Clinical Governance and Error Management

what is clinical governance a framework through which NHS organisations are accountable for continuously improving the quality of care, by creating an environment in which clinical care with excellence will flourish what does clinical governance require a pharmacist to do - consider what could go wrong - find methods of preventing errors - document the facts when something does go wrong - learn from any mistakes what is an audit - a clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria - where indicated, changes are implemented and further monitoring is used to confirm improvement in healthcare delivery 1. selecting the area that you would like to audit 2. agreeing the standards of best practice 3. collecting the data 4. analysing the data against the standards 5. providing feedback on the results obwhat are the main stages involved in an tained audit are 6. implementing agreed changed 7. allowing time for the changes to be applied 8. collecting data 9. analysing the data 10. providing feedback on the results obtained 11. discussing whether the practice has improved 1 / 10 what is a service evaluation - activities designed to examine whether or not services work - this ensures that the service supports an evidence-based approach to practice delivery and to benefit the patients who are using the healthcare service - outcome is that it can aid decisions about the effectiveness of a service and what changes are required to improve the quality of care it is important to listen to people using the service when doing a service evaluation. how is it done - through feedback - through patient suggestions using questionnaires - by using surveys - person must have an induction when they start what should happen when new staff join - must receive ongoing support with the pharmacy training and development to ensure that they are competent to carry out their role and continue to learn and develop how should pharmacies manage staff performance - they should be clear procedures in place for managing poor staff performance - members of staff have responsibility to raise concerns about other staff members and their actions that could result in risks to patients - serious unprofessional or inappropriate behaviour - dishonesty or fraud what are the five categories of concerns - criminal conduct that the GPhC will investigate - dispensing errors - working under the influence of drugs or alcohol - report without delay - report to the immediate supervisor - report to another suitable person in au2 / 10 thority or an outside body - keep a record - maintain confidentiality what is the GPhC guidance on raising concerns - PIDA protects whistleblowers from negative treatment or unfair dismissal if they explain the whistleblowing & the public have disclosed certain info in the pubinterest disclosure act (PIDA) 1998 lic interest and pharmacy professionals have a duty to raise concerns under this act what sort of disclosures are protected under the PIDA - the commission of a criminal offence - the breach of a legal obligation - a miscarriage of justice - danger to the health and safety of any individual - damage to the environment - concealment of any of the above - when it is considered to be in the public interest, when the info is required to prevent: when can pharmacy professionals dis- a serious crime close confidential info - serious harm to a person receiving care or to a third party - serious risk to public health what are SOPs Standard Operating Procedures - comprehensive written guide to correctly performing a chosen task - outlines what is to be done, when it should be done, who should be doing it, where it should be done, how it should be done - they ensure the safe and effective management of a pharmacy 3 / 10 what must SOPs cover at least - arrangements for safe and effective ordering, storage, preparation and disposal of medicines - supply of medicines - medicine delivery outside the pharmacy - record keeping for all of the above - the circumstances in which a non-pharmacist member of staff may give advice about medicinal products - identifying members of staff who are competent to perform specified tasks within the pharmacy - arrangements to apply if the responsible pharmacist is absent from the premises - steps to be taken when the responsible pharmacist is changed - a complaints procedure - an incident procedure - how changes to SOPs are communicated to all staff can you deviate from an SOP - no - if something does go wrong because of deviating from the SOP, any resulting court case would be unlikely to be in favour of the pharmacy or those involved in the incident - GDPR governs the way in which we can use, process, and store personal data what is the general data protection regu- pharmacists have access to lots of lations (GDPR) info about patients which they must keep confidential - responsible for enforcing the UK General Data Protection Regulation (GDPR) what is the role of the informations comand offering advice and assistance to missioner both the council and the individuals or groups whose information is being held. 4 / 10 - tasked by gov to uphold, regulate and prosecute breached of the DPA What is the data protection act (DPA) Everyone responsible for using personal data has to follow strict rules called 'data protection principles'. They must make sure the information is: - used fairly, lawfully and transparently - used for specified, explicit purposes - used in a way that is adequate, relevant and limited to only what is necessary - accurate and, where necessary, kept up to date - kept for no longer than is necessary - handled in a way that ensures appropriate security, including protection against unlawful or unauthorised processing, access, loss, destruction or damage who gets 'blamed' for a incident - even if a counter assistant or the pharmacists themselves commits a breach of the data protection act, the blame will fall on the employing pharmacy - the pharmacy can then take action against the employee 1. lawfulness, fairness and transparency 2. purpose limitation 3. data minimisation what are the seven principles of the gen4. accuracy eral data protection regulation (GDPR) 5. storage limitation 6. integrity and confidentiality 7. accountability 1. justify the purpose(S) for using confidential info 2. use confidential info only when it is necessary 3. use the minimum necessary confidential info 4. access to confidential info should be on a strict need-to-know basis 5 / 10 what are the caldicott principles 5. everyone with access to confidential info should be aware of their responsibilities 6. comply with the law 7. the duty to share info for individual care is as important as the duty to protect patient confidentiality 8. inform patients and service users about how their confidential info is used what information is confidential - electronic and hard copy data - personal details - info about a person's medication - other info about person's medical history, treatment or care that could identify them - info that people share that is not strictly medical nature, but that the person disclosing it would expect to be kept confidential what information is not confidential - anonymous info - pseudonymised info: info from which individuals can't reasonably be identified - info that is already legitimately in the public domain when the pharmacy professional - has the consent of the person under their care - has to disclose by law what are the four circumstances when it - should do so in the public interest, may be appropriate for pharmacy profesand/or sionals to disclose confidential info - must do so in the vital interests of a person receiving treatment or care, for example if a patient needs immediate urgent medical attention - a secure, electronic patient record that contains key info derived from patients' detailed GP records - is accessed in emergency and un6 / 10 planned care scenarios - patients have a choice whether to have an SCR or not contains: medicines, allergies, adverse drug reactions what are summary care records - CPCS and NMS service provision - private services - locally commissioned service such as emergency hormonal contraception - patient queries regarding current and/or discontinued medicines, or accessing what are the situations where SCR acinfo on allergies cess is useful - responding to symptoms over the counter where patients are taking additional medicines - establishing whether a prescription has been issued and finding lost prescriptions -explicit consent or 'permission to view' each time what is needed in order to access a SCR - have a legitimate relationship with the patient - emergency situation where the patient is unconsciousness - patient who are unable to speak english in what circumstances is it permissible to and SCR access is needed to provide access a patient's SCR without permis- appropriate care sion - patients who are confused and are unable to understand a question and access is required to address a safety issue - access for patients in care home setting what should you do when accessing the SCR due to the patient refusing to give info, but the patient is at risk of significant harm without the info - contact the SCR governance lead for you organisation to inform them and make appropriate notes in the patient's PMR what are near miss erorrs 7 / 10 - when potentially harmful errors are picked up before an item is given to a patient what are the common types of errors - wrong dose - missing items - wrong item - wrong quantity - date expired - wrong patient what are the causes of dispensing errors - poor handwriting - a mental block - calculation errors - dose forms errors - foreign bodies: medicines containing foreign bodies or dirt can cause harm to what are the practical problems that can patient arise when dispensing - poor procedures, too little space or too much clutter can cause problems, interruption and distraction can lead - unreasonable workloads what are LASA medications - drugs that look alike - drugs that sound alike what can be done to reduce selection errors - physical separation - visual warning - shelf edgers: signs of the edge of med shelves - prompts on the patient medication record (PMR) system to alert staff as to whether the correct item has been selected - dispensary should be organised to keep distraction to a minimum - atmosphere of dispensary should enexplain how to minimise the risk of makcourage good conc ing a dispensing error - alert staff to dangers of stock being placed in the wrong location - keep a segregated area for the dispens8 / 10 ing process segregate prescriptions on the workbench to avoid patients receiving someone else's meds - produce dispensing labels before any product is selected from the shelf - do not select stock using dispensing labels or patient medication records explain how to minimise the risk of mak- - dispense items from the Rx and not the ing a dispensing error - factors relating to label the dispensing process - two people should be involved in the dispensing process where this is possible - all accuracy checks should be made against the Rx what is a patient safety incident - when a dispensing error occurs and an item reaches a patient, regardless of whether there was any harm to the patient what is the suggested procedure for dealing with a patient safety incident - listen and find out the facts - apologise to the patient - stay calm when the patient is present - take all complaints seriously - work on the basis that the error is genuine, even if it proves not to be the case - no harm - low harm: sny unintended incident that required extra observation or minor treatment what is the national reporting and learn- moderate harm: unintended incident ing system (NRLS) five categories for the that resulted in further treatment and degree of harm caused short term harm - severe harm: unintended incident that caused permanent or long term harm - death - allows organisations, staff and patients to record the details of patient safety in9 / 10 what will the learn from patient safety events service provide cidents - allow providers to access data about recorded patient safety events - reporting: record the error, how it happened, who was involved, actions taken - investigating: find out why incident happened what to do after a dispensing error and - planning: action plan developed with immediate complaint has been made purpose of preventing such an incident from recurring - sharing: individuals involved must be told exactly what happened - pharmacist to complete a near miss audit on a regular basis to identify trends what should happen when a near miss and to see if procedures can be changed has occurred or if training is required to reduce the frequency of near miss what does duty of candour mean for a pharmacist healthcare professionals must: - tell the patient when something has gone wrong - apologise to the patient - offer an appropriate remedy or support to put matters right - explain fully to patient the short and long term effects of what has happened - be open and honest with colleagues, employers and relevant organisations what does the GPhC state that a phar- - take part in reviews and investigations - must raise concerns with their regulamacist do in term of duty of candour tors when appropriate and not prevent others from doing so 10 / 10