Protecting patients- now and in the future

1. Protecting patients-now and in the future Linda Matthew Senior Pharmacist National Patient Safety Agency

2. The changing face of chemotherapy • IV Oral (now) • Secondary care Primary care (the future)

3. 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

4. Public confidence

5. Managing the risks in current serviceconfigurations • Information is key • Proactive risk management • Reactive risk management

6. 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

7. Oral chemotherapy-patient safety incident data • What does data on incidents reported to the National Reporting & Learning System (NRLS) tell us?

8. National Reporting & Learning System (NRLS) Feedback International Collaboration Australia USA Europe Standardised reporting NPSA NHS Trusts PractitionersStaff Healthcare Commission MHRA NHS Complaints NHS Litigation Authority Patients Carers

9. Medication report – March 07

10. 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

11. 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

12. NRLS- All incident types v medicationJan 06 to March 07

13. NRLS Medication Incidents – reported by care sector

14. 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)

15. Degreeof harm caused

16. Stage in the process

17. Medication Error Types

18. Top 6 drugs reported

19. Key notes

20. 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

21. The changing face of chemotherapy Diagnose Secondary care Monitor Prescribe Administer IV Dispense

22. The changing face of chemotherapy Secondary careDiagnose Primary careMonitor Prescribe Self administer Dispense

23. 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

24. 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

25. Alert 18 Risk assessment Related safety data • NHSLA data – published claims and reports • NPSA NRLS data • Published audits & reports • Case reports

26. 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…)

27. Alert 18 Risk assessment- findings contd. • Poor communication across the interface • Insufficient support for patients & staff • Insufficient monitoring • Inadequate safety checks at repeat prescribing

28. 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

29. Generic risks • Lack of knowledge and expertise • Poor communication between sectors • Poor monitoring • Poor patient information and education • Inadequate documentation • Lack of standardisation

30. 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

31. 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

32. 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

33. Potential solutions • Skills and competence Secondary sector expertise in primary care Consultant Oncology Pharmacists Pharmacist led monitoring clinics Enhanced role for specialist pharmacy technicians

34. 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

35. Thank you