The advantages and disadvantages of no blame (or

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Transcript The advantages and disadvantages of no blame (or

Protecting patients now and in the future

Linda Matthew Senior Pharmacist National Patient Safety Agency

The changing face of chemotherapy

• IV Oral (now) • Secondary care Primary care (the future)

Increasing risk

Modern health care is complex • Increased volume of work • • • • Older and sicker patients Complex, new drugs, interventions & technology Cost constraints – efficiency Workforce pressures • • Changing expectations Changing shape of service delivery

Public confidence

Managing the risks in current service configurations

• Information is key • Proactive risk management • Reactive risk management

BOPA position statement (2004)

• Standards – Manual of Cancer Standards (or equiv) • Patient remain under care of a specialist • Policy & procedures- IV and oral • Risk assess the hazards of oral medications • Prescribing & dispensing standards -same for IV/oral • Education of patients • Effective communication across care interfaces • Prescribing and dispensing should be responsibility of hospital team

Oral chemotherapy patient safety incident data

• What does data on incidents reported to the National Reporting & Learning System (NRLS) tell us?

National Reporting & Learning System (NRLS) NHS Trusts Practitioners Staff Patients Carers


Healthcare Commission MHRA NHS Complaints NHS Litigation Authority International Collaboration Australia USA Europe

Medication report – March 07

Medication Report – March 2007

7 Key areas for action • Increase reporting & learning from medication incidents • Implement the safer medication practice recommendations • Improve staff skills & competence

Medication Report – March 2007

7 key areas for action • Minimise dosing errors • Ensure medicines are not omitted • Ensure the correct medicines are given to the correct patient • Document patients’ medicine allergy status

NRLS- All incident types v medication Jan 06 to March 07

100000 90000 80000 94554 74963 71643 71901 70000 60000 50000 50601 52261 40000 60987 51375 63107 59619 49684 65141 30000 20000 10000 0 4537 4548 5007 3399 5368 5337 5162 5683 6291 63820 5849 6231 47881 3944 6559 53823 4819 8523 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06

Month / Year

Total no. of incidents to NRLS Linear (Total no. of incidents to NRLS ) Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Total no. of Medication incidents Linear (Total no. of Medication incidents) Mar-07

NRLS Medication Incidents – reported by care sector 0ther Community Pharmacy GP's Mental Health Community Services Acute 0% 10% 20% 30% 40% 50% 60% 70% 80%

NRLS data Nov 03 – July 07

Search terms • Oral, chemotherapy • 26 individually named drugs • 3+ years of data from > 600 organisations (>250 acute sector organisations)

Degree of harm caused

Stage in the process

Medication Error Types

Top 6 drugs reported

Key notes


Proactive management of risks;

• review local systems (BOPA position statement 2004)

Reactive management of risks;

• Increase reporting of patient safety incidents • Review reports to identify local risk trends • Analyse incidents to identify system weaknesses • Take action to improve systems

The changing face of chemotherapy

Diagnose Secondary care Monitor Prescribe Administer IV Dispense

The changing face of chemotherapy

Secondary care Diagnose Primary care Monitor Prescribe Self administer Dispense

Managing the risks of the future service configurations

• Information is key • Define/map out the system • Proactively assess the risks • Use incident and other data/info to inform the process

Example – NPSA alert no 18 anticoagulant therapy & services

Process • Search for related safety data • Map anticoagulant therapy services in the NHS • Assess the risks in each part of the treatment process (using SWIFT) • Identify solutions to reduce the risks

Alert 18 Risk assessment

Related safety data - NHSLA data – published claims and reports - NPSA NRLS data - Published audits & reports - Case reports

Alert 18 Risk assessment - findings

- Inadequate training & work competences - Inadequate clinical audit and failure to act on results - Poor documentation Prescribing issues (errors, interacting medications…)

Alert 18 Risk assessment - findings contd.

- Poor communication across the interface - Insufficient support for patients & staff - Insufficient monitoring - Inadequate safety checks at repeat prescribing

Alert 18 – safer practice solutions

• Ensure competency of staff • Ensure policies & procedures in place • Audit services • Provide verbal and written information for patients at commencement and thro’ treatment • Prescribers and pharmacists to supply repeat prescriptions using safe systems of practice & only when safe to do so • Implement safety precautions when co-prescribing interacting drugs • Standardise the range of products available to avoid error

Generic risks

• Lack of knowledge and expertise • Poor communication between sectors • Poor monitoring • Poor patient information and education • Inadequate documentation • Lack of standardisation

The challenges

• Loss of control or a sharing of responsibility?

• Increasing complexity

longer care pathway


more stakeholders

• Different cultures (and politics) • Longer chains of communication • Different ways of working - re-designing the system

The challenges

- contd.

• Policy changes to meet future system needs (Community pharmacy services) • Resource transfers • Providing information for patients • On-going monitoring • Inadequate/unreliable systems

Potential solutions

• Technology Specialised design of e-prescription E-transfer of prescriptions Sharing of patient e-record (hospital, GP, pharmacy) On-line availability of protocol information

Potential solutions

• Skills and competence Secondary sector expertise in primary care Consultant Oncology Pharmacists Pharmacist led monitoring clinics Enhanced role for specialist pharmacy technicians


The future presents both risk and opportunity • Information is key - Incident reporting • Learning from incidents – reactive • Learning from others – proactive • Windows of opportunity for role enhancement

Thank you