Update: NHS England Post Medication Safety Officer Alert

1. Update: NHS England Post Medication Safety Officer Alert Ahmed Ameer Medication Safety Officer Ahmed.Ameer@NHS.net Safer Medication Practice & Medical Devices Team 6th November 2014

2. Agenda • MSO National Alert • Alert Vision • Medication Incident Reporting & Quality • Feedback • MSO web events

3. Improving Medication Safety % = Sign up representation Data up to Sept 2014

4. MSO Responsibilities • Active membership of the NHS Medication Safety Improvement Collaborative • Manage medication incident reporting in the organisation. Review all medication incident reports to ensure data quality for local and national learning. Where necessary investigate and seek additional information from reporters. Authorise the release of medication error reports to the NRLS each week. • Receive and respond to requests for more information concerning medication error incident reports from the patient safety team in NHS England and the MHRA. • Support the dissemination of medication safety communications from NHS England and the MHRA throughout the organisation.

5. Vision NRLS Reports Yellow Cards 2-way relationship between MSO and Healthcare Professionals to implement actions. Supported by the local Medication Safety Committee Patient Safety Alerts Drug Safety Updates / Recalls

6. Risk Management • Weekly review of NRLS severe and death medication incidents • Lookout for trends of risky practice • Collect intelligence from NRLS mini-scopes and MSOs insights / RCAs • Share thoughts with MSO Network • Develop actions for change

7. PSIs reported to the NRLS for Sept 2014

8. PSIs reported to the NRLS for Sept 2014

9. Quality of Reporting

10. Feedback • One to one discussion about local incidents whenever possible • Patient Safety First online portal for MSOs to share experience, ask for help/advice and communicate emerging risk. • Monthly web events to discuss medication error reporting, data quality, risk management and new policies. • Yearly national conferences / workshops

11. Web Events: Structure • Medication Safety Network Agenda • Chair • Incident Review - NHS England • Observatory - UKMI • Clinical / Practice Topic 1 – Outside speakers • Clinical / Practice Topic 2 – Outside Speakers • MSO Showcase – Network Members • Chairman closing remarks

12. Web Events: Feedback

13. Our Aspiration • Improve quality of reports • Showcase local learning • MSOs take charge of the Network • Bottom-up approach of risk management

14. Conclusion • Database of MSOs is continually growing • Uptake of alert is welcomed by key players across pharmacy and other healthcare bodies • Network is up and running since April 2014 • Great opportunity for pharmacists to be involved and proactive in ensuring medication is utilised safely • Finally, it’s a learning curve for everybody to ensure patients are receiving harm free care

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