Keynote 2 – Developing a safety culture: how to progress effectively?

 

The National Reporting and Learning System (the NRLS) was introduced into use in the National Health Service in England and Wales in 2005. NHS organisation report patient safety incidents where a patient was harmed or there was a potential for harm and national learning from these reports has been communicated via Patient Safety Alerts.

In a revised EU directive on Pharmacovigilance the definition of adverse drug reaction has been revised to include medication errors. There is a new requirement for national pharmacovigilance centres to establish medication error reporting and learning systems across Europe.

In the NHS in England, work is underway to share NRLS medication error reports with the national pharmacovigilance centre and improve reporting and learning by identifying medication safety officers in all NHS organisations.

 

 

• Describe the reporting and learning system for medication errors in the National Health Service in England;
• Explain the revised EU directive on Pharmacovigilance that now includes medication errors;
• Identify the need to improve the number and quality of medication error reports to enable learning and local actions to improve patient safety;
• Outline a new role of medication safety officer in healthcare provider organisations that will support the above.

 

 

After the presentation the participant should be able:

 

• to describe methods for reporting and learning medication errors and new requirements of the revised EU directive on Pharmacovigilance;
• to illustrate the need for quality assurance of local reporting and learning processes for medication errors;
• to define the new role of medication safety officers.