Encourage GP practices to report medication related incidents and near misses to enable CCG-wide learning opportunities to prevent further incidents and improve patient safety.
Another issue was how practices responded to patient safety alerts from the MHRA. E.g. despite several correspondences relating to sodium valproate risks in females of childbearing age, the proportion of practices with documented action taken regarding this was low.
Background: NHSE Primary Care Incident Report 01 Jan - 31 Dec 2015 released in May 2016 showed that 49% of 171 incidents reported were medication related. Thirty seven incidents were reported from North Central and East London of which none came from City and Hackney practices. The medicines management team (MMT) did not consider this a true reflection of practice and therefore the need to raise awareness of the benefits of learning through reporting medication related incidents.
Practice Support Pharmacists were supported to champion error reporting and risk management at practice level as well as encourage discussions and documentation of summaries of learning and action points from the incidents.
In agreement with the Prescribing Programme Board, error reporting and risk management was included in the Clinical Commissioning and Engagement Contract for 2017/18. This was identified as a QIPP item.
Practices were incentivised to report all errors and near misses via National Reporting and Learning System (NRLS) GP e-form and to share (via the NRLS portal i.e. no extra effort needed on their part to share the submission) at least FOUR of those with the CCG in order to enable access to the report and therefore share the learning across the CCG through 'Prescribing Matters'. 'Prescribing Matters' is a monthly bulletin/newsletter prepared by the Medicines Management Team (MMT) and disseminated to GP practices and Community Pharmacies within City and Hackney CCG. A section titled 'Learning and Sharing' was used to communicate learning from these errors and create awareness of associated patient safety issues.
A summary of learning and action points (template created by MMT) from ONE of the errors/near misses also needed to be submitted to MMT for practices to meet the payment criteria.
In addition, practices were incentivised to respond to MHRA Safety Alerts as applicable to their practices. MMT created a template to enable practices to document reviews conducted and action taken in relation to at least FOUR MHRA safety alerts.
Practices, with support of Practice Support Pharmacists, were required to return the completed template to MMT.
Deadlines were set for these submissions - 23 March 2018
Patients - Patient Safety:
Reduction of avoidable harm as a result of prescribers being more Increased awareness of patient safety issues and where/how things could go wrong thereby avoiding repeat occurrences and reduce avoidable harm to patients.
Practice Teams:
Through sharing and learning from patient safety incidents and near misses, practice teams are more aware of risks and other issues around medication safety (e.g. prescribing, administration, monitoring) and are more alert to prevent avoidable patient harm. Practices can also gain CPD credits from reporting errors via NRLS.
CCG:
Meeting its responsibility in commissioning safe services.
Increase in error reporting. The initial report from NHSE covering 01 Jan to 31 Dec 2015 showed ZERO (0) incidents from City and Hackney Practices out of 171 primary care incidents reported. From data shared with the CCG MMT between April 2017 and March 2018, there were 108 reported incidents from City and Hackney practices, of which NINETY-SIX (96) were medication related. Practices were only required to share at least four incidents with the CCG therefore the total number of reports is presumably higher.
Themes were identified with regular sharing of learning through the monthly MMT newsletter 'Prescribing Bulletin'.
Practices are more attentive and responsive to MHRA patient safety alerts. All 43 practices responded to at least ONE MHRA patient safety alert with documentation of review and action taken.
