Patient safety

Transcript

Pharmacy technicians and pharmacists working in hospitals, GP surgeries and in community practice, ensure that medicines ordered on prescriptions, or bought over the counter, are correctly and safely supplied. They consult with patients and provide information on use and potential side effects of medicines. Patient safety is a fundamental concern for all pharmacy professionals and the wider healthcare team.

All healthcare providers, including community pharmacy organisations, must identify a named Medication Safety Officer who is responsible for supporting local medication error reporting within their organisation.

On this page you will find resources to help you to manage risk in your pharmacy. You will also find information on safeguarding issues that you might come across in your practice. There is guidance around medicines errors and adverse drug reactions and links to further reading. All these resources will support you to provide a safe environment for people you offer pharmaceutical care to.

The aim of this programme is to provide you with background knowledge relating to patient safety and risk management, and to give you the opportunity to apply this to practice. It is also intended to help you effectively respond to, and manage, patient safety incidents.

Learning Objectives:

• patient safety concepts and the terminology relating to them
• systems and practice which can impact on patient safety
• how root cause analysis can be used when responding to patient safety incidents
• how to apply learning from patient safety incidents to future practice
• the best way to approach discussions about safety incidents with patients and colleagues.

This guide supports pharmacy professionals who want to learn more about how they can manage the risks that are inherent in their practice. It signposts you to the most appropriate places for your learning and to other key resources.

If you are using the interactive PDF version of this programme, please ensure you download and save a copy of it to your computer before attempting to make and save any changes. If you try and make changes in your browser, there is a strong likelihood of losing your work.

Learning Objectives:

• understand the risks associated with your professional practice
• prioritise the risks in your workplace
• identify the steps that you can take to reduce risk associated with your practice.

The aim of this programme is to develop the pharmacy team’s knowledge on what is meant by a just culture and the differences between a no-blame culture and just culture. The programme aims to introduce the NHS Improvement A just culture guide and apply it to a pharmacy setting.

Learning Objectives:

• explain what is meant by a just culture
• describe the differences between a no-blame culture and just culture
• use the NHS Improvement A just culture guide when a patient safety incident occurs.

In this e-learning we will introduce a toolkit which you can use to make changes in your practice to improve patient safety. This programme will help you to identify which tools may be useful for you and your team. It also provides real-world examples of people using them in practice and working through the learning will allow you to make the most of these resources.

The programme contains practical case studies, reflective exercises and a suggested action plan to ensure that your practice is as safe as possible and any negative incidents can be properly reported and actioned.

Learning Objectives:

• describe what is meant by a safety culture
• discuss the importance of reporting and analysing patient safety incidents
• identify opportunities where you can involve patients in patient safety improvements
• explain how to use the patient safety tools outlined in this programme
• select the most appropriate tool to use when you are presented with an opportunity to improve patient safety in practice
• identify the steps that you can take to improve the safety culture in your workplace.

This e-learning programme will help improve your knowledge about adverse drug reaction prevalence and the characteristics of different types of adverse drug reactions. You will be able to discuss examples of adverse drug reactions and the stages of drug marketing.

This programme is Part 1 of a three part series that will help you develop your patient safety role by increasing your understanding of adverse drug reactions (ADRs), their identification, reporting and prevention.

A range of case studies is available in Adverse drug reactions Part 3. The case studies appear as a 'video wall' providing patient scenarios in both hospital and community practice.

Please note: this e-learning programme has been developed and provided by the Welsh Centre for Pharmacy Professional Education (WCPPE). Users should recognise that this programme may refer to Welsh policies and organisations. CPPE does not maintain control over the accuracy and currency of this programme.

Learning Objectives:

• define and classify adverse drug reaction
• discuss the prevalence of adverse drug reactions in a variety of clinical practice settings
• assess the characteristics of each type of adverse drug reaction
• describe examples of adverse drug reactions
• appraise the stages of drug evaluation pre- and post-marketing.

This e-learning programme has been designed to develop your confidence in reporting adverse drug reactions.

This programme is Part 2 of a three-part series that will help you develop your patient safety role by increasing your understanding of adverse drug reactions (ADRs), their identification, reporting and prevention.

A range of case studies is available in Adverse drug reactions Part 3. The case studies appear as a 'video wall', providing patient scenarios in both hospital and community practice.

Please note: this e-learning programme has been developed and provided by the Welsh Centre for Pharmacy Professional Education (WCPPE). Users should recognise that this programme may refer to Welsh policies and organisations. CPPE does not maintain control over the accuracy and currency of this programme.

Learning Objectives:

• explain the importance of adverse drug reaction reporting
• summarise the process that led to the introduction of medicines regulation in the UK
• explain how the Yellow Card Scheme works
• differentiate between serious and non-serious ADRs and identify when completion of a Yellow Card is recommended by the MHRA
• complete a Yellow Card
• understand the pathway of a Yellow Card following submission to the MHRA
• list the potential safety actions that the MHRA can take following an ADR report.

This e-learning programme focuses on which patients may be at risk of adverse drug reactions and encourages you to develop strategies for communicating those risk factors to patients. You will be able to extend your knowledge about patient Yellow Card reporting and the role patients play in improving patient safety.

This programme is Part 3 of a three-part series that will help you develop your patient safety role by increasing your understanding of adverse drug reactions (ADRs), their identification, reporting and prevention.

You can also apply your learning from all three parts of this learning series by completing the case studies presented as a 'video wall' in the final section of this programme.

Please note: this e-learning programme has been developed and provided by the Welsh Centre for Pharmacy Professional Education (WCPPE). Users should recognise that this programme may refer to Welsh policies and organisations. CPPE does not maintain control over the accuracy and currency of this programme.

Learning Objectives:

• outline patient characteristics and drug factors which increase the risk of adverse drug reactions
• assess factors to take into account when deciding if an adverse drug reaction has taken place
• communicate risk of adverse drug reactions to patients using appropriate risk tools
• recommend evaluated internet information resources to patients
• identify patients who would benefit from increased awareness of Yellow Card reporting
• list examples where patient reporting has triggered the MHRA to conduct a product review
• assess a patient for adverse drug reactions and take appropriate action.

The aim of this learning programme is to improve the Pharmacy team's knowledge in defining look-alike, sound-alike (LASA) errors and reduce the risk of LASA errors occurring. LASA errors are recognised as an important patient safety issue that can happen in any pharmacy with potentially serious consequences for patients.

This takes you to the CPPE Safeguarding gateway page

This e-assessment is linked with the CPPE Just culture e-learning, which can be found on the CPPE Patient safety gateway page.

Why should I do this assessment?

This e-assessment is linked with the CPPE Reducing look-alike, sound-alike errors e-learning which can be found on the CPPE Patient safety gateway page.

This assessment is linked to the Pharmacy Quality Scheme.

Why should I do this assessment?

This e-assessment is linked with the CPPE Patient safety toolkit programme and assesses you on the learning objectives within that programme.

Why should I do this assessment?

This e-assessment is linked with the CPPE Risk management guide and assesses you on the learning objectives within that programme.

Why should I do this assessment?

This e-assessment is linked with the CPPE Patient safety: an anticoagulant case study focal point programme, and assesses you on the learning objectives within that programme.

Why should I do this assessment?

This course looks at the principles which inform good prescribing and details the more common reasons for prescribing errors.

NHS webpage to search for NHS Improvement - medicines safety.

This supporting information gives additional information and clarification on the thinking behind this Patient Safety Alert and its recommended actions. The alert ‘Improving medication error incident reporting and learning’ recommends changes to strengthen clinical governance arrangements, and the identification of medication safety officers (MSOs) and multi-professional groups to review medication error incidents and improve medication safety locally.

This handbook provides practical information and resources to support those who have been designated Medication Safety Officer in their organisation. It is particularly relevant to people new in post or as a quick refresh for established staff.

The Central Alerting System (CAS) is a web based cascading system for isssuing patient safety alerts, important public messages and other safety critical information and guidance to the NHS and others, including idependant providers of health and social care.

The third WHO Medication Global Patient safety Challenge - Medication Without Harm, wil propose solutions to address many of the obstacles the world faces today to ensure the safety of medication practices.

The Patient Safety Toolkit plays an important role in preventing patients from being harmed. This toolkit allows your practice to look at different aspects of patient safety with a view to making improvements. It covers the following areas of general practice: safe systems, safety culture, communication, patient reported problems, diagnostic safety and prescribing safely.

You can download the full prescribing competency framework or an editable template.

These alerts rapidly warn the healthcare system of risks. They provide guidance on preventing potential incidents that may lead to harm or death.

SPS provides various information sources related to patient safety, including regular Medicines Use and Safety Updates.