Reducing Risk in Medicines Management

1. Reducing Risk in Medicines Management Key Slides from www.npci.org.uk

2. Risk Management • Risk management is assessment, analysis and management of risks • It is simply recognising which events may lead to harm in the future and minimising their likelihood and consequence

3. Medicines and Risk • Every day, approximately 2.5 million medicines are prescribed to patients (Safety in Doses: Improving the use of medicines in the UK,NPSA, 2007) • Most systems and processes applied to medicines use are safe and effective, but sometimes errors happen that can lead to harm • By identifying areas of particular risk, NHS organisations and healthcare professionals can take action to significantly improve the safety of medicines-related processes

4. Five Steps to Easy Risk Assessment Five steps to risk assessment (idgn163). Health and Safety Executive (2006) www.hse.gov.uk/pubns/indg163.pdf

5. Seven Steps of Risk Management • Build a safety culture • Lead and support your staff • Integrate your risk management activity • Promote reporting • Involve & communicate with patients & the public • Learn and share safety lessons • Implement solutions to prevent harm Source: Seven step guide to patient safety. An overview guide for NHS staff. NPSA, 2004

6. Measuring Success • There is no single way to measure medicines management safety • Paradoxically, an increase in reporting of incidents may be a sign that you have implemented an open and fair culture where staff learn from things that go wrong

7. Why report • “Modern healthcare is a complex, at times high risk, activity where adverse events are inevitable but it is not unique - there are many parallels with other sectors (e.g. aviation)” DH (2001) Building a safer NHS for patients: implementing an organisation with a memory Department of Health London • Incident reporting has proved to be a successful error prevention tool in high risk industries for decades Giles, Sally et al.(2006) Incident reporting overview: capturing and analysing error. www.saferhealthcare.org.uk

8. NPSA • In 2004 the NPSA introduced a formal National Reporting and Learning System (NRLS) across the NHS • All NHS staff in England & Wales can now report incidents • Information is stored anonymously

9. Barriers that need to be overcome • Lack of awareness • Lack of understanding • Staff too busy • Too much paperwork • Urgency goes out of the situation • Fear • Assumption someone else will make the report • No evidence of timely feedback • No evidence of action being taken

10. Tools and Techniques • Significant Events Analysis – a way of looking at events that stand out from daily practice • Root Cause Analysis – a more structured approach to investigating incidents

11. In Summary • Many adverse events or near misses are caused by common problems • We can only learn from these events if we share the experience with our colleagues • By communicating and learning from adverse events and near misses in medicines management we can reduce risk of them happening again