Medication Errors – what are the risks?

2. Medication Errors – what are the risks? Emma Walker & Tracey Tisley

3. Medication Errors – what are the risks? By the end of this workshop participants will be able to: • discuss the consequences of medication errors • develop a tool to help minimise medication errors in their area of work

4. Medication Errors – what are the risks? ‘They ‘occur on a daily basis in all healthcare settings and processes, from prescribing to dispensing and administering medicines.’ David Cousins - NHS England.

5. Medication Errors – what is the chance? • Medication incidents may occur at any stage of the patient's journey and can include the wrong medication, wrong dosage form, wrong route of administration and, indeed, the wrong patient.

6. Medication Errors – What is the data National Reporting and Learning System (NRLS) • The NRLS was established in 2003. The system enables patient safety incident reports to be submitted to a national database. This data is then analysed to identify hazards, risks and opportunities to improve the safety of patient care.

7. Medication Errors – What is the data • Since the NRLS was established, over four million incident reports have been submitted by healthcare staff. • In general practice an estimated 1.7 million serious prescribing errors occurred in 2010

8. Medication Errors – what is the cost? • Waste • £300 million per year is wasted on medication within primary care of which £150 million could be avoided • Hospital re-admissions • More than 6% of emergency re-admissions caused by avoidable adverse reactions to medications

9. Medication Errors – what is the damage? • Patient receives the wrong medication/dose • Patient looses faith in the service • Patient may stop or not take medication • Patient’s condition worsens • Patient’s dies

10. Medication Errors – what is the risk? • Workshop • Discuss and list the potential errors that can occur for your groups activity

11. Medication Errors – what is the risk? • Workshop • Read and discuss your groups scenario • Why did this error happen? • What would happen in your workplace? • E.g. Is any paperwork or incident report completed?

12. Medication Errors – what is the risk? • Workshop • How could these errors have been avoided? • What process/tool could be produced to avoid these or similar errors occurring?

13. Medication Errors – what is the answer? • Learn from errors • Share experiences • Use and adapt your tool • Education

14. Medication Errors – what resources are there? • The NRLS/NPA website provides practical information, tools and support to improve patient safety. • Further information can be found on their website http://www.nrls.npsa.nhs.uk/ • CPPE has an e-learning package ‘Improving medicines safety’ • This can be accessed from their website http://www.cppe.ac.uk/

15. Speaker Information Emma Walker emma.walker@chelwest.nhs.uk 020 7725 5613 Tracey Tisley tracey.tisley@chelwest.nhs.uk 020 7763 6584