News and Updates for todays Medication Errors in Hospitals National Conference 2019
Medication without Harm Update: The WHO Global Initiative aiming to reduce the level of severe, avoidable harm related to medications by 50% over the next five years
Prof Philip Routeledge CBE, Clinical Director, All Wales Therapeutics and Toxicology Centre
Phil Routledge graduated in Medicine from the University of Newcastle upon Tyne and trained in general internal medicine and clinical pharmacology/toxicology in the UK and USA before being appointed Senior lecturer in Clinical Pharmacology in Cardiff University School of Medicine and honorary consultant physician/clinical pharmacologist/toxicologist at University Hospital Llandough (UHL) in 1981. He is now Professor Emeritus of Clinical Pharmacology in Cardiff University.
He is also Clinical Director of the All Wales Therapeutics and Toxicology Centre at UHL. This NHS organisation advises Welsh Government, particularly in relation to the timely introduction of new medicines and concerning policies for safe, effective and cost-effective use of medicines in Wales. He is also presently involved with the World Health Organisation in the international roll-out of the third global patient safety challenge “Medication without Harm”.
Speaking at the conference this morning, Philip said:
"Medication errors contribute 9% of the world’s total avoidable cost due to suboptimal
Total errors- 237.4 million
Types of errors- not giving the medication
Prescribing= 50.7 million/21.3%
1. Mis prescribing
2. Over prescribing
3. Under prescribing
320 hospitals beds are filled by patients admitted of adverse drug reactions’
Goal of the challenge- reduce the level of severe , avoidable harm related to medications by 50% over 5%, globally’
Social movement and culture change for the challenge to be achieved
When errors occur culture needs to change"
Full PowerPoint Presentation
Reducing Medication Errors in Practice: Setting the benchmark at zero Delivering a Medication Error Reduction Programme
Surinder Ahuja, Medication Safety Officer & Formulary and Governance Pharmacist, Rotherham NHS Foundation Trust
Surinder is the Trust Medication Safety Officer, Formulary Pharmacist and Governance lead for Pharmacy. These roles have provided Surinder many opportunities to develop key pharmacy services. These include implementing NPSA/NHSI alerts, developing the local formulary, developing policies on safe prescribing of antimicrobials and monitoring their use, implementation of NICE guidance on reducing harm from venous thromboembolism and associated CQUINs, audits, investigating and learning from incidents and near misses, giving feedback on incidents to pharmacy staff and to junior doctors, undertaking self-assessment against CQC key lines of enquiry. Currently, Surinder is working on implementing Carter recommendations in accordance with the Hospital Pharmacy Transformation Programme.
"A good culture of reporting medication incidents is needed"
"Reducing dose omissions- quality priority: aims- reduce omissions, blanks to zero"
High risk areas for Medication Error: Medication Errors and Diabetes - Reducing insulin prescribing error
Theresa Smyth, Nurse Consultant in Diabetes, University Hospitals Birmingham NHS Foundation Trust
Pre Event Abstract
Insulin is a lifesaving medication; however, it is also one of the top five high-risk medications. Due to numerous serious incidents and deaths there have been several insulin safety alerts regarding insulin.
In 2017 there was a National Inpatient Diabetes Audit (NaDIA) which found that over 260,000 people with diabetes experienced a medication error and 58,000 an episode of serious hypoglycaemia. In addition, one in 25 people with type 1 diabetes experienced hospital-acquired diabetic ketoacidosis (DKA) which is an avoidable but life-threatening condition. It is imperative that hospitals take steps to reduce insulin medication errors in order to avoid serious harm or death. This presentation will outline the problem and discuss strategies to reduce risk and improve insulin safety based on national and local initiatives.
Theresa speaking this afternoon said:
"Safety alerts- NHS Improvement 2016
Dangers of drawing insulin out of a pen
Prescriptions- confusing and unclear- How much insulin?- resulting in medication errors
National Diabetes inpatient audit (NaDIA) 2017
28% hospital sites had not diabetes inpatient nurses
Just 9% of hospitals sides provide 7 day service
58,000 cases of severe hypoglycaemia reported in 2017
6% of infusions were appropriate
Diabetes back to the floor
Initiatives have successfully improved diabetes care"
Full PowerPoint Presentation
Also of Interest
Non Medical Prescribing in Cancer Care
A Practical Guide to Effective Non-Medical Prescribing in Mental Health
1 April 2019