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Summary National patient safety agency
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Pharmacy - foundation in pharmacy practice Summary notes including bullet points, key diagrams/images
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National Patient Safety Agency (NPSA)NPSA
‘An organisation with a memory’ learn from past errors
Created 2001 to improve patient safety
National reporting and learning services (NRLS)
National clinical assessment service (NCAS)
National research and ethics service (NRES)
Across the country so errors are shared and blanket amendments can be made
Dispensing
1 billion items dispensed a year
113,953 near misses each month
20,361 dispensing errors each month
80% are picking errors (strength, dose or formunlation)
Medicines cause 6.5% of hospital admissions
Estimated that it causes 10,000 deaths a year
Working Environment
Signing- people know where to go
Lighting- too bright can cause headaches but need to be able to see clearly
Noise- at a minimum
Security- patients and staff feel safe
Privacy- discussions are confidential and computer screens can’t be seen
Flooring, temperature and seating
Stock Issues
Can get mixed up with new and old
Tote boxes are trip hazard
Involuntary automaticity
Stock stored incorrectly (fridge)
Should be shelf dividers to separate strength and formulations
Need sloping draws so stock can be seen easily
Use A-Z system
Prescription Check
Separate area for reception and collection
Pen and paper available
Clinical checks done
Computer terminals not visible
Labels
Label printed before medicine selected
Create one at a time
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