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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


2001 what’s next?

2000


National Reporting & Learning System what’s next?

Feedback

Standardised reporting

NRLS

International

Collaboration

NHS Trusts

PractitionersStaff

CQC

MHRA

NHS Complaints

NHS Litigation Authority

Research

Patients

Carers


Air safety reports volume risk

Total what’s next? % 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
NRLS – Types of incidents Wales

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


Nrls who is reporting incidents
NRLS – who is reporting incidents? Wales

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


Nrls types of harm
NRLS – Types of harm Wales

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



Nrls stage of process
NRLS – Stage of process Wales

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


Nrls error category
NRLS – Error category Wales

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


Nrls critical medicines
NRLS – Critical medicines Wales

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


Dh never events medication practice
DH – Never events – medication practice Wales

  • 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




  • Known drug allergy Wales

  • Reconciliation

  • Omitted doses

  • Anticoagulants

  • Opioids

  • Sedatives

  • Insulin




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