Medication Safety Why is it Important

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Medication Safety Why is it Important?
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Medication Safety

• Safety must be one of our paramount concerns in
  all aspects of Medicines Management, including.
• Prescribing
• Dispensing
• Administration of medicines

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Why is it so important?

• Firstly we have a duty of care to protect
  patients (first do no harm!)
• Secondly we must protect our staff (from the
  stress of an error and from risk of being
  disciplined)
• Thirdly we need to protect the organisation
  (reputation and risk of litigation)

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Powys LHB

• On average we get between one and three medicine
  related incidents each week reported from across
  Powys (via IR1s and Datix)
• This is probably only the tip of the iceberg (we
  get very few near misses reported)

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Workshop 1

• Spend a few minutes thinking at what stages in a
  patients inpatient stay a medicine related
  incident may occur.
• Think in terms of prescribing, ordering and
  dispensing and administering related incidents

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Prescribing

• An incident may occur
• Prescribing at admission
• Prescribing new drugs during an inpatient stay
• Writing a new medication chart
• Writing a TTO

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Ordering Related Incidents

• These could include
• Errors in ordering stock
• Errors in ordering inpatient items for individual
  patients (wrong drug / brand/ strength/ patient)
• Dispensing errors
• Errors in ordering TTOs (wrong patient/ drug/
  ordering drugs that are no longer needed)

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Administration Errors

• These form the bulk of our medicine related IR1s
• Include
• Wrong patient /drug / form / brand/ strength/
  dose / route
• Allergies
• Drugs patients have previously had ADR to
• Inappropriate drug or dose (i.e. prescribed
  wrongly but given)
• Crushing drugs inappropriately

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TTO errors

• Prescribing errors
• Giving the patient another patients TTOs
• Giving a patient medication that has been
  discontinued since the TTO was written

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In other wordsIf it can go wrong it probably
will go wrong (at some point)!!!
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How Do We Try to Prevent These Incidents
Occurring?

• Knowledge of
• What is expected of you when administering
  medicines
• How drugs work
• The drugs that you are administering
• Policy, Procedure and Process
• Learning from previous incidents (in Powys and
  further afield)

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Workshop 2

• Consider how the following incidents may have
  occurred and what we should do to prevent them
  happening again