LMcI_PhotoNHSScotland spends £1.65bn on prescription medicines each year and the burden of harm relating to medicines is well reported. We know that learning from past harm can support improvements in future care, but currently Scotland doesn’t have a systematic way to analyse all adverse events on a national level to identify potential learning.

“We were asked to explore whether aggregating local data on a national level would be possible. If possible, would identifying learning and opportunities for improvement result in safer use of medicines, as well as strengthening our current approach to learning nationally from adverse events?”

Therefore, we led a project in collaboration with colleagues across NHS boards, Scottish Government, the Care Inspectorate and independent healthcare colleagues to gather data on all adverse events relating to one high risk medicine, oxycodone, which was identified as a priority area for improvement.

We collected data from acute care in 12 territorial NHS boards and one special NHS board, primary care data from nine NHS boards and data from the Care Inspectorate who is responsible for regulating care homes, and Healthcare Improvement Scotland as the regulator for independent healthcare services. We were delighted that all NHS boards, social care services and independent healthcare services were willing to participate in this work, showing a genuine desire to collate information to inform national learning.

Looking at the stage of error, as was expected in the acute care and residential settings, the most frequently reported errors were related to administration, whereas in primary care the most frequently reported error was related to dispensing. The most frequently reported administration error was giving the patient the wrong formulation of oxycodone (such as long acting or short acting). Often the data had very limited information or detail about the event itself – more detailed reporting by staff would be beneficial so that there is robust information to learn from. The project also highlighted a number of ways we can improve adverse event reporting such as developing a common language, and education and training to improve recording of adverse events to ensure that recording systems are used to their full potential. In terms of harm to patients, the overall finding was that there was very little recorded harm to patients.

We will be providing our findings to the Controlled Drugs Accountable Officer Network working group for the group to consider in more detail, and will request feedback on ways in which they have used the information to inform any further improvement work.  We will also request feedback from organisations and NHS boards who also contributed to this project to evaluate the impact. We will ask what they found useful, if they identified any learning and if, as a result of this exercise, they have made any changes to the way they record adverse events relating to oxycodone.

“The project demonstrated that collection and analysis of local data at a national level is possible and the ability to consider a national data set was valuable for all the stakeholders, generating further local improvement work and sharing of potential improvement interventions.”

We’re encouraged by the findings and there is potential for additional testing of this approach in a different adverse event or medicine to explore further its added value to driving improvement.

Laura McIver is Chief Pharmacist for Healthcare Improvement Scotland.

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