Improving the safety of anti-thrombotic

drugs

Stephane Jaglin, PharmacistThrombosis UK, Bristol, May 2019

3rd

GLOBAL SAFETY

CHALLENGE

Ø WHO 3rd

global patient safety challengeØ Which medications are dangerous?Ø The case of anti-thrombotic agentsØ Anticoagulants: some figuresØ Solutions: Hints fromØ Examples and themes identified by

Learning outcomes

Ø Medication safety is now a globalpriority

Ø 2 previous challenges very successful:

Ø Clean care is safer care (2005)

Ø Safe surgery saves lives (2008)

3rd

GLOBAL SAFETY

CHALLENGE

WHO 3rd

global patient safety challenge

l 3rd

challenge: Medication without harml Started in March 2017l Goal: 50% - 5 years

How do we Identify the errors

l Current reporting/response in the UK:

l Medication Safety Dashboard (CCGs)l EEPRU Feb 2018

NRLS(DPSIMS)

Monthlyreports &OPSIR

PatientSafety

Alerts->CAS(ex-NPSA alerts)

NRLS National Reporting and learning systemsDPSIMS Development of the Patient Safety Incident Management System OPSIR Organisation Patient Safety Incident ReportCAS Central Alerting SystemNSPA National Patient Safety Agency

Policy Research Unit in Economic Evaluationof Health & Care Interventions (Feb. 2018)

ØHow many? 237M/year!Ø237M medication error in England/year

Ø72% Little or no potential for harm

Ø→ 66M moderate/severe

Policy Research Unit in Economic Evaluationof Health & Care Interventions Feb. 2018

ØWhere?Ø

Primary care Care homes Secondary care Total

Prescribing 47.9% 3.0% 8.5% 21.3%

Transitioning NO DATA NO DATA 7.1% 1.4%

Dispensing 36.1% 3.6% 2.9% 15.9%

Administration Not applicable 92.8% 78.6% 54.4%

Monitoring 15.9% 0.6% 2.9% 6.9%

Total 38.3% 41.7% 20.0%

Digoxin

Potassium

Morphine/opioids

Insulin

Anticoagulants

Antibiotics

Lithium

A lot of potentially dangerous medication

EEPRU Report February 2018

Ø 1/3rd of hospital admissions due to anti-thrombotic drugs

Ø GI bleed implicated in ½ death in primary care

Ø ↑↑ in elderly patients

Complex processes

Prescribing

Dispensing

Transitioning

Monitoring

Administering

MEDICATION ERROR

Medication Safety Indicators

NHS Business service auth., available at https://tinyurl.com/y9mzvjn7 last accessed January 2019

30%

46%

22%

2%

43%

34%

21%

2%

Proportion of severe harm and death

AVK

LMWH

DOACs

Other

Metrics on reported incidentsfrom July 2012 to July 2017 (NRLs)

Adapted from figures obtained from NHS improvement, David Gerrett UKCPA Nov. 2018

Case study obtained from NHS improvement, David Gerrett UKCPA Nov. 2018

Examples of error analysed by NHS Improvement

Case study obtained from NHS improvement, David Gerrett UKCPA Nov. 2018

Examples of error analysed by NHS Improvement

Some of the solutions

Ø Education (HCP and Patients)Ø Sharing good practice

Ø SPS WHO good practice repositoryØ PSA 18 revised in 2018

Ø Electronic prescribingØ NICE QS93 (AF), NG5 (reconciliation)

Ø Innovation (ASHNs)

https://www.sps.nhs.uk/wp-content/uploads/2011/08/Implementing-Patient-Safety-Alert-18-anticoagulant-therapy-resource-May-2018.pdf

Metrics on successfulLitigation claims (since 2010)

NHS Resolution, available at https://bit.ly/2FwbtVj last accessed January 2019

Solutions: Some hints from WHO

Ø WHO 3rd

global patient safety challengeØ Which medications are dangerous?Ø The case of anti-thrombotic agentsØ Anticoagulants: some figuresØ Solutions:the current toolsØ Solutions: Hints fromØ Examples and themes identified by

Summary of topics discussed

Some of the solutions in place

Ø

Some case studies

Soon coming onhttp://www.thrombosisuk.org/