How the new network of NHS Medication Safety Officers and Medical - - PowerPoint PPT Presentation

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How the new network of NHS Medication Safety Officers and Medical - - PowerPoint PPT Presentation

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How the new network of NHS Medication Safety Officers and Medical Device Safety Officers are affecting patient safety 9 th December 2015 April 2015 Dr David Gerrett Senior Pharmacist Patient Safety NHS E Agenda 1. Scene setting 2. MSO and

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How the new network of NHS Medication Safety Officers and Medical Device Safety Officers are affecting patient safety

April 2015

9th December 2015 Dr David Gerrett Senior Pharmacist Patient Safety NHS E

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  • 1. Scene setting
  • 2. MSO and MDSO responsibilities
  • 3. Making it safer in the NHS
  • 4. How are MSO and MDSO affecting patient safety?

Slide 2 NHS E | Presentation for NHSLA 9th December 2015

Agenda

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SLIDE 3
  • 1. Scene setting

Agenda

Slide 3 NHS E | Presentation for NHSLA 9th December 2015

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SLIDE 4

Slide 4 NHS E | Presentation for NHSLA 9th December 2015

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Directive 2001 - 2010/84/EU

Pharmacovigilance Under paragraph 5 For the sake of clarity, the definition of the term ‘adverse reaction’ should be amended to ensure that it covers noxious and unintended effects resulting not

  • nly from the authorised use of a medicinal product at

normal doses, but also from medication errors and uses outside the terms of the marketing authorisation, including the misuse and abuse of the medicinal product.

Slide 5 NHS E | Presentation for NHSLA 9th December 2015

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ADE’s ADR’s and Medication Errors

Medication errors

Potential ADE’s ADE’s THE FOCUS Preventable (ADEs, ADRs and AEs) NHS E Non preventable (ADR, MHRA) Intercepted NHS E

Bates DW, Boyle DL, Vander Vliet MB, Schneida J, leape L. Relationship between medication errors and adverse drug

  • events. J. Gen. Intern. Med, 1995;10:199-205.

No harm Low harm Things we don’t know NHS E

Slide 6 NHS E | Presentation for NHSLA 9th December 2015

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ADE’s ADR’s and Medication Errors

Medication errors

Potential ADE’s ADE’s THE FOCUS Preventable (ADEs, ADRs and AEs) NHS E add MHRA Non preventable (ADR, MHRA) Intercepted NHS E

Bates DW, Boyle DL, Vander Vliet MB, Schneida J, leape L. Relationship between medication errors and adverse drug

  • events. J. Gen. Intern. Med, 1995;10:199-205.

No harm Low harm Things we don’t know NHS E

Slide 7 NHS E | Presentation for NHSLA 9th December 2015

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Unsafe acts Unintended actions Intended actions Mistakes Violations

Basic error types

Skill based errors Attentional failures Skill based errors Memory failures Rule & Knowledge Based errors Routine Reasoned Reckless & Malicious

Slips Lapses

PSIs

Slide 8 NHS E | Presentation for NHSLA 9th December 2015

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Consciously competent Learn Unconsciously competent Practice Lapse Unconsciously incompetent Consciously incompetent Assess

and learn PSDA

Competence The implications: we are all capable of error and things change

  • NPC. MeReC bulletin.2011;22(no1)

http://www.npc.nhs.uk/merec/mastery/mast3/resources/merec_bulletin_vol22_no1.pdf

Slide 9 NHS E | Presentation for NHSLA 9th December 2015

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50000 100000 150000 200000 250000 300000 350000 400000 450000 500000

Oct - Dec 2003 Apr - Jun 2004 Oct - Dec 2004 Apr - Jun 2005 Oct - Dec 2005 Apr - Jun 2006 Oct - Dec 2006 Apr - Jun 2007 Oct - Dec 2007 Apr - Jun 2008 Oct - Dec 2008 Apr - Jun 2009 Oct - Dec 2009 Apr - Jun 2010 Oct - Dec 2010 Apr - Jun 2011 Oct - Dec 2011 Apr - Jun 2012 Oct - Dec 2012 Apr - Jun 2013 Oct - Dec 2013 Apr - Jun 2014 Oct - Dec 2014 Incidents Submitted

Patient safety Incidents reported from Oct 2003 - Dec 2014

Slide 10 NHS E | Presentation for NHSLA 9th December 2015

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The National Reporting and Learning System

Slide 11 NHS E | Presentation for NHSLA 9th December 2015

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12 42398 64484 79280 94280 113837 132069 144609 152460 164907 190619 50000 100000 150000 200000 250000 2004 2006 2008 2010 2012 2014 2016

Reported to NRLS 2005-2014

reported

MSO/MDSO

In 2014 the absolute number of medication reports to the NRLS increased more than in any previous year, representing a 15.6% increase on the year before.

Slide 12 NHS E | Presentation for NHSLA 9th December 2015

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  • Stage One Alert: Warning
  • Warns organisations of emerging risk. It can be issued very quickly
  • nce a new risk has been identified to allow rapid dissemination of

information

  • Stage Two Alert: Resource
  • Provision of resources, tools and learning materials to help mitigate

risk identified in stage one

  • Stage Three Alert: Directive
  • Organisations are required to confirm they have implemented

specific actions or solutions to mitigate the risk

New style Patient Safety Alerts (PSAs)

Slide 13 NHS E | Presentation for NHSLA 9th December 2015

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Medication Safety Officer

Slide 14 NHS E | Presentation for NHSLA 9th December 2015

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Medical Device Safety Officer

Slide 15 NHS E | Presentation for NHSLA 9th December 2015

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Supporting documents

Slide 16 NHS E | Presentation for NHSLA 9th December 2015

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Which organisations?

Slide 17 MSO 5th November 2015

As of 2nd November 2015 Guests: + 60

Row Labels Count of Name CCG 75 Community Interest Company 8 Community pharmacy sector 21 Cosmetic Surgery 1 Independent 1 Mental Health 1 NHS Acute Large 41 NHS Acute Medium 46 NHS Acute Small 25 NHS Acute Specialist 18 NHS Acute Teaching 30 NHS Ambulance Trust 9 NHS Community Trusts 16 NHS England Area Team 14 NHS Mental Health Trust 51 Other Independent Sector 20 Social Care Enterprise 1 Grand Total 378

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Healthcare Professionals and Patients Identify and REPORT Medicines Safety Officer (MSO) Quality Assurance Medication Incident Submit reports to NRLS through

  • rganisation's system or online e-form

MHRA & NHS England Analysis Request additional information Report to MHRA via Yellow Card Scheme

www.mhra.gov.uk/yellowcar d

Analysis & regulatory action Medication errors Risk /Complaint Managers Oversight & Quality Assurance Adverse drug reactions (ADRs) but not Medication errors Local Medication Safety Committee Oversight and Support

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Slide 18 NHS E | Presentation for NHSLA 9th December 2015

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Healthcare Professionals Implementation Medicines Safety Officer Ensures implementation MHRA Analysis MHRA’s Yellow Card Scheme

www.mhra.gov.uk/yellow card

Analysis & regulatory action National Medication Safety Network National learning & safety communications NHS England Analysis

Feedback and action to minimise risk

two way interaction and dissemination of safety communications MHRA safety communications:

  • Drug Safety Update

(monthly)

  • Safety Warnings (as

required)

  • Alerts (as required)
  • Recalls (as required)

NHS England safety communications:

  • Formally by three stage

Alerts,

  • Organisational Patient

Safety Incident to NHS

  • rganisations by NRLS

reports (6 monthly)

  • Publication in

professional journals feedback and interaction loop Local Medication Safety Committee Oversight and support education, training and support support

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Slide 19 NHS E | Presentation for NHSLA 9th December 2015

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  • 2. MSO and MDSO responsibilities

Agenda

Slide 20 NHS E | Presentation for NHSLA 9th December 2015

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Beware the detail

Slide 21 NHS E | Presentation for NHSLA 9th December 2015

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Agenda

MSO responsibilities

Slide 22 NHS E | Presentation for NHSLA 9th December 2015

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MSO responsibilities

Slide 23 NHS E | Presentation for NHSLA 9th December 2015

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MDSO responsibilities

Slide 24 NHS E | Presentation for NHSLA 9th December 2015

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What is in store for the MSO MDSO?

MDSO responsibilities

Slide 25 NHS E | Presentation for NHSLA 9th December 2015

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  • 3. Making it safer in the NHS

Agenda

Slide 26 NHS E | Presentation for NHSLA 9th December 2015

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National Patient Safety Agency

10 years of Medication 2002-2012 Devices 2010-2012 Medication

  • 45 Alerts, Rapid Response Reports
  • Signals
  • 6 design guides
  • Medication Safety updates

Slide 27 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 28 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 29 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 30 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 31 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 32 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 33 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 34 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 35 NHS E | Presentation for NHSLA 9th December 2015

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New style Patient Safety Alerts (PSAs)

Slide 36 NHS E | Presentation for NHSLA 9th December 2015

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  • 4. How are MSO and MDSO affecting patient safety?

Agenda

Slide 37 NHS E | Presentation for NHSLA 9th December 2015

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Essential focus

  • 1. Local learning from PSIs
  • 2. Taking National messages and implementing [Alerts] locally
  • 3. Frequency and quality of reporting
  • 4. Identifying and disseminating best practice
  • 5. Conduit between NHS England/MHRA and practice

MSOs/MDSOs local and national focus

Slide 38 NHS E | Presentation for NHSLA 9th December 2015

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Hello David, I hope that this email finds you well. Please find attached the following items of info from Derby Hospitals, as requested via the MSO network & following on from your email prompt to us this week: 1) Paracetamol dosing info 2) Critical medicines list - please note that we are currently updating ours to also include Desmopressin following on from a recent incident. I hope that this information is useful to you and your team. Look forward to seeing you guys at the MSO conference in Birmingham next week. Kind regards, Jazz.

Slide 39 NHS E | Presentation for NHSLA 9th December 2015

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Lead to a topic presentation on a MSO event Other hospitals saying it was an issue A NRLS scope Presentation to MSOs by a consultant directly involved in fatal incidents Dissemination of previous information (sureMED)

Slide 40 NHS E | Presentation for NHSLA 9th December 2015

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Slide 41 NHS E | Presentation for NHSLA 9th December 2015

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  • 1. Scene setting
  • 2. MSO and MDSO responsibilities
  • 3. Making it safer in the NHS
  • 4. How are MSO and MDSO affecting patient safety?

Slide 42 NHS E | Presentation for NHSLA 9th December 2015

Agenda

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  • 1. …..are formally recognised healthcare practitioners

working for the improvement of patient safety across the landscape of healthcare

  • 2. ……are a conduit between front-line practice and NHS

England

  • 3. …..have a role to improve the quality and frequency of

medication and/or device incident reporting and to promote local learning from such adverse incidents

  • 4. How are they affecting patient safety….they are

improving it every day, in their own way!

Slide 43 NHS E | Presentation for NHSLA 9th December 2015

Key messages MSOs and MDSOs