regulating the safe and effective use of medicines. - sps · regulating the safe and effective use...
TRANSCRIPT
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Allison Newman Pharmacist
Specialist
June 2017
Regulating the safe and effective use of medicines.
Our 5 key questions
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Key lines of enquiry
To focus our inspection, we use a standard set of key lines of enquiry
(KLOEs) that relate to the five key questions
KLOEs support consistency of what we look at under each of the five
key questions and focus on those areas that matter most
Each KLOE has a description of what good looks like
KLOEs are supported by guidance on the key things to consider as
part of the assessment; these are called prompts
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Do staff have all the information they need to deliver safe care and treatment to people?
How does the provider ensure the proper and safe use of medicines, where the service is responsible?
Are lessons learned and improvements made when things go wrong ?
Are peoples needs assessed and care and treatment delivered in line with current legislation, standards and evidence based guidance to achieve effective outcomes?
How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?
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Proposed S3, S4, S6, E1, C2:
S4: Questions?
S4.1
changed
How are medicines and medicines related stationery managed, i.e. ordered, transported, stored ,
and disposed of safely and securely (including medical gases and emergency medicines and
equipment)?
S4.2
changed
Are medicines appropriately prescribed, administered and/or supplied to people in line with the
relevant legislation, current national guidance or evidence base where these exist?
S4.3
changed
Is individualised advice provided about medicines in line with current national guidance or evidence
base where it exists?
S4.4
changed
How does the service make sure that people receive their medicines as intended, and is this
recorded appropriately?
S4.5
New
Are people's medicines reconciled in line with current national guidance on transfer between
locations or changes in levels of care?
S.4.6
New
Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate
follow up in accordance with current national guidance or evidence base where these exist?
S4.7
New Are people’s medicines regularly reviewed including the use of ‘when required’ medicines?
S4.8
How does the service make sure that people’s behaviour is not controlled by excessive or
inappropriate use of medicines?
Hospital Nexphase
• From June 2017 NHS Trusts, Independents to be rolled out at a later date.
• Annual well-led inspection and a minimum of two of the Trusts core services will be part of unannounced inspection.
• Continuous data collected, from the trust and other bodies. Difficult currently in obtaining medicines data as no access to Hospital Dashboard.
• Dedicated pharmacist from the CQC medicine optimisation team allocated to each trust. Overseeing monitoring of the data information, undertake chief pharmacist and other key staff interviews, where appropriate.
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A more targeted, responsive and
collaborative approach
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Four point scale
High level characteristics of each rating level
Innovative, creative, constantly striving to improve, open and transparent
Consistent level of service people have a right to expect, robust arrangements in place for when things do go wrong
May have elements of good practice but inconsistent, potential or actual risk, inconsistent responses when things go wrong
Severe harm has or is likely to occur, shortfalls in practice, ineffective or no action taken to put things right or improve
Quotes from reports (Outstanding)
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Lessons were learnt from medicine incidents and shared across the trust in order to improve patient safety.
We saw staff counselling patients about their medicines and handing out patient information leaflets.
The hospital had an organisational
structure to manage medicine safety
We saw that patients
had effective, timely
medicine reconciliation
completed by the
doctors and pharmacy
team during their
hospital stay.
Medicines were administered with care and dignity. Nurses tailored the administration to the needs of the individual.
Quotes from reports (Good)
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The medicines management team
carried out audits on the safe and
secure handling of medicines at all
community sites.; an individual
report and action plan was
produced for each site.
The pharmacy service provided on the community
inpatient wards was out standing and integral to the
patients’ discharge planning.
The pharmacy produce a bimonthly
newsletter which was distributed to all
clinical teams. This detailed recent
medicine alerts or changes in
guidelines.
The trust had processes
and standard operating
procedures to manage the
ordering, storage, disposal
and monitoring of
vaccines. This included
up-to-date, documented
procedures for the safe
handling and use of
vaccinations, packing and
transport of vaccines and
monitoring of fridge
temperatures.
School nurses adhered to
patient group directives
(PGD). We noted the
information was up to date
and included staff
signatures to show staff
had received appropriate
training.
Quotes from reports (Good )
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In most areas, medicines were managed
appropriately however; arrangements for the
safe handling of medicines at ….. were not
consistent showing omissions in recording and
storage.
Medicines within school settings are
administered safely and must include a valid
prescription and protocol for as required
medicines.
We found that in all the areas
we visited there had been no
issues with medicines
availability and the clinical
input of pharmacists had
benefited patients.
Services have
signed patient
group
direction
forms(PGD).
The trust had a
good incident
reporting culture
in most areas,
and there was
evidence of
improvements
following
incidents, but
systems for
sharing
information in
some services
was not as strong.
Quotes from reports (Requires Improvement)
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Staff were reporting incidents. The
trust had a strong culture for
reporting incidents and there was
evidence of learning and action
taken to improve services.
However, the process was
inconsistent.
In one community clinic, medical supplies were
inappropriately stored above room temperature
which meant that the effectiveness of the ingredients
could not be guaranteed.
We found poor practice in regard to
medicines management in in the
community hospitals and in relation to
end-of-life care, particularly around
the prescribing of pain relief and
missed doses.
We found unsafe practise
regarding the prescribing
of end of life medication
because it was open to
mistake or abuse.
Staff did not always store,
prescribe or administer
medicines appropriately or
monitor their use.
