Scottish Patient Safety Programme

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Scottish Patient Safety Programme Pharmacist
Engagement

• Gordon Thomson
• Arlene Coulson
• Shadi Botros

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Pharmacist Engagement

• Medicines management
• Peri-operative
• Critical care
• Paediatrics
• Mental health
• Primary Care
• Sepsis/VTE
• Older People in Acute Care(OPAC)

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Scottish Patient Safety Programme Medicines
Management Driver Diagram
Outcomes
Primary Drivers Processes, Rules of Conduct,
Structure
Secondary Drivers Components, Activities
Use standardised protocols and algorithms
for high risk meds  Routine and
reliable patient and laboratory
monitoring  Identify high risk areas using
FMEA  Pharmacy consultation service  Identify
patients at risk with high-alert
medications Standardise recovery protocols (e.g.
opiate over-sedation) Accuracy of
medicines at the interface One stop delivery
system  Reliable in-hospital handoffs  Communicati
on with primary care  High risk medicines
management services Patient and family
education  Self management protocols
Provide reliable medicines management processes
Safe effective medicines management (Reduce
adverse drug events r/t high risk processes
medicines e.g. medicines at the interface and
anticoagulation)
Coordination of care
Patient and family involvement
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JOINT COLLABORATIVE VENOUS THROMBOEMBOLISM
DRIVER DIAGRAM
AIM

PRIMARY DRIVERS

SECONDARY DRIVERS
Prevent VTE by ensuring a documented VTE risk
assessment is completed within 24 hours of
admission Include all elements of SIGN 122
prevention and management of venous
thromboembolism
Ensure reliable and documented appropriate
thromboprophylaxis Ensure timely prescribing and
administration of anticoagulant
therapy/mechanical intervention
Provide education and raise awareness of VTE and
improvement methodology. Ensure competent
practitioner completes risk assessment/prescribes
and administers pharmacological/mechanical
thromboprophylaxis
Provide a culture of safety and quality
improvement Ensure executive sponsorship Provide
clinical leadership Reliable collaboration of
multi-disciplinary team Develop measurement
framework to guide improvement
Ensure Patient and family centred care Provide
patient information on admission Involve
Patient/Family in risk assessment and treatment
process Promote open communication among team and
family Optimise transitions to home or other
facility
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Today in Acute Medicine Unit

• Antibiotic compliance 93
• VTE prophylaxis 90
• Medicines reconciliation on admission 72 -
  cause under investigation
• Based on random samples of 5 patients per week

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Key messages

• Pharmacists can play a key role in patient safety
• Do not rely on pharmacists alone to deliver
  improvements related to medicines
• Match tests of improvement to your existing
  resource
• Maximise use of ehealth systems
• How many pharmacists do you have?