Patient Safety Webinar

1. Patient Safety Webinar Alexa Wall Tuesday 22nd January 2013

2. Objectives At the end of the session participants will be able to: Discuss the goals, measures and definitions in relation to medicines reconciliation Describe basic quality improvement tools and how they are used in practice Discuss initiatives in the management of high risk medicines  

3. HealthCare

4. Putting it into perspective... One in ten admissions to hospital result in an adverse event The average cost of adverse events within healthcare in the UK is £6 billion Harm for medications alone occurs in 25% of all hospitalised patients

5. In practice More than half of errors occur at interfaces of care especially at point of admission 30-70% variance between patients’ drugs prior to hospital compared to those prescribed on cardex Omission most common

6. “There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.” The SGHD `Quality Strategy` 2010

7. Person-Centred- Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. Clinically Effective- The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times. The Healthcare Quality Strategy for Scotland

8. What is Quality Improvement • It’s about developing care that delivers for patients. • Its about breaking the “We've always done it like this!” culture, encouraging both patients and staff to challenge and change healthcare services for the better

9. “If I had to reduce my message for management to just a few words, I’d say it all had to do with reducing variation.” W. Edwards Deming Origins of Improvement Cycle

10. Scottish Patient Safety Programme (SPSP) Programme of quality improvement to improve patient safety Uses quality improvement methodology Concentrates on specific safety areas of harm reduction • e.g. high risk medicines, transfer of information across the interface Development of the SPSP (to involve ALL staff) Started in hospitals (2008) Rolling out in primary care in 2012/13 Plans to introduce to mental health, paediatrics, maternity, sepsis, VTE • National agenda and Board-level approaches

11. Terminology Run Charts SEA Goals and Measures NOT targets Safety Culture Rapid Cycle Improvement GTT PDSA Human Factors FMEA Driver Diagrams

12. PDSA –Rapid Tests of Change S Constructing a clear aim statement Choosing the right measures and planning how information will be collected, pre and post Coming up with ideas to improve the current statement The Improvement Guide, API

13. Start small • Small tests... 1 practice, 1 nurse, 1 doctor, 1 patient • Then 3 patients, 5 patients • Test on pilot unit • Refine the process • Test in and out of hours • Test on all patients • Q: Examples of tests of change you’ve been involved in?

14. % Compliance with Medicines Reconciliation on Admission (Meds Rec Completed) 24/05/2010:Med Rec SBAR communication to all staff in ERU 04/06/2010: Meeting with CofE consultant 14/06/2010:Detection and mitigation on ward round 19/07/2010:Impact of admission med rec on eIDL identified by FY1s 23/08/2010:Patient stories / critical incidents 09/09/2010:Ward visit awareness session 20/09/2010:SPSP Facilitators / Pharmacist message reinforced with staff 05/04/2010: Baseline data collection – tests of change for population and data collection 07/06/2010:C/W/S on ECS, Stickers on cardexes, Feedback stats, New FY1s 04/08/2010:New doctors/ Pplates 09/08/2010:ECS on sticky paper 14/08/2010:Collaborate with General Ward Workstream, CNs empowered 18/08/2010: Issues with transfer to Vision identified, access to ECS restricted 04/10/2010:Redundant step pharmacist on ward round and screening all Rxs

15. FMEA • Failure Mode Effects Analysis

16. SEA • Significant Event Analysis • What is Significant Event Analysis (SEA)? • Significant Event Analysis is the analysis of an event that has been significant to you to make you reflect and consider changing practice. • Q: what kind of incidents would be suitable for SEA?

17. How to choose / document an SEA • Such an event should be chosen because: • a) it is thought to be important in the life of the department / team, your practice i.e. is significant. • b) it may offer some insight into the care of patients. • c) the analysis of the significant event is focused on the specific reasons for actions and behaviour. • A Significant Event Analysis should include the following: • 1. What happened? • 2. Why did it happen? • 3. What has been learned? • 4. What has been changed?

18. Driver Diagram

19. National Healthcare Improvement Scotland (HIS) have set up a National Safer Medicines Network (previously Medicines Reconciliation Network) Covers all work streams that include medicines Multi-professional membership from across NHSScotland Strategic links with other complementary work e.g. SIGN discharge letter, SPARS Communication, sharing best practice, synergy and acceleration e.g. eHealth enablers: ECS, eForms, Trakcare Multidisciplinary education from NES About to launch: Recommended Practice Statements Refreshed definition, goals and measures

20. Medicines reconciliation Q: What are the definition, goals and measures for MR? High risk medicines SPSP MEDICINES WORKSTREAM

21. MEDICINES RECONCILIATION DEFINITION going through consultation / approval process The process that the healthcare team undertakes to ensure that the list of medication, both prescribed and over the counter, that I am taking is exactly the same as the list that I or my carers, GP, Community Pharmacist and hospital team have. This is achieved, in partnership with me, through obtaining an up-to-date and accurate medication list that has been compared with the most recently available information and has documented any discrepancies, changes, deletions or additions resulting in a complete list of medicines accurately communicated.

22. MR on admissiongoing through consultation / approval process Measures Patient demographics documented Allergy status on admission documented 2 or more sources, one of which should be the patient / carer, used on admission to give the best possible medicines history Medicines Plan documented for each medicine i.e. continue, withhold, stop Safe and accurate transcription of clinically appropriate medicines on in-patient prescription chart Goals 95% compliance with MR within 24hours of admission 95% of patients have an accurate in-patient prescription chart within 24hours of admission

23. MR on transfer within acute sitesgoing through consultation / approval process Measures Patient demographics documented Allergy status documented All medication reviewed and plan documented, including medicines which may have been started in hospital prior to transfer Safe and accurate prescribing of clinically appropriate medicines on in-patient prescription chart Goals 95% compliance with MR within 4hours of transfer 95% of patients have an accurate in-patient prescription chart within 4hours of transfer

24. MR on dischargegoing through consultation / approval process • Measures • Patient demographics documented • Allergy status on discharge documented • Changes from admission medicines documented to include changes, discontinuations and new medicines started • Safe and accurate prescribing of clinically appropriate medication on the Interim Discharge Letter • Goals • 95% compliance with MR on discharge • 95% of patients have an accurate medicines list on the Interim Discharge Letter

25. Medicines ReconciliationCHALLENGES Medical & nursing engagement has been poor Competing priorities for clinical teams pose difficulties Junior medical staff need support Maintaining momentum and avoiding person dependent solutions Validating accuracy in absence of a pharmacist Q: What are the challenges for you as pharmacists?

26. What are high risk medicines? • High risk medicines are: most likely to cause significant harm mistakes not more common in the use of these medications when errors occur the impact on the patient can be significant

27. Warfarin The MHRA received 2233 suspected adverse reaction reports with warfarin use between 29 June 1963–16 June 2008, of which 297 were fatal The majority of adverse reactions reported with warfarin were a result of over anticoagulation and bleeding, and the majority of fatal cases reported were associated with haemorrhage

28. Change Concepts • Q: What have you been involved in your Boards to reduce harm from anticoagulation? • Q: Can you think of any other tests of change?

29. Change Concepts • Protocol driven to reduce variation • Reversal protocols • Use algorithms • E&T checklists • Involve MDT • Limit strength of tablets dispensed

30. Questions