Quality improvement programmes for managing medicines risk

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Chapter: Hospital pharmacy : Risks with medicines

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:


Patient Safety First campaign


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.


Never events


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.


NHS Litigation Authority risk management standards


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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