Error theory Flashcards
DOH
DOH
An organisation with a memory
(2000)
Building a safer NHS for patients - implementing an organisation with a memory
(2001)
Building a safer NHS for patients IMPROVING MEDICATION SAFETY (2004)
what is the npsa known as and what does it stand for
known as NHS improvement
National Patient Safety Agency
“lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare organisations and individuals working in the health sector”
Why have the NHS IMPROVEMENT
Shroud of secrecy around health care failures
Estimated 900,000 incidents/year
NHS should learn from
Adverse events
Near misses
One organisation to
Receive reports
Analyse
Disseminate
Reporting & Learning System
RLS 2003
6 million reports
99% Local risk management
https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/
HCPs and Patients
How does it improve safety?
serious risks
10,000 incidents /yr
Initial screening
Prioritising
Topics for urgent action
RRRs
Other learning
Warfarin
Issued March 2007
Aim – Make anti-coagulation therapy safer
Looks at
Training, procedures & protocols
Audit
Written & verbal information
Safe practice & prescribing
Dental management
Supply & administration
Methotrexate
Issued 2004 – updated Jun 2006
Aim – to reduce the harm caused by oral Methotrexate
Why?
NPSA was aware of 137 incidents over 10years in England
25 deaths
26 cases of serious harm
Safe Dispensing Checklist
Ask to see the patient’s monitoring booklet and check if any dose changes have been made since the last prescription issue.
Assess the needs of the individual patient. For example, if the new packaging is not available, patients who have reduced manual dexterity should be given larger containers or ribbed easy-to-grip lids as this could reduce the likelihood of them decanting the tablets into another container at home (Disability Discrimination Act applies).
The strength of tablet supplied to the patient must stay consistent to prevent any confusion about the number of tablets they need to take, and the patient’s monitoring document and Patient Medication Record should be checked to confirm the previous supply.
Tell the patient their dose in terms of quantity of tablets and weekly frequency. Give the patient a monitoring booklet if they have not already got one.
Show the patient how to differentiate between the oral methotrexate and folic acid packaging. If they take both medicines at the same time, they will need to know how to distinguish between them, given that both may be round yellow tablets of similar size.
Be aware of patients who attend with symptoms such as breathlessness, dry persistent cough, vomiting or diarrhoea, as these can be signs of oral methotrexate toxicity or intolerance. You may need to refer them back to the prescriber. It is good practice to maintain a record of any over-the-counter items supplied to the patient.
Lithium
Dec 2009
567 reports
NHS litigation
Patient information booklet
Advice
Record of personal data
Record of results
Alert card
Pharmacy to check: is it safe to dispense SOPs
Care with interacting drugs + OTC
Insulin
RRR June 2010
2003 – 2009
3881 reports
1 death 1 harm abbreviation of units
3 deaths 17 others wrong syringe
Dispensing Environment
Workflow
Environment
Stock
Receipt
Storage
Waste
Where do names come from?
Brand & Generic names
Most products natural until ~1939-45
BAN system established 1948
WHO => INN system in 1951
Manufacturer proposes name => reviewed
Takes ~ 15 months to become rINN
1999 – EU law to label rINN
