Summary National patient safety agency

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