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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

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

Dr David Cousins

Senior Head

Safe Medication Practice and Medical Devices

slide3

National Reporting & Learning System

Feedback

Standardised reporting

NRLS

International

Collaboration

NHS Trusts

PractitionersStaff

CQC

MHRA

NHS Complaints

NHS Litigation Authority

Research

Patients

Carers

slide12
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
NRLS – Types of incidents

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

nrls who is reporting incidents
NRLS – who is reporting incidents?

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

nrls types of harm
NRLS – Types of harm

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

nrls stage of process
NRLS – Stage of process

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

nrls error category
NRLS – Error category

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

nrls critical medicines
NRLS – Critical medicines

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

dh never events medication practice
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
slide23

Known drug allergy

  • Reconciliation
  • Omitted doses
  • Anticoagulants
  • Opioids
  • Sedatives
  • Insulin
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