protecting patients- now and in the future
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Protecting patients-now and in the future
Linda Matthew
Senior Pharmacist
National Patient Safety Agency
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The changing face of chemotherapy
• IV Oral (now)
• Secondary care Primary care (the future)
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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
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Public confidence
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Managing the risks in current serviceconfigurations
• Information is key• Proactive risk management • Reactive risk management
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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
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Oral chemotherapy-patient safety incident data
• What does data on incidents reported to the National Reporting & Learning System (NRLS) tell us?
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National Reporting & Learning System (NRLS)
NHS Trusts
PractitionersStaff
Patients
Carers
NPSA
Healthcare Commission
MHRA
NHS Complaints
NHS Litigation Authority
Feedback
International
Collaboration
Australia
USA
Europe
Standardised reporting
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Medication report – March 07
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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
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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
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NRLS- All incident types v medicationJan 06 to March 07
50601 52261
60987
51375
6310759619
49684
65141
71643
63820
71901
47881
74963
53823
94554
4548 5007 3399 5368 5337 5162 5683 6291 5849 62313944
6559 48198523
4537
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07
Month / Year
Nu
mb
er
Total no. of incidents to NRLS Total no. of Medication incidents
Linear (Total no. of incidents to NRLS ) Linear (Total no. of Medication incidents)
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NRLS Medication Incidents – reported by care sector
0% 10% 20% 30% 40% 50% 60% 70% 80%
Acute
Community Services
Mental Health
GP's
CommunityPharmacy
0ther
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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)
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Degree of harm caused
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Stage in the process
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Medication Error Types
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Top 6 drugs reported
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Key notes
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Recommendations
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
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The changing face of chemotherapy DiagnoseSecondary care
Monitor Prescribe
Administer IV Dispense
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The changing face of chemotherapy
Secondary care Diagnose
Primary care Monitor Prescribe
Self administer Dispense
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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
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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
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Alert 18 Risk assessment
Related safety data- NHSLA data – published claims and reports- NPSA NRLS data- Published audits & reports- Case reports
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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…)
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Alert 18 Risk assessment- findings contd.
- Poor communication across the interface- Insufficient support for patients & staff- Insufficient monitoring - Inadequate safety checks at repeat prescribing
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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
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Generic risks
• Lack of knowledge and expertise • Poor communication between sectors• Poor monitoring • Poor patient information and education• Inadequate documentation• Lack of standardisation
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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
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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
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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
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Potential solutions
• Skills and competence
Secondary sector expertise in primary care
Consultant Oncology Pharmacists
Pharmacist led monitoring clinics
Enhanced role for specialist pharmacy technicians
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Summary
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
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Thank you