Patient safety and root cause analysis

What is patient safety

Patient safety is the avoidance of unintended or unexpected harm during the provision of healthcare

In context of pharmacy, provision of healthcare includes

• prescribing

• procurement of medicines

• storage of medicines - temperature, atmospheric humidity, cleanliness

• preparing and dispensing

• supply/sale of GSL, P and POM medicines

• administering medicines

• monitoring

• providing advice on health and/or use of medicines

• signposting and referral

• patient care, understanding each patient’s circumstances

Case study

Child prescription for propranolol

Propranolol is a beta blocker which slows your heart rate. It is used to help treat a number of conditions but in the following scenario it is to help control the symptoms of heart arrhythmias.

Prescription - Propranolol 5mg/5ml SF oral solution 12.5 (12.5mg) tds Quant - 1200ml

Theo’s weight is 25 kg

Medicine will be available in the morning

Used syringe from hospital to meausre out

Two days later he is admitted to hospital

Pharmacist didn’t check that with the patient properly if she could use the syringe.

Hospital had given 50mg/5ml, and the mum was supposed to give 1.25ml for this. But for what was given by the community it was meant to be 12.5ml.

Seven steps to patient safety

• develop and maintain a safety culture - pharmacist will need to make quick and efficient decisions. Create a culture that is open, fair and supportive which prioritises patient safety through everything you do. However, remember humans will always mistakes

• lead and support staff - effective training programmes, learning from mistakes

• integrate risk management procedures - develop systems and processes to manage your risk and identify and assess things that could go wrong.

• promote reporting - Reporting systems are essential to identify areas for improvement or additional strengthening. Create a culture that is open, fair and supportive which prioritises patient safety through everything you do

• involve and communicate with patients - duty of candour. Pharmacy professionals must speak up when they have concerns or when things could go wrong.

• learn and share safety lessons - share and learn from patient safety incidents.

• implement solutions to prevent harm - embed changes to practice, processes or systems to help prevent recurrence of an incident.

NHS patient strategy describes how NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems.

Errors in pharmacy practice

1. patient safety incidents

   Any unintended or unexpected incident, which could have or did lead to harm for one or more patients receiving healthcare is defined as a patient safety incident.

   In pharmacy the most probable patient safety incident originate in

   • the prescribing, preparing, storage, dispensing, administering, monitoring or sale/supply of medicines

   • the provision of advice on health and/or use of medicines

   • delays or omission in the supply of medicines to the patient

2. Near misses

3. - near miss is an error which is detected before the patient is handed the dispensed medication/item and in doing so, a patient safety incident is prevented.

The most frequent types of errors in pharmacy

• wrong dose/strength (30.5%)

• wrong meds (28%)

• wrong formulation (12%)

• wrong quantity (9%)

Majority of errors in this report don’t result in harm, less than 1 % resulted in severe harm or death

Case study 1

Patient wanted to pick up regular medicines. Had Crohn’s and takes prednisolone

However dispensing error was spotted - gliclazide was given instead.

As a result suffered a severe hyperglycaemic episode and collapsed into coma - she died one month later.

Degree of harm from patient safety incidents

Why do errors occur

System errors

• SOP

• Patient group directions

• technology.

• workload management

• environment

Human factors

• poor communication, low competency

• distraction or inattention

• forgetfulness

• non-compliance, carelessness, negligence

• limits/nature of human brain and behaviour

  • e.g. selective attention, skim reading and attempts to multi task

What are the outcomes of these errors in the dispensing process

• selection errors, including LASA (look like, sound alike) drug errors; incorrect medication

• bagging errors: someone else’s medication

• labelling errors (including transposing labels between medicines); wrong instructions on the medication

• dispensing of date expired medicines; potential safety issues', including underdosing and loss of control of the therapeutic effect

• incomplete or incorrect counselling for the patient

What are the outcomes in the clinical checking process, as part of prescribing or dispensing and supply

• incorrect drug for the condition

• incorrect dose/strength/dose frequency for the condition/patient; incorrect calculation

• incorrect formulation for the patient

• oversight of patient’s comorbidities, allergies, dietary intolerance, beliefs

• oversight of the patient’s social and environmental circumstances

• interactions

LASA ERRORS

Amlodipine 10mg, amitriptyline 10mg

Atenolol 100mg, allopurinol 100mg

Quinine 300mg, quetiapine 300mg

Azathioprine 25mg, azithromycin

Hydralazine, hydroxyzine

Reducing risk of LASA

• staff awareness, training and behaviour change problems

• tall-man lettering

• physical separation

• visual warnings (shelf stickers, dispensing tray warning cards)

• automation/scanning dispensing processes

• warning details on the PMR

Errors with high-risk medication

Lithium

Clozapine

methotrexate

anticoagulants

opioids

insulin

sulfonylureas

sodium valproate - pregnancy prevention programme.

Error in dose can lead to toxicity, or ineffective therapeutic action

Safeguarding against errors

Swiss cheese model

Community pharmacy patient safety group incident investigation model

The reports from all investigators and their outcomes are then shared, not only with the pharmacy team and organisation but also nationally within the NHS, via a regular upload of information to the NHS ‘Learn from patient safty events’

Possible barriers to error reporting

• knowledge

• time

• fear

A just culture

A just culture within the organisation is one which focuses on learning from incidents and improving practice to prevent their recurrence. It applies to all incidents and near misses.

A just culture

• the factors which contributed to an error are identified, and then where applicable

• pharmacy team members are supported to carry out specific activities

• which leads to a change in which they work

  So that they avoid repeating the error in the future

Benefits and drawbacks from root cause analysis

Benefits

• minimises the risk of errors and patient harm in the future

• improves the patient care/safety

• enables review and reflection of processes and performance in the dispensary

• enables the implementation of change in order to improve processes

Drawbacks

• time consuming - needs to be used when appropriate e.g. as part of investigation into complicated errors, serious errors or a type of error which has not occurred before

• staff may be fearful - root cause identification risks creating a blame culture

• teams may fall into the trap of only addressing root cause and not other contributing factors.

Clinical governance

• is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish

Seven pillars

• clinical effectiveness

• information

• risk management

• education and training

• audit

• patient and public involvement

• staff management

Clinical effectiveness

Every action you take provides the best outcomes for each patient

• adopting an evidence based approach to your practice

• implementing national standards e.g. NICE guidelines to ensure optimal care

• update your practise based on your experience and evidence

• carry out research to enhance your level of care for patients in the future

Information

information and IT is sued to ensure than

• patient data is accurate and up to date

• confidentiality of patient data is respected

• data is appropriately used to measure quality of outcomes (e.g. via audits) and to develop services for local needs

Risk management

Having systems in place to understand, monitor and minimise risks to patients and staff, and learning from mistakes

• an effective and honest reporting culture

• learning from errors and near misses; anticipating risks in new procedures

• assessing risks for their probabilty of occurence and impact, and implementing procedures to reduce risks

Education and training

Providing support to enable staff to be competent, confident and up to date with their skills and knowledge.

• supporting continuous learning so that staff can offer up to date information and skills

• regular assessment

• appraisal to identify and discuss weaknesses and provide opportunities for personal development

Audit

Audits are used to monitor practice and ensure that any deficiencies or weaknesses in the standards of care are rectified.

Patient and public involvement

Ensuring that the services provided suit patients and that patient feedback is used to improve practice in terms of quality, suitability and outcomes

• patient feedback forums

• patient forums

• patient advice and liaison services

Staff management

Ensuring that staff offer a quality service by

• recruiting appropriate staff who are suitable to carry out the work

• managing the staff electively and providing adequate staffing levels

• identifying and addressing underperformance

• motivating, involving and developing staff to encourage retention providing good working conditions