Protecting patients- now and in the future

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Protecting patients-now and in the future

• Linda Matthew
• Senior Pharmacist
• National Patient Safety Agency

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The changing face of chemotherapy

• IV Oral (now)
• Secondary care Primary care
  (the future)

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Increasing risk

• Modern health care is complex
• Increased volume of work
• Older and sicker patients
• Complex, new drugs, interventions technology
• Cost constraints efficiency
• Workforce pressures
• Changing expectations
• Changing shape of service delivery

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Public confidence

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Managing the risks in current serviceconfiguratio
ns

• Information is key
• Proactive risk management
• Reactive risk management

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BOPA position statement (2004)

• Standards Manual of Cancer Standards (or equiv)
• Patient remain under care of a specialist
• Policy procedures- IV and oral
• Risk assess the hazards of oral medications
• Prescribing dispensing standards -same for
  IV/oral
• Education of patients
• Effective communication across care interfaces
• Prescribing and dispensing should be
  responsibility of hospital team

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Oral chemotherapy-patient safety incident data

• What does data on incidents reported to the
  National Reporting Learning System (NRLS) tell
  us?

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National Reporting Learning System (NRLS)
Feedback
International Collaboration Australia USA Europe
NPSA
Standardised reporting
NHS Trusts
PractitionersStaff
Healthcare Commission MHRA NHS Complaints NHS
Litigation Authority
Patients Carers
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Medication report March 07
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Medication Report March 2007

• 7 Key areas for action
• Increase reporting learning from medication
  incidents
• Implement the safer medication practice
  recommendations
• Improve staff skills competence

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Medication Report March 2007

• 7 key areas for action
• Minimise dosing errors
• Ensure medicines are not omitted
• Ensure the correct medicines are given to the
  correct patient
• Document patients medicine allergy status

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NRLS- All incident types v medicationJan 06 to
March 07
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NRLS Medication Incidents reported by care
sector
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NRLS data Nov 03 July 07

• Search terms
• Oral, chemotherapy
• 26 individually named drugs
• 3 years of data from gt 600 organisations
• (gt250 acute sector organisations)

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Degree of harm caused
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Stage in the process
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Medication Error Types
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Top 6 drugs reported
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Key notes
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Recommendations

• Proactive management of risks
• review local systems (BOPA position statement
  2004)
• Reactive management of risks
• Increase reporting of patient safety incidents
• Review reports to identify local risk trends
• Analyse incidents to identify system weaknesses
• Take action to improve systems

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The changing face of chemotherapy

• 
  Diagnose
• Secondary care
• Monitor
  Prescribe
• Administer IV
  Dispense

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The changing face of chemotherapy

• Secondary care
  Diagnose
• Primary care Monitor
  Prescribe
• Self administer
  Dispense

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Managing the risks of the future service
configurations

• Information is key
• Define/map out the system
• Proactively assess the risks
• Use incident and other data/info to inform the
  process

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Example NPSA alert no 18 anticoagulant therapy
services

• Process
• Search for related safety data
• Map anticoagulant therapy services in the NHS
• Assess the risks in each part of the treatment
  process (using SWIFT)
• Identify solutions to reduce the risks

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Alert 18 Risk assessment

• Related safety data
• NHSLA data published claims and reports
• NPSA NRLS data
• Published audits reports
• Case reports

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Alert 18 Risk assessment- findings

• Inadequate training work competences
• Inadequate clinical audit and failure to act on
  results
• Poor documentation
• Prescribing issues (errors, interacting
  medications)

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Alert 18 Risk assessment- findings contd.

• Poor communication across the interface
• Insufficient support for patients staff
• Insufficient monitoring
• Inadequate safety checks at repeat prescribing

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Alert 18 safer practice solutions

• Ensure competency of staff
• Ensure policies procedures in place
• Audit services
• Provide verbal and written information for
  patients at commencement and thro treatment
• Prescribers and pharmacists to supply repeat
  prescriptions using safe systems of practice
  only when safe to do so
• Implement safety precautions when co-prescribing
  interacting drugs
• Standardise the range of products available to
  avoid error

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Generic risks

• Lack of knowledge and expertise
• Poor communication between sectors
• Poor monitoring
• Poor patient information and education
• Inadequate documentation
• Lack of standardisation

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The challenges

• Loss of control or a sharing of responsibility?
• Increasing complexity
• - longer care pathway
• more stakeholders
• Different cultures (and politics)
• Longer chains of communication
• Different ways of working - re-designing the
  system

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The challenges - contd.

• Policy changes to meet future system needs
  (Community pharmacy services)
• Resource transfers
• Providing information for patients
• On-going monitoring
• Inadequate/unreliable systems

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Potential solutions

• Technology
• Specialised design of e-prescription
• E-transfer of prescriptions
• Sharing of patient e-record (hospital, GP,
  pharmacy)
• On-line availability of protocol information

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Potential solutions

• Skills and competence
• Secondary sector expertise in primary care
• Consultant Oncology Pharmacists
• Pharmacist led monitoring clinics
• Enhanced role for specialist pharmacy technicians

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Summary

• The future presents both risk and opportunity
• Information is key
• Incident reporting
• Learning from incidents reactive
• Learning from others proactive
• Windows of opportunity for role enhancement

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• Thank you