1. Medicines in the Community Project Manager
Medicines Errors
Tamsin Rudolph
Medicines in the Community Project Manager
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2. People and their Medicines
Only 1 in 4 people take their medicines as directed.
The rest never fill their prescription or never pick up their prescription from the pharmacy.
Others may pick up their prescription but may skip a dose or stop taking their medicines altogether.
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3. Medicines Errors
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4. Setting the scene
A medicines error is any patient safety incident, where there has been an error while:
Prescribing, preparing, dispensing, administering, monitoring
or providing advice on medicines
It can be either:
an error of commission (wrong medicine or wrong dose)
an error of omission (omitted dose or failure to monitor)
Medicines errors are not the same as adverse drug reactions.
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5. https://yellowcard.mhra.gov.uk/yellowcards/reportmediator/
Adverse Drug Reaction
Suspected Adverse drug reactions should always be reported, we would ask you to report to the persons GP, the GP should then record the suspected drug reaction (ADR).
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6. Medicines Policy
You should have a policy which includes a process for recording all medicines. This includes related safety incidents, all ‘near misses’ and incidents that do not cause any harm. The policy should cover:
whether to notify CQC
which medicines related safeguarding incidents to report under local safeguarding processes
how to report the incident to the person, their family or carers
how to handle referrals to regulators and other agencies, such as NMC
‘Maintain an open "no blame" policy. Encourage staff to report medicines errors without delay.’
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7. The 7 Rights (Rs)
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8. When an error occurs Ensure that the organisations policy is followed.
Support your staff.
Undertake a root cause analysis.
Review the root cause.
Ensure that any actions are completed.
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9. Root Cause Analysis Using the 5 Whys
The person was administered the wrong medicine. Why?
The transcribing of the MAR Chart was wrong. Why?
The person transcribing was also covering calls into the agency. Why?
The administration team numbers in the office were low on Tuesday. Why?
The administration team rota has changed. Why?
The root cause is that a change in the rota caused an administration team member to be distracted by taking a phone call whilst transcribing a prescription ultimately causing the transcribing error that lead to the care staff member administering the wrong drug.
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10. Time Sensitive Medicines
Time sensitive medicines are those that need to be given or taken at a specific time. A delay in receiving the dose or omission of the dose may lead to serious patient harm.
Common examples include, insulin injections, medicines for Parkinson’s disease, medicines that contain paracetamol, medicines that need to be given before or after food.
Care workers should be able to prioritise visits to meet the needs of people who need support for time-sensitive medicines. (This should be detailed in your medicines policy).
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11. Every day approximately 2
Every day approximately 2.5 million medicines are prescribed to patients in hospital or the community and while most medicines are used in a safe and effective way, errors are one of the most common causes of patient harm, accounting for 20% to 30% of reportable incidents in NHS organisations.
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12. Break Out Session
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13. Project Update
Working to support the social care workforce to have a more integrated pathway with health for supporting people with their medicines.
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14. Focused Areas of Work
MAR Charts, inconsistent practice across Kent. Variance in sheets that can lead to medication errors. Standard MAR Chart criteria has been created and work has been completed with the community pharmacy network. Pilot of a MAR Chart from Maidstone Hospital at point of discharge due to start. Currently working on an LGA Digital Accelerator to digitise MAR Charts for home care providers collaborating with 4 other authorities.
Definition of medicines administration. Lack of national clarity, no set guidance. The booklet ‘Social Care Medicines Administration’ guidance for Home Care Providers and Care Workers.
Inconsistent practice in the use of dosette boxes across Kent. A clear East and West Kent divide. Scoping current services and working to pilot medicines review services that domiciliary care staff can refer into.
Pathway is flagging up commissioning issues- joint working Health and Social Care commissioning services together. Working to improve joint commissioning of services.
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15. Developing the future
Now it’s your chance to get involved to help shape the future…….
Electronic Medicines Administration Record (eMAR) questionnaire
Medicines Administration Training for Domiciliary Care
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16. Moving Forward Thank you
All your feedback will be taken away and worked upon to push this agenda forward.
Please contact us if you would like to be involved more within the project.
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