1. Scottish Patient Safety Programme – Pharmacist Engagement Gordon Thomson Arlene Coulson Shadi Botros

2. Pharmacist Engagement Medicines management Peri-operative Critical care Paediatrics Mental health Primary Care Sepsis/VTE Older People in Acute Care(OPAC)

3. OutcomesPrimary Drivers Processes, Rules of Conduct, Structure Secondary Drivers Components, Activities Safe & effective medicines management (Reduce adverse drug events: r/t high risk processes & medicines e.g. medicines at the interface and anticoagulation) Provide reliable medicines management processes Coordination of care Patient and family involvement Use standardised protocols and algorithms for high risk meds Routine and reliable patient and laboratory monitoring Identify high risk areas using FMEA Pharmacy consultation service Identify patients at risk with high-alert medications Standardise recovery protocols (e.g. opiate over-sedation) Accuracy of medicines at the interface “One stop” delivery system Reliable in-hospital handoffs Communication with primary care High risk medicines management services Patient and family education Self management protocols Scottish Patient Safety Programme Medicines Management Driver Diagram

4. Prevent VTE by ensuring a documented VTE risk assessment is completed within 24 hours of admission Include all elements of SIGN 122 – prevention and management of venous thromboembolism Ensure reliable and documented appropriate thromboprophylaxis Ensure timely prescribing and administration of anticoagulant therapy/mechanical intervention Ensure Patient and family centred care Provide patient information on admission Involve Patient/Family in risk assessment and treatment process Promote open communication among team and family Optimise transitions to home or other facility Provide education and raise awareness of VTE and improvement methodology. Ensure competent practitioner completes risk assessment/prescribes and administers pharmacological/mechanical thromboprophylaxis Provide a culture of safety and quality improvement Ensure executive sponsorship Provide clinical leadership Reliable collaboration of multi-disciplinary team Develop measurement framework to guide improvement Reliable Risk Assessment Reliable Care Delivery Patient & Family Centered care Education & Awareness Culture of Safety & Quality Improvement Improve delivery of evidence based care in prevention of Venous Thromboembolism (VTE) OUTCOME: Reliable risk assessment and appropriate thromboprophylaxis administration 95% of adult admissions in pilot ward by December 2012 95% of all adult hospital admissions by December 2014 JOINT COLLABORATIVE – VENOUS THROMBOEMBOLISM DRIVER DIAGRAM AIMPRIMARY DRIVERSSECONDARY DRIVERS

6. Today in Acute Medicine Unit Antibiotic compliance – 93% VTE prophylaxis – 90% Medicines reconciliation on admission – 72% - cause under investigation * Based on random samples of 5 patients per week

7. Key messages Pharmacists can play a key role in patient safety Do not rely on pharmacists alone to deliver improvements related to medicines Match tests of improvement to your existing resource Maximise use of ehealth systems How many pharmacists do you have?