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The Medication Safety Thermometer

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Kurt Bramfitt

on 11 June 2013

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Transcript of The Medication Safety Thermometer

The NHS Medications Safety Thermometer
'Harm free' care
'Error free' care
What did we learn from the Safety Thermometer "Classic"
Measuring harm
What do we know?
How do we record this information
The Safety Thermometer "Classic"
What does the data look like?
Question 1: How many harms?
Question 2: Was the patient protected from harm?
National CQUIN
1, 800,00 patients surveyed since January 2012
The Next Step
The Medications Safety Thermometer is a national tool. It is being developed by a steering group led by Dr David Cousins (Senior Head of Patient Safety for Safe Medication Practice and Medical Devices, NHS England) and including senior nurses, medical directors, pharmacists, safety policy leads, and improvement and measurement specialists.
NHS England safety and nursing offices have committed to developing a Safety Thermometer for medications in order to measure improvement locally and also meet the requirements of the NHS Outcomes Framework Domain 5
Measuring Error and Harm
Currently there is no one measurement system that gives us everything we need to know in order to understand the burden of harm from medication errors and to understand whether our efforts to improve patient safety have made a difference
There are many ways in which we measure error and harm from medications in healthcare.
NHS Outcome Framework
So what does this look like and how is this different ?
The Medications Safety Thermometer
'Error free' care
'Harm free' care
What does this look like

The purpose of step 1 is to identify errors in the administration of medications in the last 24 hours

Step 1 requires the collection of data on:

Patient demographics, age, gender etc
Number of regular medicines
Medicine reconciliation and medication omission as these are highly prevalent issues which can lead to serious harm
High Risk medicines
If a patient is on a high risk medicine listed in step 1 then you should move to step 2
Step 2 is then a series of trigger questions for each of the high risk medicines

If the answer to any of these questions is yes, this acts as a trigger of potential harm and the patient should be referred to an MDT for step 3 and 4 to determine whether harm has been caused by medication error
Step 2
Step 3 and 4 will be tested on a smaller scale. If you are interested in testing step 3 and 4 please let us know.
Testing will start with step 1 and 2 and guidance will be available which focuses on those 2 steps.
Step 3 and 4
Greater Manchester has a CQUIN to incentivise data collection but testing is open to anyone!
Preliminary guidance will be available with resources to help you
Whats involved
Data for Step 1 should be collected at the point of care by nursing staff as part of their daily routine, for example during a regular round.
How should data be collected
Data for step 2 should be collected by nursing staff supported (if necessary) by a specialist nurse or pharmacist.
In order to collect the data varied sources should be used including:
•The medicines chart
•Patient records
•Patient assessment
•Conversation with the patient or carer
•(having a BNF to hand could help)
Data are collected on one day each month. Throughout the pilot period the sample will grow. For acute services the aim will be to survey 100% of patients on 5 surgical wards and 5 medical wards each month (the same wards should be used)
For district nursing services the aim with be: 200 patients each month
The maximum sample will be all patients on 1 day.
Data will initially be collected using the paper form. We will start to test a web platform which will be used for data collection and submission from October onwards.
Technical platform
Organisations involved in testing the medications Safety Thermometer will be able to feedback through WebEx's, online surveys, email forums and testing groups.
Testing Feedback
Step 1 and 2
Step 1
142,695 Medication related incidents have been reported through incident reporting
What kind of incidents are frequently recorded?
What Medicines groups are frequently identified
Step 3 and 4
1.The person who completed the Safety Thermometer presents the patients information, medicines history, triggers identified and rationale for inclusion.

2.Case is discussed with MDT and medications reviewed

3.The level of harm is determined using the national patient safety agency classification for harm: no harm, mild, moderate, severe and contributing to death

4.The harm is then entered into the safety thermometer

5.A local action plan is agreed which may include: reporting the event as an incident, root cause analysis, improvement plan and discussion with the patient

6.All errors resulting in harm should be recorded on a master log and trends reviewed locally and regionally as part of routine clinical governance practice

7.The percentage of patients experiencing serious harm from medication errors should be tracked over time
Step 3: Classification of Harm from Error
Incentivising data

improvement goal
Medication Harm Development
Using the design principle of the Safety Thermometer "Classic" we began developing a tool based on these four harm measures:
Omitted medications
Sub-optimal use of antimicrobials
Dehydration or fluid overload
Use of reversal agents for medicine overdose in a care setting
After many meetings and trial testing our panel of experts were unable to agree on defined definitions as there was no clear cut way defining harm from these measures
The Medication Safety steering group agreed we needed to take a new approach
This step of the assessment is to determine whether the triggers observed by the local review have resulted in harm to the patient. It is important to consider this assessment with the medical team, pharmacy, nursing and/ or primary carer according to the following protocol
Thank you
Medication Safety

Raising awareness of the four harms and changing mindsets

Social movement..a call to action for front line staff
The NHS Safety Thermometer
measuring ‘harmfreecare’ at the point of care
More than just a measurement tool...
Its not just counting... it's caring!
Iterative testing using PDSA

Gathering user feedback

Working with content and measurement experts

Partnership working
Design Principles
Improvement over time
Measurement for improvement
Process measures collected locally
Full transcript