Med Safety: Theory into Practice in Hospital Care

Question 1

Medicines Safety Team Role

Answer 1

 Learning from medicines-related incidents
 Implement medicines-related patient safety alerts
 Review safeguards in place to prevent medicines-related
never events
 Contribute safety expertise to work systems
 Fostering a safety culture
 Collaborative working is paramount

Question 2

How can we learn from medicines-related incidents?

Answer 2

• Daily triage of reported incidents
• Input to serious incident processes
• Review other sources for medicine-related issues
• Sharing and feedback
• Agree actions

Question 3

What is the role of a Medication Safety Officer (MSO)?

Answer 3

(1) Managing medication incident reporting
(2) National Medication Safety Network
(3) Member of the Medication Safety Committee

Question 4

What is a safety walkabout?

Answer 4

Asking staff for their concerns + feedback

What went well etc

Question 5

What are LASA?

Answer 5

Look-alike sound-alike errors

Question 6

read this

Example of med error

Answer 6

Administering high- strength insulin from a pen device in hospital
* Kathleen - 73 years old, type 2 diabetes.
* Prescribed usual insulin - Humulin R U-500 KwikPen.
* Given 48 units insulin using an insulin syringe rather than by her pen device.
* Five fold overdose at least twice.
* Prolonged hypoglycaemia,
successfully treated, later discharged home.

Question 7

more waffle

What shift in framework is currently taking place in pharmacy medication safety?

Answer 7

• Accountability to reflection + learning
• ‘real’ vs ‘ideal’
• Whole pt journey focus
• Learning from what goes eight
• Work arounds