Tag Archives: Medication Safety

Risk Management: developing a learning resource to support pharmacy teams across England

3 May

Risk man guide supported by NIHR GM PSTRC

Good risk management is well recognised as the cornerstone of safe practice in the workplace and risk assessment has long been part of legal requirements for health and safety in UK workplaces.

In 2017, the World Health Organisation highlighted the importance of medication error by choosing the issue of medication-related harm as the focus of its Global Challenge. In response to this, the Medication Safety theme of the Greater Manchester PSTRC worked with CPPE (The Centre for Pharmacy Postgraduate Education) to develop their learning resources on Risk Management.

This was an ideal opportunity for the PSTRC, allowing the team to apply their broad expertise in theoretical risk management concepts to the challenges of the pharmacy context but also enabling them to incorporate the expertise and insights from the PSTRC’s Community Pharmacy Patient Safety Collaborative – a group of current in-practice community pharmacists working in the Greater Manchester region (see blog post for more information).

This ensured that the guide would be both theoretically sound in terms of risk management but also enriched with examples that pharmacists saw as pertinent to their day to day work.

Through the co-development of this guide, it was recognised that this could be part of something with much greater impact and, as a result, CPPE dedicated their 2018 learning campaign to be focussed on the topic of Patient Safety, using the guide as a focal point to provide the theoretical background for the campaign.

The guide was distributed to over 67 500 pharmacy professionals as part of CPPE Patient Safety campaign. The PSTRC continued to support CPPE designing appropriate learning activities that would be delivered by CPPE – including face to face “focal point” sessions with over 100 events due to run nationally throughout England and online weekly activities in Feb/Mar 2018 – including an e-challenge quiz and encouraging involvement via Twitter, Instagram and Facebook. This resulted in over 1500 individuals signing up to the campaign activities over the six week period and continuing beyond this with pharmacists still adding their intentions to improve patient safety on CPPE’s ‘Pledge Wall’.

Matthew Shaw, interim director of CPPE, was delighted at the opportunity to collaborate with PSTRC recognising the huge value of building an evidence base into this core learning programme. He commented “It has been a great opportunity to work with PSTRC to link theory with practice and through this to support pharmacy professionals across the country to make their practice safer, and to reduce the risks to people using our services.”

Making prescribing safer with PINCER

16 Mar

Pharmacist

Recent news reports brought home the importance of reducing medication errors in healthcare. The news coverage highlighted that research, conducted by university academics in Manchester, Sheffield and York estimated 230,000 errors each year in the administering of medication in the NHS, contributing to 22,000 deaths. While the majority of these errors are spotted (and corrected) at the point of error, or do not threaten patient safety, a drastic reduction in the number of errors is now being called for. A change from the current culture of blame to a learning culture is one solution being discussed, but there are other, more practical interventions already in existence.

Once such intervention, called PINCER, is a pharmacist-led intervention developed at the Universities of Nottingham, Manchester and Edinburgh. PINCER has been shown to be an effective method for reducing a range of clinically important and commonly made medication errors in primary care.  Using a set of ‘prescribing safety indicators’ which identify common, but potentially harmful, medication prescribing errors, the intervention involves:

  •         Running searches on GP computer systems to identify patients at risk from common and important prescribing and drug monitoring errors
  •         Pharmacists – trained in the PINCER approach – working with individual general practices to develop an action plan to address the issues identified
  •         Pharmacists (and pharmacy technicians) working with and supporting general practice staff to implement the action plan.

With funding from the Health Foundation and East Midlands Academic Health Science Network, PINCER has been rolled out to 360 practices across the East Midlands since September 2015.  Over 2.9 million patient records have been searched, identifying over 21,000 instances of hazardous prescribing. Applying trends from data collected as part of the evaluation of the rollout, it is estimated that over 10,500 patients have received an active intervention resulting in safer care as a direct benefit of implementing the intervention.

The PINCER intervention has been incorporated into national guidelines to support medicines optimisation by NICE and a more detailed evaluation of the rollout in the East midlands is being done as part of a new NIHR funded programme grant called PRoTeCT to explore whether implementing PINCER reduces avoidable medication-related harm and hospital admissions.

Building on success: Medication Safety

1 Feb

 

Meds Safety

Plans for the Medication Safety theme will extend the work programme carried out by the 2012-2017 NIHR Greater Manchester PSTRC on improving medication safety surveillance and interventions to reduce adverse drug events and make prescribing safer. This focus aligns directly with the recent World Health Organization’s (WHO) Third Global Patient Challenge “Medication Without Harm”.

The theme focuses on developing safety management systems and exploring how the prescribing, dispensing and administration of medicines within, and between, healthcare organisations can be further improved and made safer. Medicines are the most commonly used clinical intervention in healthcare, and errors can lead to significant patient harm and hospitalisation. A number of new interventions will be developed and tested, working with the Safety Informatics theme, to address these major safety challenges.

Specific projects will include the following:

  • Examining the impact of electronic audit and feedback on prescribing safety of general practice trainees
  • Enhancing and evaluating the Medication Safety Surveillance system using electronic health records to develop a library of prescribing safety indicators that can be used across the NHS
  • Building on the success of the Patient Safety Toolkit for general practice, work will continue with the Greater Manchester Community Pharmacy Patient Safety Collaborative to develop and test a patient safety and improvement toolkit for community pharmacies
  • Evaluating the impact of an electronic Refer-to-Pharmacy scheme, examining the extent to which this could improve medication safety on discharge from hospital.

Keep up to date with the work of the Medication Safety theme on its dedicated webpage.

NAPCRG 45th annual meeting

1 Feb

NAPCRG17BannerScreen

Sally Giles, Penny Lewis, Sarah Rodgers and Patient and Public Involvement (PPI) representative Antony Chuter presented a workshop at the recent Annual Meeting of the North American Primary Care Research Group (NAPCRG) in Montreal. The objectives of the workshop were to provide an overview of examples of current research into medication safety in primary care, discuss the challenges to medication safety and some of the tools that can be used in practice to improve medication safety.

Sarah highlighted the work of the ‘PINCER’ prescribing intervention and workshop participants worked through clinical scenarios using the PINCER indicators. Antony discussed his role as a PPI member in various medication safety research projects. This stimulated discussion around patient involvement in healthcare research, as this is a relatively new concept in North America.

Penny and Sally discussed patient involvement in medication safety and the development of the Manchester Patient Safety Framework (MaPSaF) with workshop participants engaging in discussions about how they currently involve patients in the prevention of safety incidents. The workshop was well attended by a mixture of primary care physicians, pharmacists and healthcare researchers and the topic fitted well with the patient-centred care theme of the conference.

Sally also presented her work on the primary care patient measure of safety (PC_PMOS) in a well-attended oral session. Sally’s work stimulated interest in the audience with US researchers hoping to carry out similar work in this area.

Drug Utilisation Research Group (Euro DURG)

1 Feb

Euro DURG logo
Stephen Campbell attended the European Drug Utilisation Research Group (Euro DURG) Conference 2017, in Glasgow in November 2017 to present at a workshop on the “Quality of quality indicators”. Healthcare and medication use are changing and the field of drug utilisation research is evolving in a digital world.

Drug utilisation is an eclectic scientific discipline that includes many methods for the “quantification, understanding and evaluation of the processes of prescribing, dispensing and consumption of medicines and for the testing of interventions to enhance the quality of these processes”.  It has overlap with the PSTRC focus on medication safety, transitional care for those with multimorbidity and safety informatics but is linked also to the broader field of pharmacoepidemiology (the study of the uses and effects of drugs in defined populations) and health outcomes research and health economics.

The overall aim is to improve the safe and efficient use of medicines in populations to shape health policy and clinical practice.  The economic and health consequences of inappropriate drug use are substantial and patients are the end users of medicines. Those in marginalised groups can experience more inconsistent outcomes due to medication. The conference emphasised the need for a partnership between researchers, policy-makers and patients.

Community Pharmacy Patient Safety Collaborative: Safety Initiatives

14 Jun

Chui Cheung photo

My name is Chui Cheung, working as a community pharmacist in Wigan, Lancashire.  I joined the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative Study with the University of Manchester in November 2015.  Looking back, it was curiosity that led to my participation and I was worried how I would handle the research projects.  Nevertheless, the title of patient safety attracted me to find out more.

Patient safety is at the centre of our everyday tasks whether we are pharmacists, technicians, dispensers, medicine counter assistants or other members of the team. Whatever we do in the course of our work, we must do it safely.

At the start of the first year project, there were 8 to 10 pharmacists with a range of different working backgrounds and age groups.  We attended a full day session every 4 to 6 weeks at the University.  We were relieved to discuss openly and share our experience on patient safety.  The aim was to build a safety case using our working environment and team resources.  My project centred on dispensing safety: ‘Are we dispensing safely?’ and later on was refined to a quantitative safety incident claim.

We were introduced to specific tools: Hierarchial Task Analysis (HTA), Failure Mode and Effect Analysis (FMEA), System Human Error Reduction & Production Approach (SHERPA) to help our analysis of the safety profile. Our team broke down the complex dispensing tasks into smaller working steps or processes systematically. On a practical application, the Proactive Risk Monitoring (PRIMO) questionnaire was helpful to use as a team to identify various patient safety risk factors.  We then made risk assessments of the dispensing processes through the SHERPA and used Plan, Do, Study, Act (PDSA) cycles to evaluate improvement.

The whole team began to monitor and record near misses and dispensing incidents on a more conscious level than before and made voluntary changes towards an open, no-blame working culture. The goal of safer dispensing became a number one priority all the times.  The team’s brainstorming revealed many common triggers or events of ‘the vulnerable moment’ during the dispensing processes.  Several checking procedures were used as checker reminders.

The pooled data of errors showed high times of errors, typical error categories and even the common medicines.  Individually, we were able to find out when and how we perform best and made aware of the pitfalls.  We discovered that we were prone to errors particularly when we were ‘expected’ to have ultra-quick dispensing.  Through a member’s suggestion and our dispenser’s effort, we now display a shop poster giving a summary of ‘the way we prepare your medicines’ and give customers opportunities to read through the additional copies whenever there is a queue forming.  It works really well and the feedback is positive too.  The team and customers seem happier.

In year 2 of the project, we came across analytical tools (Faulty Tree Analysis, Bowtie diagram) to look at our safety claim.  We continued to expand our safety interests and used a more sophisticated reporting form called  ‘Incident Investigation Form’ which covers error description, the factors causing the error, the risk category, course of the event and improvement plans.   We have since modified the form for in-house use.  The bundle of safety data showed how we had been dispensing safely or otherwise.  As a result, we implemented a couple of measures (such as safety shelf reminders, Top 20 common error medicines list) to help us improve on a regular basis.  The data is also useful in staff appraisal.

Moreover, we felt fortunate to have the ready-made patient safety data for Quality Payment application.  My experience in the patient safety collaborative has been overwhelmingly good and positive.  I wouldn’t have known about these analytical methods and thought about the improvement plans if I hadn’t been part of the study group.

I recommend that any pharmacy team who is interested should come along for a taster session to see if this is right for you.

James Hind, member of the Community Pharmacy Patient Safety Collaborative, scoops Clinical Excellence Award at Superdrug’s annual Awards Ceremony

23 Feb

by Penny Lewis, Medication Safety theme

james-hind-superdrug-awards_cropped

James Hind, pharmacist and member of the Greater Manchester Community Pharmacy Patient Safety Collaborative, scooped the Clinical Excellence Award at Superdrug’s Annual Awards ceremony in Heathrow last week. The ceremony which aims to celebrate employees’ successes and achievements also marked 25 years of Superdrug Pharmacy. Other awards included Nurse of Year, Operational Excellence Award and Pharmacist of the Year (for which James was also nominated). James was awarded this honour after being recognised for his outstanding contribution to patient safety as part of his work with the Community Pharmacy Patient Safety Collaborative.

James, who has undergone training in risk assessment techniques and incident analysis as part of the collaborative, has shared his learning across the company via their online ‘Hub’. One of James’ innovations has been the design and production of bag labels to prompt both staff and patients to check their medications or ask any questions before leaving the pharmacy. James has conducted a survey to explore patients’ views of the label which has shown that the label is well received by patients and can, in some cases, prompt patients to take a more proactive approach to checking. James hopes to evaluate the impact of the label on patient safety incidents over the next few months.

James’s passion for improving patient safety engendered by his work with the collaborative has inspired James to work more closely with Superdrug’s Safety Office and also suggest improvements to their incident reporting system. James also noted that error reporting has increased threefold as a result of his participation in the collaborative and that his team are now far more reflective of their practice when things go wrong.

Well done James!

Read James Hind’s blog post on his involvement with the Community Pharmacy Patient Safety Collaborative here