Completing the NPA online Patient Safety Incident Report form: 2016

Transcription

1 Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 The infrmatin cntained within this dcument is in line with the current Data Prtectin Act (DPA) requirements. This infrmatin may be subject t change upn implementatin f the General Data Prtectin Regulatins (GDPR) n 25th May The Natinal Pharmacy Assciatin (NPA) Patient Safety Incident reprt frm can be used within the cmmunity pharmacy t lg patient safety incidents. The nline frm shuld nt include any patientidentifiable data; this can be added by hand after printing the frm. ing and printing the frm The frm can be ed t yu, if yu cmplete yur address in the relevant sectin. If yu chse this ptin, there is n need t print the first sectin f the frm. Hwever, yu may wish t print the secnd sectin in rder t recrd the patient details by hand; alternatively, yu can add these details t the after receipt. If yu d nt pt t have the frm ed t yu, yu will need t print the frm befre submitting it. This can be dne by right clicking n yur muse and selecting print frm the menu. T print using an Apple Mac cmputer withut the use f a muse, yu can press Cmmand + P t print. Please nte that, t print the whle frm, yu need t print each page separately. Cmpletin f the frm sectin 1: essential infrmatin Pharmacy/ Branch Name If the pharmacy is part f a small chain, the branch number shuld be included here. NPA membership number The NPA membership number shuld be included here if applicable. Date reprt cmpleted This is the date the reprt is filled ut, nt the date f the incident. Date f incident Recrd when the incident ccurred. Descriptin f medicatin incident Chse the mst apprpriate frm: Adverse drug reactin (when used as intended) Cntra-indicatin t the use f the medicine in relatin t drugs r cnditins Mismatching between patient and medicine Omitted medicine/ ingredient Patient allergic t treatment Wrng/mitted/passed expiry date Wrng/mitted patient infrmatin leaflet Wrng/mitted verbal patient directins Wrng/transpsed/mitted medicine label Wrng/unclear dse r strength Wrng drug/medicine Wrng frmulatin Wrng frequency Wrng methd f preparatin/supply Wrng quantity Wrng rute Wrng strage Other Unknwn The Natinal Pharmacy Assciatin. January Prduced by the NPA Pharmacy Services team. Direct Dial: pharmacyservices@npa.c.uk Online:

2 Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 Describe what happened (give as much detail as necessary t enable thers t understand the circumstances and be able t learn frm the event. State facts nly, nt pinins.) Patient details shuld nt be included in this sectin fr reasns f cnfidentiality; cde names can be used fr patients, fr example, 'Patient A' r 'Mrs B'. Try and include as much infrmatin as pssible. Fr example: Example A Patient given wrng medicine. The abve des nt prvide a great amunt f detail abut the incident. Cmpare it t the fllwing: Example B Patient given wrng medicine. Patient A s simvastatin tablets10mg fell int Patient B s dispensing basket during the dispensing prcess. This was nt nticed at the checking stage and Patient B was supplied with simvastatin 10mg tablets. Patient B tk 10mg simvastatin daily fr ne week. Patient B was already taking 20mg f simvastatin daily, which is the maximum recmmended dse when taken in cnjunctin with amldipine, which Patient B was taking. Patient B reprted muscle pain after ne week and errr was identified by hspital pharmacist n admissin t hspital. This example prvides a lt mre infrmatin abut what actually ccurred in the incident. Were there ther imprtant factrs? Chse ne r mre f: Pr transfer/transcriptin f infrmatin between paper and/r electrnic frms Pr cmmunicatin between care prviders (verbal r written) Use f abbreviatin(s) f drug name/strength/dse/directins (e.g. MTX, 1mg, 1 p) Handwritten prescriptin/chart difficult t read Patient/carer failure t fllw instructins Failure f cmpliance aid/mnitred dsage system (MDS) Failure f adequate medicines security (e.g. missing cntrlled drug [CD]) Substance misuse (including alchl) Medicines with similar lking r sunding name Pr labelling and packaging frm a cmmercial manufacturer Invlving a medicine supplied under a Patient Grup Directin (PGD) Invlving an OTC medicine Failure in mnitring/assessing medicines therapy Other r Unknwn please specify Cntributing factrs: what were the apparent cntributing factrs? Mre than ne can be selected The Natinal Pharmacy Assciatin. January Prduced by the NPA Pharmacy Services team. Direct Dial: pharmacyservices@npa.c.uk Online:

3 Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 Table 2: examples f cntributing factrs Cntributing factrs Cmmunicatin factrs (includes verbal, written and nn-verbal between individuals, teams and/r rganisatins) Educatin and training factrs (e.g. availability f training) Equipment and resurces factrs (e.g. clear machine displays, pr wrking rder, size, placement, ease f use) Medicatin factrs (where ne r mre drugs directly cntributed t the incident) Organisatin and strategic factrs (e.g. rganisatinal structure, cntractr/agency use, culture) Patient factrs (e.g. clinical cnditin, scial/physical/psychlgical factrs, relatinships) Task factrs (includes wrk guidelines/prcedures/plicies, availability f decisin-making aids) Team and scial factrs (includes rle definitins, leadership, supprt and cultural factrs) Wrk and envirnment factrs (e.g. pr/excess administratin, physical envirnment, wrk lad and hurs f wrk, time pressures) Example Patient was nt crrectly cunselled n the use f the medicine A new medicines cunter assistant was nt apprpriately trained t make a sale ver the cunter Weighing scales had nt been apprpriately calibrated Patient did nt disclse prescribed medicine use when buying an ver-the-cunter prduct Nt enugh trained staff present in the dispensary Patient is knwn t nly take white tablets, which the prescriptin requested, red tablets were unintentinally supplied; the patient did nt take the medicine because f this Standard perating prcedures were nt apprpriately fllwed The pharmacy manager pressurised the pharmacist dispense mre prescriptins per hur and as a result an errr ccurred Untidy dispensary At what stage during the medicatin prcess did an actual r ptential errr ccur? Chse frm: Prescribing Preparatin f medicines in all lcatins/dispensing in a pharmacy Administratin/supply f a medicine frm a clinical area Mnitring/fllw-up f medicine use Advice Supply r use f ver-the-cunter (OTC) medicine Other (please specify) Details f the crrect main medicatin assciated with the incident (if applicable) Include infrmatin abut what medicine shuld have been prescribed and/r given t the patient. D nt include medical devices in this sectin; this is cvered in a later sectin. The Natinal Pharmacy Assciatin. January Prduced by the NPA Pharmacy Services team. Direct Dial: pharmacyservices@npa.c.uk Online:

4 Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 Details f the incrrect main medicatin assciated with the incident (if applicable) Include infrmatin abut what was incrrectly prescribed and/r given t the patient. Als include if the prduct was a parallel imprt, in the relevant sectin. Severity f actual harm incurred by patient Chse frm: Near miss N harm Lw Mderate Severe Death Definitins fr degree f actual harm (severity): Near miss The incident ccurred and was reslved withut invlving the patient. The ptential t cause harm was lw, fr example, the final check identified the prblem. N harm Impact prevented any patient safety incident that had the ptential t cause harm but was prevented, resulting in n harm t peple receiving healthcare. Impact nt prevented any patient safety incident that ran t cmpletin but n harm ccurred t peple receiving healthcare. Lw Any patient safety incident that required extra bservatin r minr treatment and caused minimal harm, t ne r mre persns receiving healthcare. Mderate Any patient safety incident that resulted in a mderate increase in treatment and which caused significant but nt permanent harm, t ne r mre persns receiving healthcare. Severe Any patient safety incident that appears t have resulted in permanent harm t ne r mre persns receiving healthcare. Death Any patient safety incident that directly resulted in death f ne r mre persns receiving healthcare. The Natinal Pharmacy Assciatin. January Prduced by the NPA Pharmacy Services team. Direct Dial: pharmacyservices@npa.c.uk Online:

5 Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 Table 1: examples f degree f actual harm Degree f actual harm Near miss N harm Lw Mderate Severe Death Example Prpranll was dispensed instead f prednislne. It was detected during the accuracy checking prcess and rectified befre anything was handed t the patient. The patient was dispensed 21 days wrth f treatment instead f 28 days wrth f treatment. The patient realised n day 20 that an errr had ccurred, cntacted the pharmacy and the pharmacy prvided the patient with the remaining amunt f treatment after identifying the dispensing errr. The medicine was incrrectly labelled as Take tw tablets nce daily instead f Take ne tablet twice daily. The increased amunt meant the patient tk tw tablets n ne ccasin, which meant that they needed mnitring fr 24 hurs. A spacer was nt dispensed with a sterid inhaler when it was rdered n the prescriptin. The patient subsequently suffered frm ral thrush that was treated with nystatin ral suspensin and the patient was later prvided with a spacer t enable them t use their sterid inhaler crrectly. Incrrect labelling f a medicine meant that the patient tk subptimum dsing f medicine that led t a lng-term cnsequence fr the patient. The patient was dispensed an incrrect medicine and as a result the patient died. Details f the crrect medical device assciated with the incident (if applicable) Include infrmatin abut what shuld have been prescribed and/r given t the patient. Details f the incrrect medical device assciated with the incident (if applicable) Include infrmatin abut what was incrrectly prescribed and/r given t the patient. Cmpletin f the frm sectin 2: ptinal questins fr pharmacy use nly Reference number This shuld be decided by the pharmacy. Fr example, 2016/01 culd be used fr the first incident reprted in 2016 and the pattern carried n accrdingly. Reprter s details Details f wh is filling ut the incident reprt shuld be added here, nt the name f the persn wh reprted the incident t the pharmacy. Staff invlved in incident Include the name(s) and emplyment status f the staff invlved in the errr. Details f main patient affected by the incident This sectin must nt be filled ut electrnically fr reasns f patient cnfidentiality; it shuld be cmpleted by hand after printing. The Natinal Pharmacy Assciatin. January Prduced by the NPA Pharmacy Services team. Direct Dial: pharmacyservices@npa.c.uk Online:

6 Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 If the patient tk/used the medicine/medical device, what symptms did they experience? Patient details shuld nt be included in this sectin fr reasns f cnfidentiality; cde names can be used fr patients, fr example, 'Patient A' r 'Mrs B'. Try and include as much infrmatin as pssible. Fr example: Example A The patient was in pain. The abve des nt prvide a great amunt f detail abut the incident. Cmpare it t the fllwing example: Example B Patient cmplained f muscle pain and weakness in the legs and self-referred t Accident and Emergency. This example prvides mre infrmatin abut the type f pain the patient suffered. The Natinal Pharmacy Assciatin. January Prduced by the NPA Pharmacy Services team. Direct Dial: pharmacyservices@npa.c.uk Online: