‘Reducing Needless Medication
Errors’
Gillian Honeywell, Chief Pharmacist, NHS Isle of Wight
Clare Howard, Pharmaceutical Adviser, SHA
South Central
Medication Errors do happen..
South Central
Reported incident types in England
April 2008 to March 2009
Medication 86,287
NPSA ‘Patient Safety Incidents in the NHS’ 2009
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
1.
2.
Pharmacy in England Building on strengths – delivering the future, Department of Health. 2008
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/
South Central
Metrics
Metric 1: Means of ensuring patient receive oral anticoagulation therapy
within safe parameters (INR >5 & >8)
Metric 2: Medicines reconciliation: safer admission to hospital and ensuring
that patients’ medicines are reconciled within 24 hours of admission
Metric 3: Allergies: A means of ensure that patients allergy status is recorded
on prescription charts
Metric 4: SCIP 2 - Promoting the safer use of injectable medicines
Metric 5: Reduce the number of preventable NSAID related harms
Metric 6: Reduction of harm from omitted and delayed medicines in hospital
Metric 7: Reduce the number of insulin dosage errors caused by
inappropriate use of abbreviations
South Central
South Central Patient Safety Summary Data
Average
% of Adult Patients with Allergy Status Documented
Average % of Adult Patients with Medicines Reconciliation
Completed within 24 hrs
100%
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
90%
80%
70%
60%
50%
40%
30%
Average % of Adult Patients with INR >5
Average % of Adult Patients with INR >8
12.0%
6.0%
10.0%
5.0%
8.0%
4.0%
6.0%
3.0%
4.0%
2.0%
2.0%
1.0%
0.0%
0.0%
Metric 1: INR>5 & INR >8
Percentage of warfarin patients with an INR 5.0 + at the ORH & NOC
Special cause effect
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
0
Feb-09
2
Jan-09
mean
4
Dec-08
lower control limit
6
percentage
percentage of
warfarin patients
with an INR 5.0 +
upper control limit
Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct -09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct -10
Percentage of warfarin patients with an INR 8.0 + at the ORH & NOC
2.97
3.92
3.50
3.06
3.23
2.73
2.96
4.545
4.545
4.545
4.545
4.545
4.545
4.545
4.545
Oxford Radcliffe Hospitals
2.90
3.31
4.06
4.80
3.60
3.04
2.76
3.27
3.01
3.22
2.64
3.14
2.50
4.545
4.545
4.545
4.545
4.545
4.545
4.545
4.545
4.545
4.545
4.545
4.545
4.545
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
1.87
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
3.207
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Jan-10
Dec-09
Nov-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
Feb-09
Jan-09
Dec-08
Oct-09
month / year
1.50
1.00
0.50
0.00
2.54
4.545
Sep-09
2.00
3.207
Percentage
percentage
of warfarin
patients
with an INR
8.0 +
Upper limit
mean
Aug-09
1.87
lower cont rol limit
4.545
Mar-10
3.40
upper cont rol limit
Feb-10
percent age of warf arin pat ient s wit h an INR 5.0 +
Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct08 09 09 09 09 09 09 09 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10
percentage of w arfarin patients w ith an INR 8.0 + 1.16 0.78 1.24 0.82 0.82 1.21 0.82 0.83
South Central
0.73 0.56 0.64 0.90 1.16 0.59 0.74 0.62 0.94 0.72 0.93 0.50 0.84 1.02
Metric 2: Medicines
Reconciliation
% of Adult Patients with Medicines Reconciliation
Completed within 24 hrs
100%
90%
Implementation
of 7 Day Working
Target line
80%
70%
60%
50%
40%
30%
20%
Staff
vacancies
10%
Implementation
of Green Bag
Scheme
0%
Jan-10 Feb-10 M ar -10 A pr -10 M ay-10 M ay(2)
Jun-10 June(2) Jul -10
Jul (2) A ug-10
Sep-10 Oct -10 Nov-10 Dec-10
NHS Isle of Wight
South Central
Green Bag Scheme
• £20,000 Pump Prime PSF
• Improves Medicines reconciliation by
supporting the safe transfer of patient’s
medicines between care settings
• Scheme has been rolled out throughout
the South Central region
• Collaboration with 2 other regions on
tendering process is currently underway
to achieve best value for money
South Central
Metric 3: Allergy Status
Target line
New doctors
Increased
intervention
effort by
pharmacists
New doctorsimproved
induction on
allergy status
New
prescription
chart
Berkshire Healthcare NHSFoundation Trust
South Central
Metric 4: Safer Use of Injectable
Medicines: SCIP2
Focus on practical implementation of targeted products identified by NPSA
alert 20:
• Dobutamine 250mg in 50ml vial
• Morphine 1mg/ml & 2mg/ml – 50ml vial
• Human soluble insulin 50 units in 50ml pre-filled syringe
•Chief Pharmacists signed up to implement within agreed timescales
•Practical ‘How to guides’ produced for each product (see Workstream stand)
•Progress assessed by purchasing data, questionnaire & liaison with manufacturing unit
South Central
South Central
Next steps…………
‘Moving on from a culture of measuring and
benchmarking to action’
• PDSA cycle for current metrics & sharing of good practice
• Medicines Management training – to provide a standardised training kit
for all involved in medicines management
• Work is underway on following metrics:
– NSAIDS related harms
– Omitted & delayed medicines in hospital
– Reducing the number of insulin dosage errors caused by inappropriate use of
abbreviations
• NNME workstream annual conference on the 12th & 13th May 2011 Isle of Wight
‘Moving on from a culture of measuring and benchmarking to action’
South Central
PSF to QIPP?
• Medicines are the most frequently used
healthcare intervention = £12 billion (11%) of
overall NHS budget (South Central = £777
million)
• Avoidable medication errors costs the NHS in
England £750million (South Central =
£58million)1
1. NPSA Patient Safety Observatory ‘Safety in doses: medication safety incidents in the NHS’
South Central
Safety Metrics & QIPP
• What is the economic impact of improving safety in
the areas selected?
• Initially, we set out to reduce medication related
incidents by 20% which could (crudely) indicate
savings of roughly £12 million per year.
• Does it add up? Can we QIPP the patient safety
agenda? With medication errors we think we can
South Central
Next steps
Some of the assumptions need to be tested locally……..
•
•
•
•
•
Costs and Meds Rec rates before and after green bags?
How many INR > 8 result in an admission?
What does it cost your Trust to treat a drug induced bleed?
Can we determine the cost of omitted doses?
How many admissions per year by Trust for insulin induced
hypoglycaemia?
• Will “cost avoidance” fall on deaf ears?
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 Manager
Fiona.eccleston@iow.nhs.uk
South Central