In the NICE Guideline on Medicines Optimisation (NG 5) section 1.1 contains recommendations on Systems for identifying, reporting and learning from medicines‑related patient safety incidents. Lancashire Care NHS Foundation Trust has implemented a system whereby all interventions identified by clinical pharmacists are recorded in their DATIX system along with the incidents. This system ensures sharing and learning of the interventions and incidents and supports implementation of the NICE recommendations in section 1.1 of NG 5.
Aims and objectives
The current system in place within Lancashire Care NHS Foundation Trust has evolved from the initial Datix pharmacy intervention reporting template developed with Datix in 2004 from monies received from Innovation Fund. At the time the driver for this development was to introduce an electronic reporting system that could readily produce reports highlighting the clinical input by the medicines management team to share with key stakeholders.
Since its inception, systems and processes have been constantly reviewed to ensure that the categories and sub-categories remain relevant to the organisation and facilitate easy reporting and identification of near misses both within the organisation and to external stakeholders including the National Reporting and Learning System (NRLS).
Reasons for implementing your project
Prior to the development of the Datix pharmacy intervention reporting system, an Excel database was being used to record pharmacy interventions. This was very labour intensive and reporting capabilities were limited. There was also no interface with the NRLS meaning that significant near misses were not being captured. We were keen to introduce a more efficient system to highlight the clinical pharmacy interventions being made by the medicines management team within and outside of the organisation.
How did you implement the project
During implementation we met regularly with the medicines management team and provided updates and Datix training. The pharmacy intervention categories and subcategories have been regularly updated based on team feedback and in response to important medicines management guidance such as the National Patient Safety Alerts to ensure the reporting system remains current and relevant. To support new staff, a reporting guide has also been produced and this forms part of the induction programme for new staff.
More recently a decision has been taken to undertake a whole system review of the medication incident reporting on Datix agreeing the key medicines management incidents which are to be reported, stratification of mandatory fields depending on whether the report relates to a near miss or actual incident, severity of the incident and harm to the patient. The underpinning principles of this review are to:
- Ensure the same categories available for pharmacy staff and other trust staff to enable consistent reporting
- Reduce the need for free typing to reduce time for input and promote automatic report generation
- Introduce links to medication list as drug name is free typed to ensure correct spelling and quicker input
- Continue to include key incidents which need to be monitored in response to National Patient Safety Alerts
- Multidisciplinary agreement of medicines management incidents which must be reported as well as the key information to be reported under each category
- Real time information available to networks/teams
- Automatically generated reports for medication errors committee, accountable officer reports, and network medicines management quarterly reports
- Maintain automatic reporting of key incidents to the National Learning and Reporting System (NRLS)
The progress of this datix update is being monitored by the medication safetygroup and multidisciplinary representation across all networks ensures that revisions to the system have multidisciplinary, trustwide approval.
Designation of pharmacy intervention categories or subcategories that would automatically be forwarded to the NRLS as a report of a near miss by intervention has resulted in the organisation being recognised by the NRLS as a good reporter.
Pharmacy intervention reports have also been utilised to showcase the work of the medicines management team to the trust, external stakeholders and inspectors. They are actively reviewed as part of clinical supervision of team members and are shared to support training of new and existing staff who can view the clinical interventions being made by other members of the team. They have also been used as a basis for performance development review meetings.
We provide quarterly reports to the Networks on the Pharmacy interventions made with the requirements that appropriate actions and assurances are received.
The prescribing interventions are all reviewed by the Deputy Medical Director which then feeds into the medical appraisal and revalidation process.
Reviews of specific themes have resulted in sharing the learning newsletters and events in particular around the correct storage of medicines and the governance and record keeping for Controlled Drugs
Reviews of the medicines administration incidents were utilised in the development design and build of new inpatient services i.e. safe places for medicines administration to reduce the risk of interruptions, ensure privacy and dignity and enhance the therapeutic intervention.
Thematic reviews of incidents e.g. insulin errors, have also been used to ensure that training is kept relevant to practice and real life situations.
For details of pharmacy interventions forwarded to the NRLS and the nature of these interventions, please refer to the supporting evidence.
Key learning points
- Ensure that all key stakeholders are represented during the development stages
- Produce guides for staff to ensure consistent reporting
- Constantly review and update the system to ensure it is still viewed as a useful reporting tool
- Limit the option for free text recording to ensure that reports produced do not need to be reworked to ensure correct spelling and grammar
- Agree reporting structures to ensure that data is circulated and considered within the organisation
- Re-enforce open and positive reporting practices