Dr David Gerrett

Senior Pharmacist

Patient Safety

NHS Improvement

The Wesley Hotel & Conference Venue Euston House, London

26th September 2017

Medicines Safety: The Work of the MSO

Slide 1 NHS Improvement 20160607

NHS Improvement

Its just after lunch, you are tired. Just want

to have a quick sleep?

This is the

graveyard

slot

Blood supply

Essential blood for your brain is being re-

directed to your GI tract.

Essential messages

Relax, enjoy 20 minutes (it’s the maximum)

then ask (me) some really easy questions!

I’ll get in first!

if you know your local MSO?

Essential messages

Relax, enjoy 20 minutes (it’s the maximum)

then ask (me) some really easy questions!

I’ll get in first!

if you know your local MSO?

if you know your local MDSO?

Unsafe

acts

Unintended

actions

Intended

actions

Mistakes

Violations

Basic error types

Skill based errors

Attentional failures

Skill based errors

Memory failures

Rule & Knowledge

Based errors

Routine

Reasoned

Reckless & Malicious

Slips

Lapses

Unsafe

acts

Unintended

actions

Intended

actions

Mistakes

Violations

Basic error types

Skill based errors

Attentional failures

Skill based errors

Memory failures

Rule & Knowledge

Based errors

Routine

Reasoned

Reckless & Malicious

Slips

Lapses

Essential messages

All you have to take away is,

the ‘M’ in MSO Medication implies they

‘know’ about medicines, they need you!

Essential messages

All you have to take away is,

the ‘M’ in MSO Medication implies they ‘know’ about

medicines, they need you!

UKMi/MI/DI what ever you are, you deal with

knowledge problems – solving these is

inherently making the system safer – you

are de facto MSO/UKMI /knowledge-based error

If you are….MSO/UKMI /knowledge-based error

Then the title

Medicines Safety: The Work of the MSO

is about you !

An example…

The work of an MSO

18 page summary with

recommendation produced in

collaboration with

stakeholders including

Mental Health

The work of an MSO

Another example

Product

Risk

Assessment

Spreadsheet

Another example

The work of an MSO

Another example

The work of an MSO

Another example

The work of an MSO

Another example

https://www.sps.nhs.uk/articles/ukmi-product-assessment-tool/

The work of an MSO

And emulation is the sincerest form of flattery

The work of an MSO

The Observatory

https://www.sps.nhs.uk/articles/ukmi-medication-safety-officer-evidence-

observatory/

The work of an MSO

The Observatory

https://www.sps.nhs.uk/articles/ukmi-medication-safety-officer-evidence-

observatory/

The work of an MSO

https://www.sps.nhs.uk/articles/npsa-rapid-response-report-reducing-harm-from-omitted-and-delayed-medicines-in-

hospital-a-tool-to-support-local-implementation/

The work of an MSO

So, we have proved that UKMi is already ‘doing safety’ in its own way

The WHO safety challenge, heard of it?

Yes / No / maybe?

The work of an MSO

The work of an MSO

Box of activities to improve

Medication safety in the NHS

Your role…

adding in the

knowledge

The work of an MSO

Adding in the

knowledge

in partnership

with the MSO

and the MDSO

With permission Alistair Gray, Clinical Services Lead Pharmacist, East Lancashire Hospitals NHS Trust

September 2017 Refer-to-Pharmacy newsletter

The work of an MSO An example in the box… perhaps

Summary

All you have to take away is,

the ‘M’ in MSO Medication implies they ‘know’ about

medicines, they need you, all 397!

UKMi/MI/DI what ever you are, you deal with knowledge

problems – solving these is inherently making the system

safer – you are de facto MSO/UKMI /knowledge-based error

You may be called upon to support the ‘box of activities –

flexible, proactive…supportive

‘Update for patient safety’

David Gerrett

Senior Pharmacist, Patient Safety

NHS Improvement

Slide 31 CCG 11th November 2016

Questions

Many thanks for your time

What have I forgotten?