‘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

South Central

1. Pharmacy in England Building on strengths – delivering the future, Department of Health. 20082. 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/

Project PlanProject 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 careRisk assessments to reduce errors with injectables: collaborative

procurement

South Central

Project PlanProject 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 insulinBaseline 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

South Central

% of Adult Patients with Medicines Reconciliation Completed within 24 hrs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

J an-10 Feb-10 Mar-10 Apr-10 May-10 May(2) J un-10 J une(2) J ul-10 J ul (2) Aug-10 Sep-10 Oct-10 Nov-10 Dec-10

Staff vacancies

Implementation of Green Bag Scheme

NHS Isle of Wight

Target line

Implementation of 7 Day Working

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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

28-Mar-11 17-May-11 06-Jul-11 25-Aug-11 14-Oct-11 03-Dec-11

5QF Berkshire West PCT

5QT Isle of Wight NHS PCT

RBF-X Nuffield Orthopaedic Centre NHS Trust

RD7 Heatherwood and Wexham Park Hospitals NHSFoundation TrustRD8 Milton Keynes Hospital NHS Foundation Trust

RHM Southampton University Hospitals NHS Trust

RHU Portsmouth Hospitals NHS Trust

RN1-X Winchester and Eastleigh Healthcare NHSTrustRN5-X Basingstoke and North Hampshire NHSFoundation TrustRNU Oxford Health NHS Foundation Trust

RTH Oxford Radcliffe Hospitals NHS Trust

RW1 Hampshire Partnership NHS Foundation Trust

RWX Berkshire Healthcare NHS Foundation Trust

0 10 20 30

0-1011-2021-3031-4041-5051-6061-7071-8081-90

91-100

Frequency

Percentage of Meds Rec Completed(since 01 Apr 2011)

%

Medicines Reconciliation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

26/02/2011 17/04/2011 06/06/2011 26/07/2011 14/09/2011 03/11/2011 23/12/2011 11/02/2012

5QT Isle of Wight NHS PCT

RBF-X Nuffield Orthopaedic Centre NHS Trust

RD7 Heatherwood and Wexham Park Hospitals NHSFoundation Trust

RD8 Milton Keynes Hospital NHS Foundation Trust

RHM Southampton University Hospitals NHS Trust

RHU Portsmouth Hospitals NHS Trust

RN1-X Winchester and Eastleigh Healthcare NHSTrust

RN5-X Basingstoke and North Hampshire NHSFoundation Trust

RTH Oxford Radcliffe Hospitals NHS Trust

RXQ Buckinghamshire Healthcare NHS Trust

0 10 20 30

0-1011-2021-3031-4041-5051-6061-7071-8081-90

91-100

Frequency

Medicines ReconciliationAcute Trusts in FY 2011

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Medicines Reconciliation

Further Cost AvoidancesCosts Avoided

£5,157

£61,093

£3,419

£150,434

£84,179

£286,853

£264,429

£393,085

£102,505

£152,605

£9,812

£99,003

£10,315

£3,903

£371,790

0 100000 200000 300000 400000

Bucks HT

Berks HFT

Southern HFT

ORH

Oxford HFT

BNHFT

WEHT

RBHFT

PHT

SUHT

MKFT

HWPFT

NOC

IOW

Berks West£1,993

£61,227

£25,281

£219,936

£211,996

£379,197

£389,411

£125,360

£5,300

£473

£375,737

£7,395

£5,062

£32,075

0 100000 200000 300000 400000

Bucks HT

Berks HFT

Southern HFT

ORH

Oxford HFT

BNHFT

WEHT

RBHFT

PHT

SUHT

MKFT

HWPFT

NOC

IOW

Berks West

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 totalAverage of 61% medicines reconciliation achieved = £69,137 in cost avoidance achievedwith 39% further potential savings = £44,203 in avoidable costs

Isle of Wight ExampleCost avoidance Min Avg Max

Med Rec 0 5 10

Trust (HES title) 2010/11 2011/12 Month average

5QT Isle of Wight NHS PCT 25911 26688 2224

Trust IoW 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-11Adult patients sampled 208 211 194 215 196 204 173 164 150 175 156 161 124 180 137 179 185Med Rec completed 67 92 125 139 139 120 111 99 73 93 104 112 93 103 77 109 117% Med Rec 32% 44% 64% 65% 71% 59% 64% 60% 49% 53% 67% 70% 75% 57% 56% 61% 63%

Trust IoW 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

HES adult admission 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224 2224% Med Rec 32% 44% 64% 65% 71% 59% 64% 60% 49% 53% 67% 70% 75% 57% 56% 61% 63%Avoidable cost 7538 6272 3955 3931 3234 4579 3985 4407 5708 5211 3707 3384 2780 4757 4870 4349 4087Costs avoided 3582 4849 7165 7189 7886 6541 7135 6713 5412 5910 7413 7736 8340 6363 6250 6771 7033

South Central

South Central

Safer Use of Injectable Medicines

• Dobutamine 250mg in 50ml vial

• Morphine 1mg/ml & 2mg/ml – 50ml vial

• Human soluble insulin 50 units in 50ml pre-filled syringe

Focus on practical implementation of targeted products identified by NPSA alert 20:

Four work streams were funded by PSF :Injectables: purchasing for safety

Assessing risk to operators from exposure to hazardous injectable medicines

Neonatal InjectablesMedicine package inserts

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 yearsCost 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 tenderProcess 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)

South Central

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 ManagerFiona.eccleston@iow.nhs.uk