AH ANNUAL REPORT 2018

• A more formal process for involving educational
supervisors in follow up of prescribing errors by junior
doctors has been well received. This is supported by
circulation of a monthly summary of incidents caused
by prescribing errors.
• Developed a medication safety mandatory training
workbook. This has been approved by MMC and was
implemented in April 2017.
• Line managers are offered support when investigating
incidents by MSOs. This has improved the response
time for investigations following an incident.
• ‘Medication Safety Surgeries’ have been set up for
managers needing support to complete or review
incidents. This has improved timeliness of reports and
ensured reporters know their incidents are followed
and should reduce the risk of a similar error recurring.
• Ensuring any medication errors involving Meditech
(our Electronic Prescribing and Medication
Administration (EPMA) system) are fed back to the
Meditech team and used to shape and prioritise
developments and training programmes.
• Developed links with universities which have
increased the delivery of medication safety training to
student nurses who are placed within the Alder Hey.
• Showcased our successes at the Sign up to Safety
event held at Alder Hey to re-iterate to staff to follow
the “Five rights for medication safety” and encourage
reporting of near misses and actual medication errors
• The Nurse MSO was a speaker at the Medication
Safety Summit in London in June 2017 and ran a
workshop on safe administration of medicines at the
Neonatal and Paediatric Pharmacists Group annual
conference in November 2017
• MSOs continue to provide regular training on many
aspects of prescribing, administering and dispensing
medicines to medical, theatre, nursing and pharmacy
staff.
• Monthly reports for nursing staff regarding medication
errors and specific medication reports are provided
to each Division and also the education department
for prescribers.
• An intranet page dedicated to medication safety has
been developed which includes recent alerts and
lessons learned.
• We have publicised the need to report more adverse
drug reactions via the Yellow Care Scheme by
running a competition between the doctors and the
pharmacists. Since this was set up, the number of
adverse drug reactions reported to the MHRA via
the Yellow card scheme has increased from 19 to 43
(126% increase from 2014/15).
• A TPN errors reduction working group and workshop
has highlighted 3 key areas for improvement:
• Developing criteria for when TPN is appropriate to
start.
• Develop a training package on TPN for nurses and
doctors.
• Develop a new TPN prescription form
• A MSO dashboard is used to monitor progress and
training activity
• The Medication Safety Committee have led the Trust
response to appropriate national medication safety
alerts.
• A new Pharmacy Medication Safety Officer, has been
appointed.
Future Goals and Plans:
• A WhatsApp group for Junior Doctors was initiated
to communicate medication alerts. Currently we are
not utilising this service as intended and is to be reevaluated
for the following year.
• To improve the process of involving prescribers in
the incident by forging closer links with the Medical
Leads.
• Developing close working links with the new MDSO.
• Assist with the development of an app with the
innovation team. This app will allow the patients to
have a better understanding of their medications.
This is being driven by feedback from children, young
people and parent’s workshop.
• Decreasing the incidents that involve TPN and
Heparin. To embed the work from the workshops that
has been done.
• Develop more medication safety audits including
TPN, controlled drugs and critical medicines and
involve more staff in undertaking these audits and
taking ownership for resulting actions
• Furthering links with ward-based Patient Safety
Champions and the newly appointed practice
education facilitators
Alder Hey Children’s NHS Foundation Trust 131
Annual Report & Accounts 2017/18