Critical Care Services Pharmacist Royal Manchester Children’s Hospital Afia Manaf Critical Care Services Pharmacist Royal Manchester Children’s Hospital

Learning Objectives Recognise who MiST are and their relevance to UK paediatric hospitals Background to the formation of MiST Understand NCC MERP Medication Error Index and its application in clinical practice Discuss current and future risk reduction strategies to minimise medication errors

MiST - Background MiST – Making it Safer Together A new paediatric patient safety collaborative – new alliance of hospitals Share a vision of achieving harm free paediatric care through a process of sustained year on year reduction in adverse events.

MiST - Background MiST collaborative was born following a meeting of senior clinicians and managers in late 2013 Came together to discuss how a UK model of the USA project could be established Open forum for the sharing of ideas & methodology for enhancing patient safety

MiST - Background Each participating centre is asked to collect data in the following areas for pilot work in the UK: Adverse Drug Events Readmissions Central Line Associated Blood Stream Infections

MiST - Background Results are used to promote discussion and enable identification of centres who perform strongly & those who have made major improvements in performance. These centres are encouraged to share their care bundles, guidelines etc. for other organisations to learn from.

MiST - Background The results are NOT used for benchmarking and there is no place in the collaboration for competition Simply for sharing ideas and improving practice The goal for each organisation is a year on year improvement The current membership is largely drawn from tertiary children’s centres

MiST - Adverse Drug Events NCCMERP – National Coordinating Council for Medication Error Reporting and Prevention is an independent body composed of 27 national organisations Formed in the United States in 1995 National healthcare organisations meet, collaborate & cooperate to address the interdisciplinary causes of errors and to promote the safe use of medicines

MiST - Adverse Drug Events NCCMERP Vision and Mission Vision No patient will be harmed by a medication error Mission Maximise the safe use of medicines and to increase awareness of medication errors through open communication, increased reporting and promotion of medication error prevention strategies

MiST - Adverse Drug Events NCCMERP Goals & Objectives Promote the development and use of reporting and evaluating systems by individual health care organisations Promote reporting to a national system for review, analysis and development of recommendations Examine and evaluate the cause of errors

MiST - Adverse Drug Events NCCMERP Goals & Objectives Increase awareness and methods of prevention throughout the health care system Recommend strategies for system modifications, practice standards and guidelines, changes in packaging and labelling

MiST - Adverse Drug Events NCCMERP Goals and Objectives Promote reporting, discussion and communication about safe medicines use, error prone processes & error prevention strategies Disseminate NCCMERP’s recommendations Collaborate with other interested stakeholders to address special topics

NCCMERP Types of Medication Errors The council recognised the need for a standardised method of categorising medication errors in order to meet their goals and objectives The council defines a medication error as:

Medication error definition “A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures and systems including prescribing, ordering, labelling, packaging, compounding, dispensing, distribution, administration, education, monitoring and use”

NCCMERP Types of Medication Errors The council encourages medication error researchers, software developers and institutions to use this standard definition The NCC MERP adopted a medication error index in 1996 which classifies errors according to the severity of the outcome

NCC MERP Index for categorising errors Category A - No Error Error, No Harm Category B – Error did not reach the patient Category C – Reached patient but did not cause harm Category D – Reached patient and required monitoring to confirm that it resulted in no harm

NCC MERP Index for categorising errors Error, Harm Category E – error may have resulted in temporary harm & required intervention Category F – error may resulted in temporary harm and initial or prolonged hospitalisation Category G – error resulted in permanent patient harm Category H – error required intervention to sustain life

NCC MERP Index for categorising errors Error, Death Category I - error contributed or resulted in patient’s death “A good performing institution will probably have a high incidence of errors in category A-D, fewer in E-H and no category I errors”

Advantages of NCC MERP Index Various systems available for reporting medication errors e.g. Safeguarding, Datix CMFT uses Safeguarding

Advantages of NCC MERP Index vs. Safeguarding Safeguarding reporting system not specific to medication errors Doesn’t capture information in detail Doesn’t capture extent of interventions Doesn’t indicate if error has been identified pre or post administration Doesn’t capture outcome details

Advantages of NCC MERP Index MERP index will allow standardisation across collaborating hospitals Promotes sharing of ideas Promotes improved medication practice and implementation of safe strategies Create a culture for learning, feedback and support Provides greater detail and quality of information

NCC MERP Index Useful to UK paediatric Hospitals? Operates on a larger scale in the US Publish alerts nationally No real benefit unless other centres are collaborating

Future Goals for MiST MiST will grow and develop nationally More paediatric hospitals will participate! Hospitals will upload care bundles and guidelines onto website Share ideas to enhance patient safety