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Medication Safety Landscape – What have we achieved and what’s next? Dr David Cousins Senior Head Safe Medication Practice and Medical Devices.

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Presentation on theme: "Medication Safety Landscape – What have we achieved and what’s next? Dr David Cousins Senior Head Safe Medication Practice and Medical Devices."— Presentation transcript:

1 Medication Safety Landscape – What have we achieved and what’s next? Dr David Cousins Senior Head Safe Medication Practice and Medical Devices

2 2001 2000

3 National Reporting & Learning System NHS Trusts Practitioners Staff Patients Carers NRLS CQC MHRA NHS Complaints NHS Litigation Authority Research Feedback International Collaboration Standardised reporting

4 Air Safety Reports: Volume & Risk 0.0% 0.5% 1.0% 1.5% Year 2.0% 2.5% 3.0% Total % High Risk

5

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12 National Reporting and Learning System (NRLS) in England and Wales medication incident reports 2005 - 10 Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

13 NRLS – Types of incidents Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

14 NRLS – who is reporting incidents? Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

15 NRLS – Types of harm Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

16 NRLS – Ratio of serious harm / all

17 NRLS – Stage of process Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

18 NRLS – Error category Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

19 NRLS – Critical medicines Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

20 DH – Never events – medication practice Wrong prepared high risk injectable medicine Maladministration of potassium containing solutions Wrong route administration of oral/enteral products Intravenous administration of epidural injections/infusions Maladministration of insulin products Overdose of midazolam during conscious sedation Opioid overdose in opioid naive patents Inappropriate administration of daily oral methotrexate Wrong gas administered

21 NHS Outcomes framework

22 Domain 5 Patient Safety

23 Known drug allergy Reconciliation Omitted doses Anticoagulants Opioids Sedatives Insulin

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25 Patient Safety Collaborative

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27 Safety is no accident!

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