PJ Online | MM: We have reached a turning point for clinical risk management

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Medicines Management
Issue no 5, p11-13
September/October 2002

Features

We have reached a turning point for clinical risk management

Clinical risk management must be an integral part of any medicines management strategy. David Kaye argues the case from the point of view of a primary care trust

David Kaye is Clinical Risk Co-ordinator for Bolton Primary Care Trust

Clinical risk management is at a turning point in the NHS. It nearly turned the corner when the National Patient Safety Agency reported on the results of its pilot study in June 2002. Unfortunately the event was overshadowed by claim and counter-claim about a cover-up by the Department of Health [England].The true turning point will come when the public are aware of what everyone in the NHS knows, that health care is an extremely risky business. Only then will the issues of clinical risk be able to be addressed.

The importance of involving the public in the process cannot be overstated. Patients need to be involved in their care to reduce the risk of adverse events. So professionals need to engage more fully with patients to reduce clinical risks. The move from compliance to concordance in medicines management is part of this process. And the National Patient Safety Agency has issued guidance to patients on "5 steps to safer health care":

1. Speak up if you have any questions or concerns

2. Keep a list of all the medicines you take

3. Make sure you get the results of any test or procedure — ask what it means for your care.

4. Talk with your doctor and health care team about your opinions if you need hospital care

5. Make sure you understand what will happen if you need surgery

Many patient complaints arise from differences between their expectations and the service delivered. The scale of the task is considerable. There are estimated to be 850,000 adverse events in the UK each year accounting for 11 per cent of hospital admissions and costing at least Ł2 billion a year in additional hospital stays alone. The additional costs in primary care have yet to be quantified.

Role for pharmacists

Risk management is natural for pharmacists who have been undertaking it as an integral part of their professional role. However, pharmacists can play a part in risk assessment beyond basic medicines management.

The types of clinical risks to which PCTs are exposed is increasing as their responsibilities expand.

Risk assessments need to be considered for local pharmaceutical services schemes, for repeat dispensing schemes, when employing salaried GPs, in the provision of intermediate care, and for services provided in diagnostic and treatment centres.

The Commission for Health Improvement has recently criticised a PCT for not undertaking risk assessments of extended nurse prescribing.

Service redesign will also generate new risks that will need assessment. For example, where PCTs are taking over the management of services, such as diabetes and care of the elderly, from acute trusts, the effect of these changes on medicines usage will need careful consideration.

The training and education infrastructure needs to be in place to support service redesign. One of the problems in PCTs is that the rapid expansion of services means that it may be difficult for managers to keep up with the pace of change. A balance has to be struck between the need for information and the amount of bureaucracy involved.

There is a Controls Assurance Standard: Medicines Management (Safe and Secure Handling) with which new PCTs will have to comply from April 2004. Although this deadline may seem a long way off, organisations should consider the standard as good practice and work towards compliance. Independent contractors — including GPs — do not have to comply with the Controls Assurance Standards but this will probably be included in any new contracts.

Although GPs and pharmacists are still responsible for their own risk management it is the PCT which is likely to attract the adverse publicity surrounding any incident as well as absorbing the costs of handling complaint and treating any adverse outcome.

NPSA incident reporting

Incident reporting has already been piloted in a number of acute and primary care trusts and the reporting system is due to roll out to PCTs by March 2003. Standardised e-forms should be available soon with guidance and improved grading system for errors.

The NPSA pilot evaluation report has already examined the problems of extending risk management to primary care. The number of incidents involving medication errors was highlighted during the pilot studies and their reduction is likely to be a priority. The NPSA will require serious incidents to be reported within three working days of the occurrence. This is likely to require electronic submission of incident reports. An integrated incident/claims reporting/risk register system would be most efficient. Although the exact nature of the form is not yet known the NPSA website contains the type of data which is likely to be included, this provides a starting point for developing a report form. The reporting organisation is required to undertake root cause analysis within 45 days of the incident. PCTs will need to ensure that the skills are available to facilitate this process.

Incidents will need to be reported by independent contractors including community pharmacists. It is important that they are aware of these responsibilities in advance of the reporting system being introduced.

Improving outcomes

The impact of clinical risk management will only be apparent once it starts to improve patient care. The incident reporting scheme has already produced guidance on the use of potassium injections. Let us hope that it will produce recommendations on the design of packaging to reduce dispensing and administration errors and on electronic prescribing.

Conclusions

Clinical risk management is a key element in clinical governance in the NHS. Pharmacists should anticipate an increase in demand for their advice as the scale number of incidents involving medication becomes apparent to organisations.