Transcript The advantages and disadvantages of no blame (or

Protecting patientsnow and in the future
Linda Matthew
Senior Pharmacist
National Patient Safety Agency
The changing face of chemotherapy
• IV
• Secondary care
Oral (now)
Primary care (the future)
Increasing risk
Modern health care is complex
• Increased volume of work
• Older and sicker patients
• Complex, new drugs, interventions & technology
• Cost constraints – efficiency
• Workforce pressures
• Changing expectations
• Changing shape of service delivery
Public confidence
Managing the risks in current service
configurations
• Information is key
• Proactive risk management
• Reactive risk management
BOPA position statement (2004)
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Standards – Manual of Cancer Standards (or equiv)
Patient remain under care of a specialist
Policy & procedures- IV and oral
Risk assess the hazards of oral medications
Prescribing & dispensing standards -same for IV/oral
Education of patients
Effective communication across care interfaces
Prescribing and dispensing should be responsibility
of hospital team
Oral chemotherapypatient safety incident data
• What does data on incidents reported to the National
Reporting & Learning System (NRLS) tell us?
National Reporting & Learning System
(NRLS)
International
Practitioners
Staff
Patients
Carers
Standardised reporting
Feedback
NHS Trusts
NPSA
Collaboration
Australia
USA
Healthcare
Commission
MHRA
NHS Complaints
NHS Litigation
Authority
Europe
Medication report – March 07
Medication Report – March 2007
7 Key areas for action
• Increase reporting & learning from medication
incidents
• Implement the safer medication practice
recommendations
• Improve staff skills & competence
Medication Report – March 2007
7 key areas for action
• Minimise dosing errors
• Ensure medicines are not omitted
• Ensure the correct medicines are given to the correct
patient
• Document patients’ medicine allergy status
NRLS- All incident types v medication
Jan 06 to March 07
100000
94554
90000
80000
70000
Number
60000
50601
52261
65141
63107
60987
74963
71901
71643
63820
59619
53823
51375
49684
47881
50000
40000
30000
20000
10000
4537
4548
5007
3399
5368
5337
5162
5683
6291
5849
6231
3944
6559
8523
4819
0
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06
Jul-06
Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07
Month / Year
Total no. of incidents to NRLS
Total no. of Medication incidents
Linear (Total no. of incidents to NRLS )
Linear (Total no. of Medication incidents)
NRLS Medication Incidents
– reported by care sector
0ther
Community
Pharmacy
GP's
Mental Health
Community Services
Acute
0%
10%
20%
30%
40%
50%
60%
70%
80%
NRLS data Nov 03 – July 07
Search terms
• Oral, chemotherapy
• 26 individually named drugs
• 3+ years of data from > 600 organisations
(>250 acute sector organisations)
Degree of harm caused
Stage in the process
Medication Error Types
Top 6 drugs reported
Key notes
Recommendations
Proactive management of risks;
• review local systems (BOPA position statement
2004)
Reactive management of risks;
• Increase reporting of patient safety incidents
• Review reports to identify local risk trends
• Analyse incidents to identify system weaknesses
• Take action to improve systems
The changing face of chemotherapy
Diagnose
Secondary care
Monitor
Prescribe
Administer IV
Dispense
The changing face of chemotherapy
Diagnose
Secondary care
Primary care
Monitor
Self administer
Prescribe
Dispense
Managing the risks of the future service
configurations
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Information is key
Define/map out the system
Proactively assess the risks
Use incident and other data/info to inform the process
Example – NPSA alert no 18
anticoagulant therapy & services
Process
• Search for related safety data
• Map anticoagulant therapy services in the NHS
• Assess the risks in each part of the treatment
process (using SWIFT)
• Identify solutions to reduce the risks
Alert 18 Risk assessment
Related safety data
- NHSLA data – published claims and reports
- NPSA NRLS data
- Published audits & reports
- Case reports
Alert 18 Risk assessment
- findings
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Inadequate training & work competences
Inadequate clinical audit and failure to act on results
Poor documentation
Prescribing issues (errors, interacting medications…)
Alert 18 Risk assessment
- findings contd.
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Poor communication across the interface
Insufficient support for patients & staff
Insufficient monitoring
Inadequate safety checks at repeat prescribing
Alert 18 – safer practice solutions
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Ensure competency of staff
Ensure policies & procedures in place
Audit services
Provide verbal and written information for patients at
commencement and thro’ treatment
• Prescribers and pharmacists to supply repeat prescriptions
using safe systems of practice & only when safe to do so
• Implement safety precautions when co-prescribing interacting
drugs
• Standardise the range of products available to avoid error
Generic risks
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Lack of knowledge and expertise
Poor communication between sectors
Poor monitoring
Poor patient information and education
Inadequate documentation
Lack of standardisation
The challenges
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Loss of control or a sharing of responsibility?
Increasing complexity
longer care pathway
more stakeholders
Different cultures (and politics)
Longer chains of communication
Different ways of working - re-designing the system
The challenges - contd.
• Policy changes to meet future system needs
(Community pharmacy services)
• Resource transfers
• Providing information for patients
• On-going monitoring
• Inadequate/unreliable systems
Potential solutions
• Technology
Specialised design of e-prescription
E-transfer of prescriptions
Sharing of patient e-record (hospital, GP, pharmacy)
On-line availability of protocol information
Potential solutions
• Skills and competence
Secondary sector expertise in primary care
Consultant Oncology Pharmacists
Pharmacist led monitoring clinics
Enhanced role for specialist pharmacy technicians
Summary
The future presents both risk and opportunity
• Information is key
- Incident reporting
• Learning from incidents – reactive
• Learning from others – proactive
• Windows of opportunity for role enhancement
Thank you