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Progress on Medication Safety
 Medication Safety Forum Chaired by the Health & Children, Ms Marita Kinsella, improvement projects designed to achieve safer, more effective use of medicines.
Three Primary Drivers for Safety
1. Reliable Medication Management
Processes in residential care settings
(acute hospitals, mental health facilities, 2. Good Co-ordination of Care at interfaces
where care is transferred in the system.
3. Patient and family involvement in their
1. Reliable Medication
Management Processes
 Project 1 (Standardised national hospital drug  Project 2 (Primary care prescription form) Project 4 (Dispensing double check guidance) Project 5 Pilot Drug Administration Project – Reduce Interruptions to Nurses during rounds – successful pilot 1. Reliable Medication
Management Processes
 Project 6 Coordinated approach to unlicensed medicines Project 10 Issue Guidance on Safe Supply of Codeine- containing non-prescription medicines - Pharmaceutical Society of Ireland issued guidance in May 2010  Project 14 Enhanced focus on safety factors during  Project 15 Improve controls on herbal medicines - IMB Project 16 Improve management of medicines shortages 1. Reliable Medication
Management Processes
 Project 17 (Medication in mental health facilities) Project 18 (Long-term repeat prescription guidelines) Project 19 (Medication management in nursing homes) Project 27 Develop agreed Principles for Safe Medication  Project 28 Education and training for healthcare professionals in safe prescribing, dispensing and drug Reliable Medication Management
Processes for High Risk Issues
 Project 7 Eliminate risk from Intravenous Potassium  Project 8 Prevent accidental oral Methotrexate overdose Project 9 Prevent deaths from errors with Vinca alkaloids  Project 11 Improve Insulin Management in Hospitals Project 12 Prevent accidents with Epidural medications Project 13 Standards for Aseptic Drug Preparation in  Project 29 Improve Prevention of Venous Thrombo- 2. Coordination of Care at Interfaces
 Project 21 Medication Reconciliation – developments at Naas General Hospital, Portiuncula Hospital  Project 22 Make PCRS Prescription Database available for interrogation by health professionals at interfaces (e.g.  Project 23 Standardise and Improve Design of Discharge Prescription Forms – developments at Naas General Hospital and Portiuncula Hospital Ballinasloe 3. Patient & Family Involvement
in Medication Management
 Project 20 Pilot Asthma Management Project – launched November 2009 in 25 primary care centres with support of  Project 24 Accessibility of medicines information Project 25 Let's Talk Medication Safety booklet – launched November 2009 (Irish Society of Quality in  Project 26 Facilitate the implementation of the Personal Information Pack (PIP) for use by patients and health HSE Establishes a National
Medication Safety Programme
HSE Medication Safety Programme
Initial Projects
 Develop a standard Drug Prescription & Administration Record for Acute Hospitals;  Develop a National Medication Management  Implement Irish Medication Safety Network Guidance Documents on specific High-Risk Progress on Medication Safety –
Specific Madden Recommendations
 R7.37: deal with problems surrounding
HSE has put a new system in place to
improve patient access to the majority
of unlicensed medicines.
Progress on Medication Safety –
Specific Madden Recommendations
 R7.38 The powers of the IMB should be enhanced to
ensure that all medicinal products, herbal, homeopathic and traditional remedies undergo rigorous control of safety, quality and efficacy, both at the licensing stage  IMB published its Guide to the National Rules
Scheme for Homeopathic Medicinal Products for
Human use (May 2010).
 IMB is currently undertaking a public consultation
process on herbal substances (Aug 2010)
Progress on Medication Safety –
Specific Madden Recommendations
 R7.39 The licensing requirements of the IMB
should include risk assessments of the medicinal product in use…. Risks identified should be minimised and user testing repeated to ensure risk reduction is brought to an acceptable level.  Volume 9A of The Rules Governing Medicinal
Products in the European Union published
September 2008 deal with risk assessment
in use (Section 8, Risk/Benefit Assessment)
Progress on Medication Safety –
Specific Madden Recommendations
 R7.40: Deal with problems identified with
products on the market through emergence of medication errors where product name, labelling and packaging were contributory  Irish Medication Safety Network
briefing document on Sound-Alike
Look-Alike Drugs (SALADs) published
July 2010
Progress on Medication Safety –
Specific Madden Recommendations
 R7.41 Establish communication structures
 Medication Safety Forum in place
Progress on Medication Safety –
Specific Madden Recommendations
 R7.42 As part of the safety and quality
governance framework, healthcare organisations must prioritise the implementation of formal  Med Rec implemented Naas, Portiuncula
will be evaluated for feasibility of roll-out
 Research programme in place to evaluate
Med Rec at Tallaght/Naas/Trinity College
Dublin.

Source: http://www.patientsafetyfirst.gov.ie/attachments/article/10/T_Delaney.pdf