Transcript Slide 1

‘No Needless Medication Errors’
Gillian Honeywell, Chief Pharmacist
NHS Isle of Wight
South Central
Medication Errors do happen..
South Central
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
1.
2.
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/
South Central
Project Plan
Project 1: Metrics: 3rd year: Improvement Methodology:
Trust Quality Standard kpi’s and SHA monitoring
1: Means of ensuring patient receive oral anticoagulation therapy within safe
parameters (INR >5 & >8)
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
South Central
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.
South Central
Metric 2: Medicines
Reconciliation
% of Adult Patients with Medicines Reconciliation
Completed within 24 hrs
100%
90%
Implementation
of 7 Day Working
Target line
80%
70%
60%
50%
40%
30%
20%
Staff
vacancies
10%
Implementation
of Green Bag
Scheme
0%
Jan-10 Feb-10 M ar -10 A pr -10 M ay-10 M ay(2)
Jun-10 June(2) Jul -10
Jul (2) A ug-10
Sep-10 Oct -10 Nov-10 Dec-10
NHS Isle of Wight
South Central
Green Bag Scheme
£20,000 Pump Prime PSF
Medicines reconciliation supporting the
safe transfer of patient’s 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
South Central
5QF Berkshire West PCT
Medicines Reconciliation
5QT Isle of Wight NHS PCT
RBF-X Nuffield Orthopaedic Centre NHS Trust
Percentage of Meds Rec Completed
(since 01 Apr 2011)
RD7 Heatherwood and Wexham Park Hospitals NHS
Foundation Trust
RD8 Milton Keynes Hospital NHS Foundation Trust
RHM Southampton University Hospitals NHS Trust
100%
RHU Portsmouth Hospitals NHS Trust
RN1-X Winchester and Eastleigh Healthcare NHS
Trust
RN5-X Basingstoke and North Hampshire NHS
Foundation Trust
RNU Oxford Health NHS Foundation Trust
90%
80%
70%
RTH Oxford Radcliffe Hospitals NHS Trust
RW1 Hampshire Partnership NHS Foundation Trust
60%
RWX Berkshire Healthcare NHS Foundation Trust
50%
Frequency
40%
%
91-100
81-90
71-80
61-70
51-60
41-50
31-40
21-30
11-20
0-10
30%
20%
10%
0%
28-Mar-11
0
17-May-11
06-Jul-11
25-Aug-11
14-Oct-11
03-Dec-11
10
20
30
5QT Isle of Wight NHS PCT
Medicines Reconciliation
RBF-X Nuffield Orthopaedic Centre NHS Trust
Acute Trusts in FY 2011
RD7 Heatherwood and Wexham Park Hospitals NHS
Foundation Trust
RD8 Milton Keynes Hospital NHS Foundation Trust
100%
RHM Southampton University Hospitals NHS Trust
90%
100%
RHU Portsmouth Hospitals NHS Trust
80%
90%
70%
RN1-X Winchester and Eastleigh Healthcare NHS
Trust
60%
RN5-X Basingstoke and North Hampshire NHS
Foundation Trust
80%
70%
RTH Oxford Radcliffe Hospitals NHS Trust
50%
60%
RXQ Buckinghamshire Healthcare NHS Trust
40%
50%
Frequency
30%
40%
%
91-100
81-90
71-80
61-70
51-60
41-50
31-40
21-30
11-20
0-10
20%
30%
10%
20%
0%
10%
0%
26/02/2011
17/04/2011
06/06/2011
26/07/2011
14/09/2011
03/11/2011
23/12/2011
11/02/2012
0
10
20
30
Medicines Reconciliation
Further Cost Avoidances
Costs Avoided
Bucks HT
£32,075
£5,062
Berks HFT
£7,395
Southern HFT
£473
Oxford HFT
£5,300
BNHFT
Southern HFT
£10,315
ORH
£99,003
Oxford HFT
£9,812
£102,505
RBHFT
£389,411
PHT
£379,197
SUHT
£211,996
£1,993
200000
300000
400000
MKFT
£150,434
HWPFT
£3,419
NOC
£61,093
IOW
£5,157
Berks West
100000
SUHT
£84,179
IOW
0
RBHFT
PHT
£286,853
NOC
£61,227
0
£264,429
HWPFT
£25,281
WEHT
£393,085
MKFT
£219,936
BNHFT
£152,605
WEHT
£125,360
Berks HFT
£3,903
ORH
£375,737
Bucks HT
£371,790
Berks West
100000
200000
300000
400000
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.
Cost avoidance
Min
Avg
Max
0
5
10
Med Rec
Trust (HES title)
5QT Isle of Wight NHS PCT
2010/11
2011/12
Month average
25911
26688
2224
3. Actual data collated by Trust – used to calculate % achieved
Trust
IoW
Adult patients sampled
Med Rec
completed
% Med Rec
Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
208
211
194
215
196
204
173
164
150
175
156
161
124
180
137
179
185
67
32%
92
44%
125
64%
139
65%
139
71%
120
59%
111
64%
99
60%
73
49%
93
53%
104
67%
112
70%
93
75%
103
57%
77
56%
109
61%
117
63%
4. Calculated avoidable and avoided costs (monthly average from 2 applied to % achieved from 3)
Trust
IoW
HES adult admission
% Med Rec
Avoidable cost
Costs avoided
Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
2224
32%
7538
3582
2224
44%
6272
4849
2224
64%
3955
7165
2224
65%
3931
7189
2224
71%
3234
7886
2224
59%
4579
6541
2224
64%
3985
7135
2224
60%
4407
6713
2224
49%
5708
5412
2224
53%
5211
5910
2224
67%
3707
7413
2224
70%
3384
7736
2224
75%
2780
8340
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
2224
57%
4757
6363
2224
56%
4870
6250
2224
61%
4349
6771
2224
63%
4087
7033
South Central
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
Medicine package inserts
South Central
OUTCOMES
• Less delay to start administration for emergency injections
(Magnesium for eclampsia- 0.5h)
• Ensure correct concentration (ward based preparation >10%
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)
QIPP OUTCOMES…£261k 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)
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
South Central
Challenges
• Linking quality with safety to tangible
savings
• Engaging with other professions
• Moving forward to kpi’s and standards for
safety
• Communication, continuity and
commitment
South Central
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
[email protected]
South Central