NHS Leeds website is no longer live - this content is for historical use only
Date:
25 May 2013
Page URL:
http://www.leeds.nhs.uk/About-us/Information for Professionals/Medicines Management/Safer-Medication-Practice.htm
Safer Medication Practice
Keeping patients safe is a top priority for NHS Leeds. There are many initiatives nationally and locally that aim to improve medication safety. Safer medication practice can be adopted in any field of medicines use such as prescribing, dispensing, administering, purchasing, storing or disposing of medicines.
Enquires on medication safety in Leeds can be made to Tony Jamieson, Lead for Medicines Safety and Governance.
Incidents including errors, concerns and failures in providing care can be reported by patients to NHS Leeds through the Patient Advice and Liaison Service.
Lessons from medicines safety incidents
The learning that has been identified locally from medication incidents in 2011/12 is summarsed in this report.
A detailed review of safety issues relating to medication use was published by the Department of Health in
Building a Safer NHS for Patients- Improving Medication Safety and by the NPSA in Safety in doses.
Prescribing
'Safety Snippets' are locally produced recommendations for improving the safety of prescribing in general practice.
There are 10 tips for safer prescribing given by National Prescribing Centre.
The GMC have published an influential report on the safety of prescribing in general practice. This can be found here.
A case study about a patient safety incident involving an alteration to a hand written prescription for ciprofloxacin can be found here.
Dispensing
Resources to help community pharmacies improve the safety and accuracy of dispensing can be found here.
Opioids
The consequences of error in the management of opioid medication can be server or even fatal. Guidance on how to avoid errors can be found here.
Warfarin
Warfarin use requires vigilance from everyone involved to protect patients from harm. Click here for resources and information on the safer use of warfarin.
Midazolam
Midazolam 5mg/5ml ampoules are not suitable for S/C administration or for addition to a syringe driver. Midazolam 10mg/2ml ampoules are necessary for these routes of administration because of the smaller volumes needed to deliver the dose. Confusion between the two strengths has led to a number of local incidents which have resulted in delays in treatment and loss of nursing time.
To assist prescribers in product selection it may be beneficial to use these settings:
On SystmOne add the 10mg/2ml product to Formulary and remove the 5mg/5ml product.
On Emis (LV) add the 10mg/2ml product to Formulary and remove the 5mg/5ml product and add a practice defined age related (0-120 years) contraindication to the 5mg/5ml product specifying "Use 10mg/2ml amps for S/C orsyringe driver use" (How?)
Pharmacists should make an intervention if the 5mg/5ml product is prescribed for S/C or syringe driver use.
Guidance on the safe use of midazolam in palliative care can be found here.
The NPSA has issued an alert in relation to the use of midazolam for conscious sedation. This can be found here.
Loading Doses
Over 1000 error reports about loading doses have been received by the NPSA over a 5 year period. Seven of the incidents resulted in death or severe harm. Reported fatalities occurred with phenytoin and amiodarone.
Loading doses are uncommon in primary care. When asked to prescribe or dispense a dose that is higher than the normal maintenance dose it is worthwhile checking that the dose is correct. Particular care is needed when dosing children. The following is a list of common primary care drugs which are used with loading doses:
Drug Trigger for intervention Aspirin Maintenance doses greater than 150mg daily Amiodarone Frequency of more than once a day Clopidogrel Maintenance doses greater than 75mg daily Digoxin All doses greater than the BNF recommended i.e. 125-250mcg for AF, 62.5-125 for heart failure Prasugrel maintenance doses greater than 10mg daily Warfarin Doses other than the dose on the warfarin clinic’s dose & appointment letter Click here for more information.
Lithium
Getting the right dose of lithium is the subject of an NPSA alert. NHS Leeds has produced a Pharmfax dedicated to Lithium treatment.
A checklist for pharmacists and nurses which guides them through a patient consultation about Lithium has been developed locally by Charanjit Sandhu and Fiona Fox on behalf of Lloyds Pharmacy. It is available here for printing, with their kind permission.
Methotrexate
The NPSA has issued a patient safety alert on the safer use of methotrexate. This can be found here.
To assist pharmacies to dispense methotrexate safely and to consider methotrexate side-effects when making over-the-counter recommendations, Leeds PCT has produced two template standard operating procedures which can be found here:
SOP for the safe processing of prescriptions in Community Pharmacy and here:
Bullet point checklist Community Pharmacy
The guideline that describes the prescribing and monitoring responsibilities for GPs and consultants who are sharing the care of patients taking methotrexate can be found on Leeds Health Pathways (NHS.net connection required).
Heparin Flushes
The NPSA has published Guidance on the safe use of solutions for flushing peripheral and central intravenous lines. A poster summarising the advice can be found here.
Side effects, adverse reactions and faulty or counterfeit drugs
The Medicines and Healthcare products Regulatory Agency (MHRA) is the medicines "watchdog" for the UK.
The MHRA has published web-pages customised for a range of providers such as Care Homes and Pharmacists which includes guidance, safety alerts, and links to educational material to assist staff in the safe use and management of the wide range of medicines and medical devices.
Click here to report side effects or adverse reaction to a drug. This report can be anonymous and your doctor or pharmacist will not be informed.
Click here to report a faulty medicine or here to report a medicines that you think might be a counterfeit.
Safeguarding Children and Vulnerable Adults
The NHS Leeds medicines management team supports the Leeds Adult Safeguarding Partnership and the Leeds Safeguarding Children Board to investigate and resolve concerns about the abuse of people through the use or misuse of medicines.A Serious Case Review concerning a child aged 2 years who died as a result of ingestion of antidepressants. There had been a history of domestic abuse, alcohol misuse and parental mental illness. Some of the key messages can be found here.
Leeds PCT publications
Guidance on safe prescribing is included in the newsletter of Leeds PCTs medicines management team, PharmFax. Therapeutic guidance is also available from Leeds Health Pathways (NHS.net connection required).
Social Care Providers
A guide for carers to help understand what a medication incident is can be found here.
An alert on medication safety in care homes has been published by the Department of Health. The Royal Pharmaceutical Society of Great Britain has also issued guidance on the handling of medicines in social care settings. NHS Leeds commissions local community pharmacies to provide advice to Care Homes on the management of medicines. Information of the Pharmaceutical Services to Care Homes (PAtCH) service can be obtained by contacting Gazala Khan, NHS Leeds Head of Community Pharmacy.
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