Medication safety landscape what have we achieved and what s next
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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. 2001. 2000. National Reporting & Learning System. Feedback. Standardised reporting. NRLS. International Collaboration. NHS Trusts.

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Medication Safety Landscape – What have we achieved and what’s next?

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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


2001

2000


National Reporting & Learning System

Feedback

Standardised reporting

NRLS

International

Collaboration

NHS Trusts

PractitionersStaff

CQC

MHRA

NHS Complaints

NHS Litigation Authority

Research

Patients

Carers


Total % HighRisk

Air Safety Reports: Volume & Risk

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%

Year


National Reporting and Learning System (NRLS) in England and Wales medication incident reports 2005 - 10

Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012


NRLS – Types of incidents

Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012


NRLS – who is reporting incidents?

Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012


NRLS – Types of harm

Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012


NRLS – Ratio of serious harm / all


NRLS – Stage of process

Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012


NRLS – Error category

Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012


NRLS – Critical medicines

Cousins D, Gerrett D, Warner B. Br J ClinPharmacol. 2012


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


NHS Outcomes framework


Domain 5 Patient Safety


  • Known drug allergy

  • Reconciliation

  • Omitted doses

  • Anticoagulants

  • Opioids

  • Sedatives

  • Insulin


Patient Safety Collaborative


Safety is no accident!


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