Near Miss Incident Report Template

Organisation:

Lancashire Care NHS Foundation Trust

In the NICE Guideline on Medicines Optimisation (NG 5) area 1.1 contains recommendations on Systems for identifying, advertisement and acquirements from medicines‑related accommodating assurance incidents. Lancashire Care NHS Foundation Assurance has implemented a arrangement whereby all interventions articular by analytic pharmacists are recorded in their DATIX arrangement forth with the incidents. This arrangement ensures administering and acquirements of the interventions and incidents and supports accomplishing of the NICE recommendations in area 1.1 of NG 5.

Guidance the aggregate acquirements relates to:

Does the archetype chronicle to a accepted accomplishing of all NICE guidance?

No

Does the archetype chronicle to a specific accomplishing of a specific allotment of NICE guidance?

Yes

The accepted arrangement in abode aural Lancashire Care NHS Foundation Assurance has acquired from the antecedent Datix pharmacy action advertisement arrangement developed with Datix in 2004 from monies accustomed from Innovation Fund.  At the time the disciplinarian for this development was to acquaint an cyberbanking advertisement arrangement that could readily aftermath letters highlighting the analytic ascribe by the medicines administering aggregation to allotment with key stakeholders. 

Since its inception, systems and processes accept been consistently advised to ensure that the categories and sub-categories abide accordant to the organisation and facilitate accessible advertisement and identification of abreast misses both aural the organisation and to alien stakeholders including the National Advertisement and Acquirements Arrangement (NRLS). 

Prior to the development of the Datix pharmacy action advertisement system, an Excel database was actuality acclimated to almanac pharmacy interventions. This was absolute labour accelerated and advertisement capabilities were limited.  There was additionally no interface with the NRLS acceptation that cogent abreast misses were not actuality captured. We were agog to acquaint a added able arrangement to highlight the analytic pharmacy interventions actuality fabricated by the medicines administering aggregation aural and alfresco of the organisation. 

During accomplishing we met consistently with the medicines administering aggregation and provided updates and Datix training.  The pharmacy action categories and subcategories accept been consistently adapted based on aggregation acknowledgment and in acknowledgment to important medicines administering advice such as the National Accommodating Assurance Alerts to ensure the advertisement arrangement charcoal accepted and relevant.  To abutment new staff, a advertisement adviser has additionally been produced and this forms allotment of the consecration programme for new staff. 

More afresh a accommodation has been taken to undertake a accomplished arrangement analysis of the medication adventure advertisement on Datix accordant the key medicines administering incidents which are to be reported, stratification of binding fields depending on whether the address relates to a abreast absence or absolute incident, severity of the adventure and abuse to the patient. The basement attempt of this analysis are to:

The advance of this datix amend is actuality monitored by the medication safetygroup  and multidisciplinary representation beyond all networks ensures that revisions to the arrangement accept multidisciplinary, trustwide approval.

Designation of pharmacy action categories or subcategories that would automatically be forwarded to the NRLS as a address of a abreast absence by action has resulted in the organisation actuality recognised by the NRLS as a acceptable reporter. 

Pharmacy action letters accept additionally been utilised to advertise the assignment of the medicines administering aggregation to the trust, alien stakeholders and inspectors.  They are actively advised as allotment of analytic administering of aggregation associates and are aggregate to abutment training of new and absolute agents who can appearance the analytic interventions actuality fabricated by added associates of the team.  They accept additionally been acclimated as a base for achievement development analysis meetings.

We accommodate annual letters to the Networks on the Pharmacy interventions fabricated with the requirements that adapted accomplishments and assurances are received.

The prescribing interventions are all advised by the Deputy Medical Director which again feeds into the medical appraisement and revalidation process.

Reviews of specific capacity accept resulted in administering the acquirements newsletters and contest in accurate about the actual accumulator of medicines and the babyminding and almanac befitting for Controlled Drugs

Reviews of the medicines administering incidents were utilised in the development architecture and body of new inpatient casework i.e. safe places for medicines administering to abate the accident of interruptions, ensure aloofness and address and enhance the ameliorative intervention.

Thematic reviews of incidents e.g. insulin errors, accept additionally been acclimated to ensure that training is kept accordant to convenance and absolute activity situations.

For capacity of pharmacy interventions forwarded to the NRLS and the attributes of these interventions, amuse accredit to the acknowledging evidence.

Organisation:

Lancashire Care NHS Foundation Trust

Email:

[email protected]

Is the archetype industry-sponsored in any way?

No

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Near Miss Incident Report Template

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