Accuracy Checking A Good Practice Guide

Transcription

1 Yorkshire and the Humber Accuracy Checking Training (ACT) Scheme Accuracy Checking A Good Practice Guide Visit our website Contact: Administration Team Pharmacy Development Unit Baines Wing School of Healthcare University of Leeds Leeds LS2 9JT yptssdu@healthcare.leeds.ac.uk Document Reference Number: Review Date: Version: Supersedes: ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 1

2 This document has been produced on behalf of the Yorkshire and Humber Pharmacy Education Programme Board (PEPB), based on the NHS Pharmacy Education & Development Committee (PEDC) document; Nationally Recognised ACPT Framework for the Final Accuracy Checking of Dispensed Items.. It has been adapted by the Yorkshire and Humber Pharmacy Development Unit (Y&H PDU) to assist in the training and development of Pharmacy Technicians and adapted for use in the region. Thanks are given to the members of NHS Pharmacy Education & Development Committee (NHS PEDC) - Pharmacy Technician and Support Staff (pre and post qualification) Group and the Association of Pharmacy Technicians UK who have reviewed the national framework and are committed to its further and continuing development. Further acknowledgement is given to the Yorkshire and Humber Accuracy Checking Training Programme Board and members of the CPD Strategy Group in development of the Yorkshire and the Humber ACT frameworks. This is one of a series of ACT Work Based Learning Programmes, and associated training resources which can be accessed via ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 2

3 Table of Contents Introduction... 4 How to Check A Good Practice Guide... 5 Yorkshire and Humber Accuracy Checking Good Practice Standards... 6 The HELP acronym... 6 Three-way check... 6 Patient Safety... 7 Risk Assessment Procedures... 8 Appendix... 9 Appendix 1: Definition of Errors... 9 Appendix 2: A Checklist for Accuracy Checking References ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 3

4 Introduction This document aims to provide you with an introduction to the Accuracy Checking process. This will be delivered as: Underpinning knowledge, and Links to further reading Knowledge and skills required for Accuracy Checking Some essential knowledge will be provided on: Local dispensing Standard Operating Procedures Principles of how to check It is advised that further reading and practice is undertaken. Please refer to Reference section at the end of this Appendix. ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 4

5 How to Check A Good Practice Guide FOCUS BEFORE YOU START you must have the right MINDSET you must be very disciplined. Switch-off from surround environment & other issues Do not allow yourself to become distracted by: o External conversation (do not listen, or get involved) o Internal conversation (thinking what you have to do next, tonight s tea, etc.) ONE JOB AT A TIME Try to distance yourself from other tasks do not feel you have to answer the phones, etc. Do not let others interrupt you. Try not to break off to check something else. You will need to restart the checking process again. THE PROCESS Always work to STOP; if you have to break off, start again. Understand all the team roles/responsibilities; trained staff are vitally important. As a check, you should have played no part in the dispensing process. Employ a structured approach to checking e.g. see Appendix 2: a checklist for issues to consider. LOOK AT THE PRESCRIPTION AND ASK YOURSELF has it been clinically checked (pharmaceutical assessment)? Has the doctor and pharmacist signed the prescription? does it look correct to me is there anything unusual (you may want to recheck)? is allergy box ticked or are any allergies listed? how much supply is needed? work it out for yourself first, before looking at the dispensed item read the prescription, then look at the drug pick up the pack and READ the drug name carefully does it match the request? Is it in-date? look at the drug form requested has the correct drug form been dispensed? look at the directions does the label match the written directions? have all the additional warning labels been included/affixed? check your BNF if unsure. are there any counselling requirements? is there a PIL enclosed, or supplied? are there any procedural considerations, e.g.: two eye drop bottles for ward supply, labels flagged, large labels for partially sighted, etc. how will the patient measure the dose? Spoons/medicine measure/oral syringes been supplied. correct container/closure used? Is it intact? storage considerations? compliance aids? bag label correct patient name and ward? ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 5

6 Yorkshire and Humber Accuracy Checking Good Practice Standards Work to local and national standards Accuracy Checking practice should be carried out in accordance with the national occupational standard Pharm 28. The checker should always work to local SOP, which includes pre-checks: clinical check, allergies, legal requirements Safe Systems of practice must be employed The checker should have had no involvement in the prescription assembly prior to checking The individual should be free from interruptions whilst checking If a checker has to break off, they must re-start from the beginning The checker should use a three-way check i.e. the prescription against the product against the label A structured checking method must be employed, e.g. GPhC HELP. Keep knowledge and skills up-to-date Accuracy checkers should undertake revalidation biannually, as a minimum o A knowledge update o Simulation Test with at least 20 items (including 6-8 errors) o Reflection on practice, including test outcomes and personal error log The HELP acronym How many Expiry date Label Three-way check How much has been dispensed CHECK calculations Expiry date of product how long is the supply for? Label pt name, product name, dose, warnings, direction, etc. correct drug, form and strength supplied However don t forget your three-way check Prescription Label ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 6

7 Now systematically apply this PPL to the HELP formula as you check, ensuring that each reads the same: How many Expiry Label Prescription Label Prescription (how long?) Label (if appreciate) Prescription Label Prescription Label Patient Safety Take a few moments to think about safe practice. There has been much written about systems failures, e.g. the Swiss cheese model. If all the holes in a number of slices line up, this is where the problems can escape! In analysing medication errors, systems have been found to fail. With checking errors, this may be due to short staffing, inadequate training, lack of awareness of potential errors, etc. However errors do not always arise from a system failure. We must think how we as individuals can reduce risk. As part of your Accuracy Checking training, you will probably have to complete a log of checking practice. This may be 500 items, 1000 items or even more. Does this mean you are safe to practice? Does this mean you will always be competent? It probably does help you to practice your checking practice makes perfect Or does it? You may just be lucky to have escaped error. Let us take the driving analogy: Does it make you a safe driver to have driven 1000 miles without an accident? Probably not! Safe driving means remaining aware hazard perception training is essential Always expect the unexpected! This is equally important when checking medicines. ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 7

8 Risk Assessment Procedures Look in your SOPs for specific risk assessment procedures; however you may find some of the following useful. Be aware of tricks your mind can play: o Read what you see it is easy to read WHAT you think/expect to see. o Pictorial - similar packs etc. o Similar names (e.g. Co- dydramol, codamol, benaldopa, etc.) Top 10 medication errors, and why these may have occurred. (e.g. see Bellingham 2004 or NPSA web do those reported in the national data reflect local trends why? what circumstances led to the errors?) Short staffing plan carefully Assumption of competence is dangerous a qualified or experienced person can also make mistakes, don t assume anything is correct. Always self-check you too can make mistakes! Be aware of local error categories (see Appendix 1) Certain processes - you may have additional training before embarking on accuracy checking in these areas, e.g. o Aseptic / production o Intrathecal preparations (must be on the Trust register) o Clinical Trials o Extemporaneous manufacture (Check your local procedures for guidance) There are some simple steps which contribute to reducing the likelihood of making errors, e.g.: o Consideration of safe systems of work Layout of dispensary segregation SOPs o Individuals Appropriate training Attitude and conduct Self-preparation for task Health o Packaging (can you influence this?) Feedback concerns to manufacturers Feedback concerns to NPSA ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 8

9 Appendix Appendix 1: Definition of Errors (from Yorkshire Accuracy Checking Framework) Serious (Major) Errors Incorrect Label: Wrong drug name Wrong drug form Wrong drug strength Incorrect patient s name Wrong directions Missing or inappropriate use of BNF additional warnings Incorrect quantity * Wrong drug, right label Right drug, wrong label PMR not matching the dispensed item Incorrect Contents: Wrong drug Wrong drug form Wrong drug strength Incorrect quantity * Less Serious (Minor) Errors Incorrect Label: Incorrect cost code Incorrect expiry date Incorrect batch number Incorrect spelling Missing additional warnings Incorrect ward/destination Outer packaging incorrectly labelled Other: Incorrect container/closure Missing signature (own or dispenser s or prescriber s) Missing owing information sheet Missing spoon, oral syringe or PIL Other: Expired contents Missing or incorrect Patient Information Leaflet (PIL) Wrong warning, cautionary or advisory label Missing item sundry Missing medication Missing identification of clinical screen Inappropriate container * Quantity may be a serious or less serious error depending on the drug involved. For example incorrect quantity of medicines such as prednisolone, amiodarone, methotrexate and antibiotics should be categorised as serious errors, whereas with other medicines it may be appropriate to categorise an error in quantity as less serious. The final decision on this is to be made in individual circumstances by the work based facilitator. ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 9

10 Appendix 2: A Checklist for Accuracy Checking The trainee should check for: Clinical check performed: Drug name Drug strength and form Patient s name in full (and weight if under 12) Ward Directions Tick Container which medicine has been dispensed from: Drug name Drug strength and form Expiry date Appearance Label: Drug name Drug strength and form Directions Warnings / additional labels Patient s name Quantity Signed by dispense (clear initials) Dispensed product: Appearance Quantity Correct container and lid B/N and exp (if not an original pack) Misc.: Large labels added if needed Patient Information Card supplied if needed Spoon/oral syringe supplied if needed TTO endorsed with quantity supplied, signed and dated by checker ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 10

11 References Essential Reading "Medicines Ethics and Practice A Guide for Pharmacists Latest edition available from the Royal Pharmaceutical Society OR Standards of conduct ethics and performance Latest edition available from GPhC AND GPhC Guidance Note: Responding to Complaints and Concerns Provides guidance on minimising dispensing errors, how to carry out a review of circumstances at the time of error and the most appropriate way to deal patients and their carers when mistakes have been made. (Including HELP acronym). How medication errors can be avoided, PJ Vol th January 2004 p.80 Bellingham C, Available from the PJ Online A short review of the report Building a safer NHS for patients: Improving medication safety which covers identification and recording of errors and risk reduction recommendations. Safety in Doses Improving the use of medicines in the NHS (published 2009) PDF File Reference Number 0469/1007 National Reporting and Learning Service (NRLS) Patient Safety Resources, Data Report A review of the frequency, number and type of medication incidents in the NHS. Chapters cover specific examples of medication errors and patient harm and a look at what can be learnt from incidents involving the most vulnerable groups of patients. Local Standard Operating Procedures These provide detailed procedural guidance on local practice Further Reading Being Open: Communicating patient safety incidents with patients, their families and carers. NPSA reference number 1097 (November 2009) Being Open-Patient Safety Alert: NPSA/2009/PSA003 Supporting Information Document NPSA reference number 1097A ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 11

12 National Patient Safety Agency-National Reporting and Learning Service A new framework on best practice guidance for all healthcare staff on how to communicate with patients and their carers when errors have been made. It also includes information on how to support healthcare staff involved in incidents. Building a Safer NHS for patients: Department of Health Publication - Building a safer NHS for Patients - Implementing an Organisation with a Memory (17th April 2001) licyandguidance/dh_ A look at the history behind some of the developments and systems we now have in place e.g. the reason for the introduction of the NPSA, a system of reporting adverse events, establishing agreed definitions of adverse events, reporting and feeding back errors and areas of risk. AND Department of Health Report - Building a safer NHS for Patients Improving Medication Safety (22 January 2004) licyandguidance/dh_ This report takes a detailed look at medication and prescribing errors and how they occur. It also examines ways of reducing risks within specific patient groups and medication groups. The report looks at ways in which organisations might invest in new technology and electronic prescribing systems and how better communication is needed between healthcare professionals when patients are discharged from hospital. Skills for Health National Occupational Standards (NOS) PHARM28 Undertake the final accuracy check of dispensed medicines and products This document details the requirements needed to demonstrate competence to carry out a final accuracy check on a prescription National Prescribing Centre The NPC website contains useful information on Medicines Management and a variety of publications and topics including patient safety and medication errors. ACT Good Practice Guide - Copyright 2013 School of Healthcare, University of Leeds 12

13 MedsLearning MedsLearning is an excellent resource for training and development. We offer: Learning Resources, such as the: Accredited Medicines Management Training Scheme Yorkshire & the Humber Accuracy Checking Framework Interactive Aseptic Processing Programme Calculations e-learning Package Courses, events and study days: Customer Care and Communication, Coaching for Improved Performance, Employment Skills Workshop, Introduction to Medicines Management, Mentoring, Pharmacy Calculations Workshop, Understanding CPD CPD related topics and resources: Monthly CPD updates Links to online learning Information on pharmacy careers and the pre-registration trainee pharmacy technician apprenticeship There s much more to be discovered online, please visit our website for full detailed information. Contact us: Pharmacy Development Unit Baines Wing School of Healthcare University of Leeds Leeds LS2 9JT Pharmacy Development Unit T: E: yptssdu@healthcare.leeds.ac.uk Visit our Blog The Pharmacy Development Unit is run in partnership with the Pharmacy Practice and Medicines Management Group at the University of Leeds and Leeds Teaching Hospitals NHS Trust and reports to the Yorkshire and the Humber Pharmacy Education and Training Committee. PDU is commissioned and funded via Health Education Yorkshire and the Humber.