Tag Archives: #pharmacy

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.”

PhD Fellow Focus: Ahmed Ashour

3 May

Ahmed Ashour_cropped

Ahmed Ashour is the latest PhD student to join the NIHR Greater Manchester Patient Safety Translational Research Centre at The University of Manchester. Ahmed began his PhD in January 2018, having graduated with a distinction MPharm degree in the summer of 2017. He has worked in community pharmacy since 2014 in a variety of roles including as a dispenser, pre-registration pharmacist and ultimately a community pharmacist. Ahmed’s main passion derives from personal development and he has taken an active interest in ways of developing communication skills, especially in young people.

Ahmed’s research will revolve around identifying the skills that are essential to patient safety in community pharmacy. These skills are complementary to the technical knowledge acquired by pharmacists at university and while on their pre-registration placement. Since the 1970s, other sectors have extensively researched the impact non-technical skills have on outcomes, with many areas in healthcare now using specific classifications to identify these skills, in addition to the elements and behaviours attributed to safe practice.

Ahmed aims to present these skills to be able to ensure pharmacists in the future are well equipped with the skills that are necessary for the central role they now play in the health of communities all around the country. Ahmed will aim to identify these skills by first looking at the role community pharmacists currently play within the healthcare team, and then extracting the skills that are required to complete the tasks involved within this role.

How was it for you? Reflections on involvement

3 May

People speech bubble_cropped

This edition’s reflection comes from Lauren Worrall, a pharmacist who is involved in the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative.

Lauren, why did you become involved in the Greater Manchester Community Pharmacy Patient Safety Collaborative?

My motivation to join the collaborative was to receive training on different skills and techniques to improve patient safety within my own practice area.  Furthermore I wanted to explore the world of research within pharmacy.

How do you think the Greater Manchester PSTRC benefitted from your involvement – what difference do you feel that you made?

As a group we devise potential ways to improve practice and develop various interventions.  As an individual I can then go out and test the efficacy of the interventions in pharmacy practice settings. My experience in community pharmacy allows me to positively contribute to the work of the collaborative.

Personally and professionally, how do you feel you benefitted from your involvement?

Getting involved with the group has allowed me to work with other pharmacists and safety experts to reflect upon and improve my own practice. It has also afforded me a better knowledge of what is involved in research.

Would you recommend becoming involved in research to other healthcare professionals? If so, why?

Participating in research allows you to be creative and explore innovative methods in whichever healthcare setting you are working in. If you are interested in improving your practice and that of others then I would highly recommend getting involved.

Pharmacists working towards safety improvements

3 May

CP Patient Safety Collaborative image

The Greater Manchester PSTRC’s Community Pharmacy Patient Safety Collaborative was set up by the PSTRC to encourage a mutually-beneficial dialogue between community pharmacy workers and researchers, and ultimately to improve patient safety.

The PSTRC’s Medication Safety team shares their knowledge on best practice in patient safety and risk management techniques with the Collaborative and in turn, the Collaborative shares their experiences and insights of practical day-to-day pharmacy practice with the PSTRC.

The group of 9 pharmacists are employed in a range of pharmacies from small independents to large chains, and they meet on a monthly basis. Sessions involve teaching of safety concepts and risk management techniques, sharing of experiences and discussions on the issues currently impacting on the safety of work in pharmacies. Outside of the sessions, the Collaborative engages in research-based activities – such as audits, or applying the taught risk management techniques to their own practice – with a view to sharing their insights within the group.

Pharmacists have seen real-world benefit through their involvement in the Collaborative:

  • James Hind, Community Pharmacist, says:  “I developed the idea of label that could be attached to the dispensing bag. I wanted something that could be used as a quick check (have we got the right patient; did we tell them what their medication was for, and are they confident that they know how to use it).”
  • Tomasz Niebudek, Community Pharmacist, says: “The tool that, in my opinion, had the biggest impact on my practice was PRIMO (Proactive Risk Monitoring for Organisational Learning). This was a questionnaire given to all staff members in my team to find out what affects their ability to dispense accurately. I have very carefully analysed all the data from those questionnaires and shared my conclusions with my whole team during a staff meeting. We have straight away implemented changes to our practice.”

You can read more about the Community Pharmacy Patient Safety Collaborative in our blog series.

Past PhD Fellows: Where are they now? Christian Jones

1 Feb

In this new series, we catch up with past Greater Manchester PSTRC PhD Fellows to see what they are doing now and how their PhD projects affected patient safety. Our first past PhD Fellow is Christian Jones.

Christian Jones photo_cropped

What did you learn during your PhD project?

My PhD project focused on how and why community pharmacy staff deviate from or bypass procedures. Although the idea of not following the rules might sound sinister, my project highlighted that staff use their professional judgement daily to tailor care to patient’s individual needs.

My PhD project also taught me many personal skills. I learnt about the importance of being passionate about your work and the importance of being determined, focused and tenacious in order to reach a goal. I’m so grateful for the PhD experience and for the support that I received from my supervisors and colleagues – definitely some of the best years of my life so far!

How has your PhD changed the patient safety landscape?  

My PhD has illuminated how procedures are viewed and followed in practice by both pharmacists and pharmacy support staff. As well as exploring the types of violations that occur in this setting and why, I was also the first to explore the impact of motivation, opportunity and capability on the frequency of violations in this setting.

What you are doing now and where you see yourself going in your future career?

I now work as a senior project manager for the community pharmacy commissioning team at NHS England. So far, it has been fascinating to understand how policies are created and implemented on a national scale. I am also an honorary lecturer at the University of Manchester, which means a great deal as I adore teaching and I am passionate about patient safety research.

For the future, I would love to continue building a career in community pharmacy policy and research alongside my own blog on mindfulness.

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.

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.