s seven steps to medication safety : identifying and reporting medication safety incidents...

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Seven Steps to Medication Safety:

Identifying and Reporting Medication Safety Incidents

Bite-sized training

P SEast & South East England Specialist Pharmacy ServicesEast of England, London, South Central & South East Coast

Medicines Use and Safety

©East & South East England Specialist Pharmacy Services 1

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P S Learning Outcomes

• Define medication safety incidents and adverse drug reactions and events

• Describe why reporting of medication safety incidents is important • Identify where errors occur in the MR process and how this links to

incident reporting • Identify incidents occurring as part of a case study• Identify the prescription of insulin as abbreviated units as a Never

Event• Describe the pros and cons of reporting incidents in the workplace

√ Practice aim: To identify and report incidents as expected as part of the pharmacy team

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P S Incident vs ADR

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Example of both?

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P S Why is it important to report them?

Research shows that:

“Trusts with significantly high levels of incident reporting are more likely to demonstrate other features of a strong safety culture”

NPSA 2008

NHS providers are required to report incidents

NHS Outcomes Framework

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Stage 1Clerking by Doctor

Stage 2Selection of patients for MR

Stage 3Sourcing the information for use in the MR process

Stage 4Comparing the sourced list(s) and patient sourced information against the written prescription: Identifying discrepancies

Stage 5Listing and documenting unintentional discrepancies

Stage 6Referring unintentional discrepancies: For doctor to make changes or to a pharmacist or nurse for further analysis/follow-up

Meds Reconciliation (MR) Process Map

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Real examples of things going wrong

GP prescription PODs Inpatient prescription

Hospital disp item in locker

Simvastatin 20mg ON

Simvastatin 20mg daily

Simvastatin 20mg ON

Simvastatin 20mg ON

Sodium valproate 1200mg BD



Sodium chloride 1200mg BD

Betaxolol ED --- --- ---

Methotrexate 2.5mg weekly


Methotrexate 2.5mg daily


Lisinopril 25mg OD Lisinopril 2.5mg OD Lisinopril 25mg OD Lisinopril 2.5mg OD

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Simvastatin 20mg ON


Simvastatin 20mg ON

Simvastatin 20mg ON











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Simvastatin 20mg ON


Simvastatin 20mg ON

Simvastatin 20mg ON











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Simvastatin 20mg ON


Simvastatin 20mg ON

Simvastatin 20mg ON











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Simvastatin 20mg ON


Simvastatin 20mg ON

Simvastatin 20mg ON











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P S Barriers and enablers for reporting

National drivers e.g. Outcomes FrameworkOrganisational or departmental strategy for

what to reportRoles need to be clear – who can report and

whatTime needed to reportHuman factors

E.g. fear of reprisals, upsetting existing relationships, making the organisation/division look bad, public image concerns

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P S Evaluation

• Define medication safety incidents and adverse drug reactions and events

• Describe why reporting of medication safety incident is important

• Identify where errors occur in the MR process and how this links to incident reporting

• Identify incidents occurring as part of a case study• Identify the prescription of insulin as abbreviated units as

a Never Event• Describe the pros and cons of reporting incidents in the

workplace

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P S Using this session for CPD

• By taking part in this session you will be able to record or include what you have learnt as a CPD entry starting at “Action”: For example you could:– complete the further reading or practical next steps

and document this – Document your participation in the session and

explain how you have applied this to your day to day practice.

• This learning could identify further learning needs that you can complete as Plan and Record CPD entries starting at “reflection”

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P S Further Reading

Further information about reporting medication incidents

and other aspects of medication safety are available in

• An SPS Resource “Seven Steps to medication Safety: A Development Resource for Pharmacists and Senior Pharmacy Technicians. Download it here: NeLM link

• CPPE provide some modules on medication safety: www.cppe.ac.uk

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s seven steps to medication safety : identifying and reporting medication safety incidents...

Documents

s p s stage

s p s barriers

s p s evaluation

od p s

s p s learning outcomes

s p s incident vs adr

daily simvastatin

s real examples of things