Transcript Patient safety powerpoint slides

Pharmacy
Patient Safety Webinar
Alexa Wall
Tuesday 22nd January 2013
Quality Education for a Healthier Scotland
Objectives
Pharmacy
At the end of the session participants will be able to:
Discuss the goals, measures and definitions in relation
to medicines reconciliation
Describe basic quality improvement tools and how they
are used in practice
Discuss initiatives in the management of high risk
medicines
Quality Education for a Healthier Scotland
DANGEROUS
(>1/1000)
REGULATED
ULTRA-SAFE
(<1/100K)
100,000
Pharmacy
Total lives lost per year
Driving
10,000
HealthCare
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
1,000,000 10,000,000
Number of encountersQuality
forEducation
each fatality
for a Healthier Scotland
Putting it into perspective...
Pharmacy
One in ten admissions to hospital result in an
adverse event
The average cost of adverse events within
healthcare in the UK is £6 billion
Harm for medications alone occurs in 25% of all
hospitalised patients
Quality Education for a Healthier Scotland
In practice
Pharmacy
More than half of errors occur at interfaces of
care especially at point of admission
30-70% variance between patients’ drugs prior
to hospital compared to those prescribed on
cardex
Omission most common
Quality Education for a Healthier Scotland
The SGHD `Quality Strategy` 2010
“There will be no
avoidable injury or
harm to patients from
healthcare they
receive, and an
appropriate clean and
safe environment will
be provided for the
delivery of healthcare
services at all times.”
Quality Education for a Healthier Scotland
Pharmacy
THE HEALTHCARE QUALITY
STRATEGY FOR SCOTLAND
Pharmacy
Person-Centred - Mutually beneficial partnerships between patients, their families, and
those delivering healthcare services which respect individual needs and values, and
which demonstrate compassion, continuity, clear communication, and shared decision
making.
Clinically Effective - The most appropriate treatments, interventions, support, and
services will be provided at the right time to everyone who will benefit, and wasteful or
harmful variation will be eradicated.
Safe - There will be no avoidable injury or harm to patients from healthcare they receive,
and an appropriate clean and safe environment will be provided for the delivery of
healthcare services at all times.
Quality Education for a Healthier Scotland
What is Quality Improvement
It’s about developing care that delivers for
patients.
Its about breaking the “We've always done it
like this!” culture, encouraging both patients
and staff to challenge and change healthcare
services for the better
Quality Education for a Healthier Scotland
Pharmacy
Origins of Improvement Cycle
“If I had to reduce
my message for
management to just
a few words, I’d say
it all had to do with
reducing variation.”
W. Edwards Deming
Quality Education for a Healthier Scotland
Pharmacy
Scottish Patient Safety Programme (SPSP)
Pharmacy
Programme of quality improvement to improve patient safety
Uses quality improvement methodology
Concentrates on specific safety areas of harm reduction
e.g. high risk medicines, transfer of information across the interface
Development of the SPSP (to involve ALL staff)
Started in hospitals (2008)
Rolling out in primary care in 2012/13
Plans to introduce to mental health, paediatrics, maternity, sepsis, VTE
National agenda and Board-level approaches
Quality Education for a Healthier Scotland
Terminology
Pharmacy
Run
Charts
SEA
Goals and Measures
NOT targets
Safety
Culture
Rapid Cycle
Improvement
GTT
PDSA
Human
Factors
FMEA
Driver
Diagrams
Quality Education for a Healthier Scotland
PDSA –RAPID TESTS OF CHANGE
Constructing a clear
aim statement
S
Pharmacy
Choosing the right
measures and planning
how information will be
collected, pre and post
Coming up with ideas to
improve the current
statement
The Improvement Guide, API
Quality Education for a Healthier Scotland
Start small
Pharmacy
Small tests... 1 practice, 1 nurse, 1 doctor, 1 patient
Then 3 patients, 5 patients
Test on pilot unit
Refine the process
Test in and out of hours
Test on all patients
Q: Examples of tests of change you’ve been involved in?
Quality Education for a Healthier Scotland
% Compliance with Medicines Reconciliation on Admission (Meds Rec Completed)
24/05/2010:
Med Rec SBAR
communication to all
staff in ERU
04/06/2010:
Meeting with
CofE
consultant
14/06/2010:
Detection and
mitigation on
ward round
19/07/2010:
Impact of admission
med rec on eIDL
identified by FY1s
23/08/2010:
Patient stories
/ critical
incidents
09/09/2010:
Ward visit
awareness
session
20/09/2010:
SPSP Facilitators /
Pharmacist message
reinforced with staff
Pharmacy
05/04/2010:
Baseline data
collection – tests of
change for
population and data
collection
07/06/2010:
C/W/S on ECS,
Stickers on
cardexes,
Feedback stats,
New FY1s
04/08/2010:
New doctors/
Pplates
09/08/2010:
ECS on
sticky paper
14/08/2010:
Collaborate with
General Ward
Workstream,
CNs empowered
18/08/2010:
Issues with
transfer to Vision
identified, access
to ECS restricted
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04/10/2010:
Redundant step
pharmacist on
ward round and
screening all Rxs
FMEA
Pharmacy
Failure Mode Effects Analysis
Quality Education for a Healthier Scotland
SEA
Pharmacy
Significant Event Analysis
What is Significant Event Analysis (SEA)?
Significant Event Analysis is the analysis of an event
that has been significant to you to make you reflect
and consider changing practice.
Q: what kind of incidents would be suitable for SEA?
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How to choose / document an SEA
Such an event should be chosen because:
a) it is thought to be important in the life of the department / team, your
practice i.e. is significant.
b) it may offer some insight into the care of patients.
c) the analysis of the significant event is focused on the specific reasons
for actions and behaviour.
A Significant Event Analysis should include the following:
1. What happened?
2. Why did it happen?
3. What has been learned?
4. What has been changed?
Quality Education for a Healthier Scotland
Pharmacy
Driver Diagram
Pharmacy
Quality Education for a Healthier Scotland
National
Pharmacy
Healthcare Improvement Scotland (HIS) have set up a National Safer
Medicines Network (previously Medicines Reconciliation Network)
Covers all work streams that include medicines
Multi-professional membership from across NHSScotland
Strategic links with other complementary work e.g. SIGN discharge
letter, SPARS
Communication, sharing best practice, synergy and acceleration
e.g. eHealth enablers: ECS, eForms, Trakcare
Multidisciplinary education from NES
About to launch:
Recommended Practice Statements
Refreshed definition, goals and measures
Quality Education for a Healthier Scotland
SPSP
Pharmacy
MEDICINES WORKSTREAM
 Medicines reconciliation
• Q: What are the definition, goals and measures for MR?
 High risk medicines
Quality Education for a Healthier Scotland
MEDICINES RECONCILIATION
DEFINITION
going through consultation / approval process
Pharmacy
The process that the healthcare team undertakes to ensure
that the list of medication, both prescribed and over the
counter, that I am taking is exactly the same as the list that
I or my carers, GP, Community Pharmacist and hospital
team have. This is achieved, in partnership with me,
through obtaining an up-to-date and accurate medication
list that has been compared with the most recently
available information and has documented any
discrepancies, changes, deletions or additions resulting in
a complete list of medicines accurately communicated.
Quality Education for a Healthier Scotland
MR on admission
going through consultation / approval process
Pharmacy
Measures
Patient demographics documented
Allergy status on admission documented
2 or more sources, one of which should be the patient / carer, used on
admission to give the best possible medicines history
Medicines Plan documented for each medicine i.e. continue, withhold,
stop
Safe and accurate transcription of clinically appropriate medicines on
in-patient prescription chart
Goals
95% compliance with MR within 24hours of admission
95% of patients have an accurate in-patient prescription chart within
24hours of admission
Quality Education for a Healthier Scotland
MR on transfer within acute sites
going through consultation / approval process
Measures
Patient demographics documented
Allergy status documented
All medication reviewed and plan documented, including medicines
which may have been started in hospital prior to transfer
Safe and accurate prescribing of clinically appropriate medicines on
in-patient prescription chart
Goals
95% compliance with MR within 4hours of transfer
95% of patients have an accurate in-patient prescription chart within
4hours of transfer
Quality Education for a Healthier Scotland
Pharmacy
MR on discharge
going through consultation / approval process
Measures
Patient demographics documented
Allergy status on discharge documented
Changes from admission medicines documented to include changes,
discontinuations and new medicines started
Safe and accurate prescribing of clinically appropriate medication on the
Interim Discharge Letter
Goals
95% compliance with MR on discharge
95% of patients have an accurate medicines list on the Interim Discharge
Letter
Quality Education for a Healthier Scotland
Pharmacy
Medicines Reconciliation
CHALLENGES
Pharmacy
 Medical & nursing engagement has been poor
 Competing priorities for clinical teams pose difficulties
 Junior medical staff need support
 Maintaining momentum and avoiding person dependent solutions
 Validating accuracy in absence of a pharmacist
Q: What are the challenges for you as pharmacists?
Quality Education for a Healthier Scotland
What are high risk medicines?
High risk medicines are:
most likely to cause significant harm
mistakes not more common in the use of these
medications
when errors occur the impact on the patient can be
significant
Quality Education for a Healthier Scotland
Pharmacy
Warfarin
Pharmacy
The MHRA received 2233 suspected adverse
reaction reports with warfarin use between 29
June 1963–16 June 2008, of which 297 were
fatal
The majority of adverse reactions reported with
warfarin were a result of over anticoagulation
and bleeding, and the majority of fatal cases
reported were associated with haemorrhage
Quality Education for a Healthier Scotland
Change Concepts
Pharmacy
Q: What have you been involved in your Boards
to reduce harm from anticoagulation?
Q: Can you think of any other tests of change?
Quality Education for a Healthier Scotland
Change Concepts
Protocol driven to reduce variation
Reversal protocols
Use algorithms
E&T checklists
Involve MDT
Limit strength of tablets dispensed
Quality Education for a Healthier Scotland
Pharmacy
Questions
Pharmacy
Quality Education for a Healthier Scotland