Medication safety thermometer 2016 Quality accounts meeting

• The New Zealand context

• The background

• What is involved

• The UK experience

Medication safety thermometer

Adverse drug events (ADEs) in New Zealand

Up to $158m is the estimated annual

cost of preventable ADEs in New Zealand.

Frequency of ADEs

13% with two medicines

58% with five medicines

82% with seven or more

NZ medication incidents Do they match what is on the safety thermometer?

• Anticoagulants

• Opioids

• Insulin

• Sedatives

• Allergy

• Omissions

UK development

• National Patient Safety Agency and National Reporting and Learning system established 2003

• Identified frequent events that caused harm and near-miss events

• Published bulletins, alerts, rapid response alerts etc

• The system changes required were not always actioned in health care settings

Safety thermometer introduced and the NPSA

• were keen to change their approach because of the low response to alerts

• identified the principles and the information the safety thermometer provided at ward / service level on what was happening locally

• started work with the Haelo team on developing a medication safety thermometer

Safety thermometer

• A measurement tool for improvement

• Engages frontline teams on the issues of medication error and harm

• Data provides a baseline, directs improvement efforts and measures improvement over time.

Medication safety thermometer

Measuring: • Allergy documentation • Medicine reconciliation on admission • Omitted doses • Anticoagulants error/harm • Opioids error/harm • Sedatives error/harm • Insulin error/ harm

Medication safety thermometer

UK choice of medicines

Medicine/therapeutic group % incidents fatal or severe harm outcome

Anticoagulants 11.2

Opioids 10.83

Antibiotics 5.84

Insulin 5.6

Benzodiazepines 3.28

NSAIDs 2.19

UK medication incidents category of error

Category of error Incidents % of medication incidents Omitted and delayed medicine 82, 028 15.58 Wrong dose or strength 80, 170 15.23 Wrong medicine 48, 834 9.28 Wrong frequency 44, 165 8.39 Wrong quantity 28, 764 5.46 Mismatch patient and medicine 21, 915 4.16 Wrong/transposed/omitted medicine label 13, 755 2.61

Medications Safety Thermometer trial

Initial observations

• Busy audit tool – needs NZ-ising!

• Requires MDT input

• Concept familiar to us as links strongly to Trigger tool methodology

• Well worth a considered trial

The UK experience

• Non- judgemental

• Identifies how many patients are not harmed by these incidents in a hospital or organisation

• Organisations can track improvement over time (rather than for comparison)

• Teams understanding and use of the tool varies

• Local leaders are important

• Local definitions based on national guidance can give ownership locally

The UK ideal / experience

Medication safety thermometer