Mapping and Implementing a Safe Medicines Pathway

Jennifer Dorey

Pharmaceutical Adviser, NHS South

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South Central

Summary1. Map the current medicines pathway

2. Pilot improvements to the pathway and roll out

3. Multidisciplinary workshop to propose a redesigned Safe Medicines Pathway

4. Action plan for implementation and monitoring of Safe Medicines Pathway.

South Central

No needless medication errors workstream projects

• Medicines reconciliation• Injectable high risk medicines• Omitted and delayed doses• Allergy status• High INRs• E-learning mandatory medicines training• Secure storage of medicines• Medicines management metrics • Multidisciplinary collaborative conferences

South Central

But are we really making medicines use safer?

South Central

Safe Medicines Pathway

South Central

Safe Medicines Pathway

Map current medicines pathway ( 3 areas, one hospital)

Month 1

Failure Mode and Effects Analysis to identify priorities for improvement

Month 2

Simple interventions piloted and rolled out across NHS South ( 3 series)

Month 3,4,5

Document interventions , impacts and outcomes Month 6

Workshop to review and propose fundamentally changed Safe Medicines Pathway

Month 7

Final report and action plan for development and implementation

Month 8

Potential for research submissions and publications ongoing

Patient Safety Incident ReportingPatient Safety Incident Reporting:This should initially be increasing, probably for several years, as the culture of reporting all incidents spreads more widely and deeply across the NHS, and then eventually remaining steady or even decreasing, as the habit of reporting incidents becomes more routine and incidents are learnt from.

Severity of harm ( measuring the number of incidents resulting in severe harm or death) :This should be decreasing as fewer serious incidents should occur if a patient safety culture is developing and lessons are being learnt.

Number of similar incidents:This should be decreasing as organisations learn from specific kinds of safety incidents and take action to ensure that they do not happen again.

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Reporting and learning from medication incidents

• The NPSA received 64,678 medicines related incident reports in 2006, which increased to 86,085 in 2007.

• Medication incidents were 8% of reports in 2005 and increased to 11% in 2010.

• 133,726 medication incident reports were reported to the NRLS in the year to June 2011, of these 45 resulted in death and 236 caused severe harm. South Central SHA reported 24 medicines related SIRIs in 2011.

• Estimated at least 1 in 10 medicines prescribed involve an error at some stage. 7,000 doses a day in an average DGH, i.e. under reporting is still significant.

South Central