‘No Needless Medication Errors’

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No Needless Medication Errors

• Gillian Honeywell, Chief Pharmacist
• NHS Isle of Wight

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Medication Errors do happen..
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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
• NPSA medication errors account for 9 total

• 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/

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Project Plan

• Project 1 Metrics 3rd year Improvement
  Methodology Trust Quality Standard kpis and SHA
  monitoring
• 1 Means of ensuring patient receive oral
  anticoagulation therapy within safe parameters
  (INR gt5 gt8)
• 2 Medicines reconciliation safer admission to
  hospital patients medicines are reconciled
  within 24 hours of admission
• 3 Allergies A means of ensuring that patients
  allergy status is recorded on prescription charts
• Project 2 Promoting the safer use of injectable
  medicines
• Pre-filled syringes for high risk medicines
  nursing time released to care
• Risk assessments to reduce errors with
  injectables collaborative procurement

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Project Plan

• Project 3 NSAID related harm
• Baseline audit completed. Usage data reported 3
  monthly, preparation for monthly prescription
  metric
• Project 4 Reduction of harm from omitted and
  delayed medicines in hospital
• Baseline audit for antibiotics completed. Single
  Trust audit for all drugs / doses completed.
  Preparation for monthly metric
• Project 5 Reduce the number of errors and harms
  with insulin
• Baseline audits completed. Preparation for
  monthly metric
• Project 6 Standardised accessible Medicines
  Management Training
• E-learning modules for all aspects of the
  medicines trail, for all professions.

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Metric 2 Medicines Reconciliation
Implementation of 7 Day Working
Target line
Implementation of Green Bag Scheme
Staff vacancies
NHS Isle of Wight
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Green Bag Scheme

• 20,000 Pump Prime PSF
• Medicines reconciliation supporting the safe
  transfer of patients medicines between care
  settings
• QIPP and Waste Campaign
• Recent audit in South Central estimated saving
  of approx. 10 per patient admitted- from
  admissions data this equates to potential
  savings of 3.6million
• A further 1.26m from MR safety cost- avoidance
  for 70 of these patients

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Medicines Reconciliation
Percentage of Meds Rec Completed (since 01 Apr
2011)

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Medicines Reconciliation
Acute Trusts in FY 2011

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Medicines Reconciliation
Further Cost Avoidances
Costs Avoided
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Isle of Wight Example
1. Estimated cost avoidance from medicines
reconciliation within 24 hours of patient arrival
(per patient).
2. HES data admission figures for 2010/11 and
calculated uplift (3) for 2011/12.
3. Actual data collated by Trust used to
calculate achieved
4. Calculated avoidable and avoided costs
(monthly average from 2 applied to achieved
from 3)
Therefore, using IoW data for 2011 5 cost
avoidance per patient x 26688 admissions
113,340 total Average of 61 medicines
reconciliation achieved 69,137 in cost
avoidance achieved with 39 further potential
savings 44,203 in avoidable costs
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Safer Use of Injectable Medicines
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

Four work streams were funded by PSF
Injectables purchasing for safety Assessing
risk to operators from exposure to hazardous
injectable medicines Neonatal Injectables Medici
ne package inserts
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OUTCOMES

• Less delay to start administration for emergency
  injections (Magnesium for eclampsia- 0.5h)
• Ensure correct concentration (ward based
  preparation gt10 out Wheeler et al, 2008)
• Reduced waste
• Reduced rework (e.g. inadequate labelling)
• Less risk of contamination
• Eliminate human error
• Standardise concentration (ICS standards)
• Health safety (needlestick injury, RSI)
• Assistance with assurance (NHSLA, NPSA alerts)

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QIPP OUTCOMES261k over 3 years

• Cost of medicines
• Adenosine for cardiac cath labs (save 10k pa)
• Morphine for PCA and continuous infusion (save
  4k pa)
• Suxamethonium and thiopentone for emergency
  caesarean section (also eliminate unsafe practice
  save 3.5k pa)
• Noradrenaline PFS no UK instructions in ampoule
  pack
• NHS manufacturing units tender
• Process improved
• 1,667 minutes nurses time per month released by
  introducing ready to use potassium syringes in
  adult critical care (approx. 20 band 5 5k)

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IN PROGRESS

• Established current use of NSAIDs and are
  developing metrics and methodology for QIPP
• Medicines management e learning project published
  on Nelm
• Missed doses in process of audit and analysis for
  potential for metrics
• Number admissions hypoglycaemia evaluated for
  frequency and cost. Insulin in hospital. To
  identify areas for improvement and metrics
• Injectables in the community

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Challenges

• Linking quality with safety to tangible savings
• Engaging with other professions
• Moving forward to kpis and standards for safety
• Communication, continuity and commitment

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• 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_at_iow.nhs.uk