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Medication Safety Landscape – What have we achieved and what’s next?

Medication Safety Landscape – What have we achieved and what’s next?. Dr David Cousins Senior Head Safe Medication Practice and Medical Devices. 2001. 2000. National Reporting & Learning System. Feedback. Standardised reporting. NRLS. International Collaboration. NHS Trusts.

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Medication Safety Landscape – What have we achieved and what’s next?

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  1. Medication Safety Landscape – What have we achieved and what’s next? Dr David Cousins Senior Head Safe Medication Practice and Medical Devices

  2. 2001 2000

  3. National Reporting & Learning System Feedback Standardised reporting NRLS International Collaboration NHS Trusts PractitionersStaff CQC MHRA NHS Complaints NHS Litigation Authority Research Patients Carers

  4. Total % HighRisk Air Safety Reports: Volume & Risk 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Year

  5. National Reporting and Learning System (NRLS) in England and Wales medication incident reports 2005 - 10 Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012

  6. NRLS – Types of incidents Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012

  7. NRLS – who is reporting incidents? Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012

  8. NRLS – Types of harm Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012

  9. NRLS – Ratio of serious harm / all

  10. NRLS – Stage of process Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012

  11. NRLS – Error category Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012

  12. NRLS – Critical medicines Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012

  13. DH – Never events – medication practice • Wrong prepared high risk injectable medicine • Maladministration of potassium containing solutions • Wrong route administration of oral/enteral products • Intravenous administration of epidural injections/infusions • Maladministration of insulin products • Overdose of midazolam during conscious sedation • Opioid overdose in opioid naive patents • Inappropriate administration of daily oral methotrexate • Wrong gas administered

  14. NHS Outcomes framework

  15. Domain 5 Patient Safety

  16. Known drug allergy • Reconciliation • Omitted doses • Anticoagulants • Opioids • Sedatives • Insulin

  17. Patient Safety Collaborative

  18. Safety is no accident!

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