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Safety Team, a team to promote a safety culture in the Pharmacy Service

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European Statement

Patient Safety and Quality Assurance

Author(s)

Laura Doménech Moral, Raquel López Martínez, Maria Eugenia Palacio Lacambra, Emili Vallvé Alcon, Ángel Arévalo Bernabé, María Guerra González, Maria Queralt Gorgas Torner

Why was it done?

At PS Vall d’Hebron, one of our strategic objectives is to enhance the patient safety culture internally and externally within PS.

What was done?

Establishment of a core safety team within the Pharmacy Service (PS) with representatives from various areas and positions, along with established activities and indicators: the Safety Team.

How was it done?

By organising internal meetings of the Safety team to manage, lead, and plan activities related to medication safety. These activities include:
Advising on and/or managing medication safety incidents reported to the Patient Safety Incident Notification System of Catalonia (SNiSP) Vall d’Hebron.
Conducting biweekly “5 minutes of safety” meetings between pharmacy technicians and a member of the Safety team in the General, Maternal-Infant, Trauma, Outpatient, and Oncology-Haematology areas. In each meeting, the minutes from the previous one are reviewed to report on agreements and progress related to the topics discussed. Incidents reported to SNiSP related to medication dispensing and logistics are discussed, and there is an open discussion for technicians to share safety issues, questions, and medication-related incidents. These situations (reported incidents and those detected by technicians) are collectively analysed to propose prevention measures. Minutes of each meeting are documented and made available in a shared resource.
Weekly “safety pearls” presentations where sentinel medication incidents are presented, along with root cause analysis, by a representative of the Safety team. Situations that have led to medication incidents/errors in prescription and treatment validation are also discussed, along with proposed prevention measures by other PS members.
Conducting sessions related to safety during PS Sessions to present the actions taken by the safety core team and its collaboration with the Hospital’s Error Prevention Subcommittee.

What has been achieved?

More than 100 medication incidents reported to SNiSP have been managed.
Over 50 meetings with PS technicians, resulting in more than 45 improvement actions derived from notifications and detected issues, such as creating infographics for proper medication identification (everolimus, vitamin D), improving the urgent medication dispensing process without a prescription, or enhancing the management of “off-label” medications.
Around 20 safety pearls involving all pharmacists, leading to the creation of protocols, default guidelines, and updates to prescription and administration advice in the prescription programme.
Two annual patient safety-related sessions.

What next?

Continuing to enhance the safety culture through sessions and meetings involving various stakeholders, implementing an online medication error prevention course, and expanding the team.

PATIENT SAFETY: INTERVENTIONS TO REDUCE RISKS IN MEDICATION USE PROCESSES

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European Statement

Patient Safety and Quality Assurance

Author(s)

Nadia El Hilali Masó, Elvira Ramió Montero, Gemma Baronet Jordana, Marina De temple Pla, Paula Montoliu Alcon, Maria Jaume Gaya, Núria Pi Sala, Joan Altimiras Ruiz, Montserrat Pons Busoms

Why was it done?

The confusion between drug names represents a common cause of medication errors due to similarities between trade names and active ingredients or vice versa. Very new drugs coexisting with others that are very well known can easily induce errors in wards, unclear prescription may lead to misunderstanding of prescription.

What was done?

Development and implementation of measures to improve patient’s safety from purchase to drug prescription and administration.When we switch to a new provider maybe forced by drug shortage, we perform a review to avoid medication errors in all dosage forms.If needed, we elaborated alerts (pharmalerts) and newsletters. We applied Tall Man letters (TML) method to manage look-alike and sound-alike drugs, and to reduce prescription errors we elaborated a “Best practices on drug prescription” validated by Commission of pharmacy.

How was it done?

We prepared a formulary online on the intranet where pharmacist introduces relevant drug information as composition (i.e, excipients, contents latex or not, etc.), dilution, stability, source of errors (name, brand name,etc) among others. We compare them with existing ones to take an action, if necessary, that will be spread to all professionals. To implement TML method we followed the ISMP recommendations. First, we selected 3 antibiotics: cefOTAXime, cefAZOLin, cefTRIAXone. We changed these names in the prescription program so that the differentiation is reflected when drugs are prescribed, dispensed and administered. The implementation was explained to pharmacy, nursery and medical staff.After a month, we evaluated its acceptance.

What has been achieved?

We reviewed 61 new products: 50 trademarks, 14 new drugs and 7 dosage forms. 70.48% of products, acquired temporally or permanently, were new trademarks; 19.71% new drugs and 9.81% new dosage forms. The review is a good tool for a safe use of drugs and improves communication between healthcare providers. To evaluate TML implementation 240 questionnaires were completed: Acceptance was 92.05% (nursery and medical staff). 91.17% thought that it is possible to make a mistake with look-alike or sound-alike drugs and 68.72% that TML is useful to minimise medication errors.

What next?

The huge acceptance of TML encourages us to select other drugs from ISMP list. We have 6 pairs of drugs. We are planning to extend its use to storage shelves on wards.

DEVELOPING A PROJECT FOR BROADCASTING INFORMATION ABOUT MEDICATION ERRORS

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European Statement

Patient Safety and Quality Assurance

Author(s)

Sergio Plata-Paniagua, Alfredo Montero-Delgado, Jose Javier Arenas-Villafranca

Why was it done?

Currently, with the extended use of social-networks (SN), information related to medication errors can be disseminated quickly and directly, and also provide interaction with professionals enhancing the information. This is very important to promote safety culture among health professionals to prevent medication errors.

What was done?

Two hospital pharmacy specialists from two spanish hospitals created a project based on web 2.0 to broadcast information about medication errors and how to prevent them.

How was it done?

First step was to create a website in which we could post information related to medication errors. The main part of the website is the blog, where we develop all information that we consider interesting. The website also has other sections containing useful resources: photo gallery with examples of look/sound-alike drugs, infographics, educational information, information about the authors and a section where readers can share content with the authors.

Second step was to create accounts on SN to spread the information posted in the website and also for sharing original content. We chose Twitter and Facebook as ideal SN. Twitter allows sharing information quickly and concisely and also is used by a different groups of healthcare providers by allowing us a wide spread. On the other hand, Facebook allows us to reach to a different audience, especially patients.

What has been achieved?

-Currently we have more than 16.000 followers on Facebook, 5.500 on Twitter and the website receives more than 3.500 monthly visits.
-Because of the multiple warnings that we have carried out about Look-Alike/Sound-Alike drugs, some pharmaceutical companies have considered changing the packaging of their drugs.
-We have achieved more than 70.000 signatures on change.org website requesting Spanish healthcare authorities to develop guidelines for the proper packaging and labeling of drugs. Because of this initiative, the Spanish press became interested in this problem and our project and the problem of drug packaging was mentioned in multiple media.

What next?

Currently, we have included another pharmacist in our project in order to enhance the quality and periodicity of our publications. On the other hand, we are trying to work together with institutions dedicated to preventing medication errors to carry out joint projects in order to improve patient safety.

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