merp combined data - feb 2017 - mist- · pdf file@docrobbo data made easy merp datasheet v1.0...
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MERPMiST February 2017Dr Simon Robinson
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PSF030G
Category A:Circumstances or
events that have the capacity to cause error
Category B:An error occurred but the error did not reach the patient (An "error
of omission" does reach the patient)
Category C:An error occurred that
reached the patient but did not cause patient harm
Category D:An error occurred that
reached the patient and required monitoring to
confirm that it resulted in no harm to the patient and/or
required intervention to preclude harm
Category E:An error occurred that may have contributed
to or resulted in temporary harm to the patient and required
intervention
Category F:An error occurred that may
have contributed to or resulted in temporary harm to the patient and required
initial or prolonged hospitalization
Category G:An error occurred that
may have contributed to or resulted in permanent
patient harm
Category H:An error occurred that required intervention
necessary to sustain life
Category I:An error occurred that
may have contributed to or resulted in the patients death
NCC MERP Index for Categorizing Medication Errors
DefinitionsHarmImpairment of the physical, emotional, or psychological function or structure of the body and/or pain resulting therefrom.
MonitoringTo observe or record relevant physiological or psychological signs.
InterventionMay include change in therapy or active medical/surgical treatment.
Intervention Necessary to Sustain LifeIncludes cardiovascular and respiratory support (e.g., CPR, defibrillation, intubation, etc.)
No Error
Error, No Harm
Error, Harm
Error, Death
2001 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved.* Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.
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Was the harm temporary?
HarmImpairment of the physical, emotional, or psychological function or structure of the body and/or pain resulting therefrom.
MonitoringTo observe or record relevant physiological or psychological signs.
InterventionMay include change in therapy or active medical/surgical treatment.
Intervention Necessary to Sustain LifeIncludes cardiovascular and respiratory support (e.g., CPR, defibrillation, intubation, etc.)
*An error of omission does reach the patient.
Category A
Category B
Category C
Category D
Category E Category F
Category G
Category H
Category I
Circumstances or events that have the
capacity to cause error
Did an actual error occur?
Did the error reach the patient? *
Did the error contribute to or
result in patient death?
Was the patient harmed?
Was intervention to
preclude harm or extra monitoring required?
Did the error require an
intervention necessary to sustain life?
Was the harm permanent?
YES
YES
YESYES
NO
YES
YES
NO
YES
NONO
NO
YES
NO
NO
NO
NCC MERP Index for Categorizing Medication
Errors Algorithm
Did the error require
initial or prolonged hospitalization?
NO
YES
PSF030G
2001 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved.* Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.
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Data Three hospitals
o Manchester, Leicester & Birmingham Childrens Hospitals Plus Southampton Plus Nottingham
Data to report to MiSTo Number of reported MIs per calendar montho Percentage of reported MIs in each MERP level (A - I)o Percentage of reported MIs in the combined MERP levels [A - D]
and [E - I]o Type of MI
Prescribing incidents Administration incidents Other incidents
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Data Made EasyMERP Datasheet V1.0
Toolkit calculates data automatically Makes data submission easier for you http://www.mist-collaborative.net/medication-news-new-merp-tool/
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Getting Better Medication Incidents
o Hospital A: 217 Incidents (100% analysed)o Hospital B: 631 Incidents (67.4% analysed)o Hospital C: 1079 Incidents (73.9% analysed)o Hospital D: 635 Incidents analysed (? Of total ?)o Hospital E: 237 Incidents (95.8 % analysed)
Big Numberso 2301 Medication Incidents MERP Categorisedo 115,000 paediatric bed days across 3/5 hospitalso > 569 Occurred with PIC (>25%) incomplete dataset o 98% of Hospital Wide data associated with no harmo 97.9% of PIC data associated with no harm
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MIs per Month
0
20
40
60
80
100
120
Janu
ary
Febr
uary
Mar
ch
Apr
il
May
June
July
Aug
ust
Sept
embe
r
Oct
ober
Nov
embe
r
Dec
embe
r
2016
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MIs per Month
0
50
100
150
200
250
300
Janu
ary
Febr
uary
Mar
ch
Apr
il
May
June
July
Aug
ust
Sept
embe
r
Oct
ober
Nov
embe
r
Dec
embe
r
2016
A AA A A A A A A A A A
BB
B
B
B BB B
BB
BB
CC
C
C
C
C
C C C CC C
DD
D
D
D
D
D D
D
D DD
EE
E
E
E
E
EE
E
EE
E
FF
F
F
F
F
FF
F
FF F
GG
G
G
G
G
GG
G
GG G
HH
H
H
H
H
HH
H
HH H
II
I
I
I
I
II
I
II I
I
H
G
F
E
D
C
B
A
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MIs by MERP
0%
10%
20%
30%
40%
50%
60%
A B C D E F G H I
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MIs by MERP Harm
98.54% 96.00%
97.87% 99.53%
96.92%
1.46% 4.00%
2.13% 0.47%
3.08%
60%
65%
70%
75%
80%
85%
90%
95%
100%
E-I A-D
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Harm LearningIn 2016, 48 Children experienced
temporary harm related to medication incidents across the 5 hospitals
No deaths and no permanent harm
In depth data for 35/48 available for further analysis (see next slide)
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Harm Learning - Pareto
0
20
40
60
80
100
0
2
4
6
8
10
12
14
16
% o
f Tot
al (R
ed)
Med
icat
ion
Inci
dent
s (B
lue)
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Harm Action Proposed Interventions
o Review strategies for attenuating drug dosing when there are comorbidities e.g. renal insufficiency
o Review strategies for area transition E.g. Hospital admission E.g. Transfer between wards
o Move away from Staff informed Consider preventative strategies - see next slide
Looking for examples of excellence in prevention of these sorts of incidents
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Intervention Effectiveness