,
leape L. Relationship between medication errors and
adverse drug events. J. Gen. Intern. Med,
1995;10:199-205.
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ADE’s, ADR’s and Medication Errors
No harm
Low harm
Things we don’t know
NHS E
Medication errors
THE FOCUS
Preventable (ADEs, ADRs and AEs)
NHS E, MHRA
ADE’s
Non
preventable
Potential
ADE’s
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Intercepted
NHS E
ADE’s, ADR’s and Medication Errors
No harm NOT MHRA
Low harm
Things we don’t know
NHS E
Medication errors
THE FOCUS
Preventable (ADEs, ADRs and AEs)
NHS E, MHRA
But NOT NHS E, ‘pure’ ADR
Potential
ADE’s
Intercepted
NHS E
But NOT MHRA
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Total Patient Safety Incidents NRLS for March 2014
16000
14000
12000
10000
8000
6000
4000
2000
0
April
May
June
July
Extraction month
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August
September
Medication errors reported to NRLS
250000
Reported to NRLS 2005-2014
200000
190619
164907
152460
144609
132069
150000
reported
113837
100000
94280
MSOs
79280
64484
50000
0
2004
42398
2006
2008
2010
2012
2014
2016
In 2014 the absolute number of medication reports to the NRLS increased more
than in any previous year, representing a 15.6% increase on the year before.
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From the January 2016 CAS dataset
Row Labels
England London Midlands
and East
East of
England
CCG
12
1
Community Interest Company
Community pharmacy sector
26
3
National North of South
England East
2
19
2
17
2
1
1
NHS Acute
1
NHS Acute Large
3
6
3
5
7
1
2
1
8
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
11
14
9
4
6
3
7
7
14
Online Pharmacy
14
13
6
7
12
2
4
1
15
1
11
12
7
2
5
3
3
5
14
95
1
81
1
1
1
Social Care Enterprise
Grand Total
1
1
Independent
Other Independent Sector
Yorkshire (blank) Grand Total
South South
West
of
England
21
Cosmetic Surgery
Mental Health
N/A
2
22
49
19
1
104 23
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1
1
1
1
77
8
21
1
1
1
1
41
45
25
18
30
9
16
14
51
1
20
1
381
Future Developments
• MSO Network going from strength-to-strength
• Clinical Pharmacists in GP practices (many could be MSOs)
• Medicines Optimisation embedded into the ‘Right Care’
programme, which looks to identify and embed best practice
www.rightcare.nhs.uk
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1 key objective + 3 key phases + 5 key ingredients =
COMMISSIONING FOR VALUE
OBJECTIVE - Maximise Value (individual and population)
Five Key Ingredients:
1. Clinical Leadership
2. Indicative Data
3. Clinical Engagement
4. Evidential Data
5. Effective processes
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23
The patient safety vision
Black box
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To Summarise the MSO role, to:
1. gather evidence of a local learning culture
2. incrementally improve reporting and learning
3. implement better, safer medication practice locally and
nationally
4. work together as discrete groups on common topics
5. be the formal conduit between NHS England Patient Safety
and practice for medication safety issues
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To focus the role - Most importantly
3. implement better, safer medication practice locally and
nationally
5. Implement local system safety improvements and be able
to prove it
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Questions (15 minutes, or less?)
Many thanks for your time
[email protected]
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