A number of quality improvement programmes which include medicines risk have developed within the NHS:
Quality improvement programmes for managing medicines risk
A number of quality improvement programmes which include medicines risk have developed within the NHS:
The vision of the
Patient Safety First campaign is ‘no avoidable death and no avoidable harm’.
The campaign, which, at the time of writing, is sponsored by the NPSA, the NHS
Institute for Innovation and Improvement and the Health Foundation, focuses on
five interventions, one of which is reducing harm from high-risk medicines:
anticoagulants, opiates, injectable sedatives and insulin. Organisations
signing up to Patient Safety First are expected to develop and implement
improvement programmes specifically designed to reduce the risk of harm from
these high-risk medicines by making changes at organisational, clinical area
and patient level. The campaign provides participants with tools to support the
design of improvement programmes. Suggestions are made for monitoring the
outcomes of strategies implemented and organisations are invited to share their
successes with other participants. It is not clear how this programme will
continue following the 2010 arm’s-length body review.
In 2009 the NHS
published a list of never events (http://www.nrls.npsa.nhs. uk). Never events
are serious, largely preventable patient safety incidents that should not occur
if the available preventive measures have been implemented. At the time of
writing, the core list of never events includes two that relate to medicines
use:
·
wrong route administration of chemotherapy
·
intravenous administration of misselected concentrated potassium
chloride
Both of these
aspects of medicines use have been covered by national guidance to minimise the
risk of error and incidents can be used as a marker of the quality and
effectiveness of risk management systems that have been implemented within
organisations. Trusts are obliged to record and report information on these
incidents to commissioners, and from 2010–2011 national service contracts will
include a financial penalty against organisa-tions involved in a never event.
If an organisation is involved in a never event, commissioners will be entitled
to recover the cost of the patient’s procedure and any care subsequent to the
event, introducing a financial incentive to ensure risks, including risks with
medicines, are managed. Primary care trusts are also required to monitor the
occurrence of never events within the services they commission and publicly
report them on an annual basis. It is likely that the never event list relating
to medicines will be extended.
The NHS Litigation
Authority sets a risk management programme to reduce the number of negligent or
preventable incidents. NHS organisations are regularly assessed against a
series of standards that have been developed to reflect the types of issues
that arise in claims to the NHS Litigation Authority. Trusts are given
incentives to achieve compliance with the standards set in the form of
reductions in the financial contributions they make to the schemes Clinical
Negligence Scheme for Trusts and Risk Pooling Scheme for Trusts. Standards for
hospitals are defined in the NHS Litigation Authority risk management standards
for acute trusts, primary care trusts and independent sector providers of NHS
care. Standards that specifically relate to medicines management are included
and require organisations to have an approved documented process for managing
the risks associated with medicines in all care environments that are
implemented and monitored. Pharmacists make a significant contribution to the
development of policies for the safe use of medicines and play a role in
auditing and monitoring the impact of such policies. They therefore play a key
role in supporting organisations to achieve the standards of high-quality
organisations.
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