5PY009

PHARMACY LAW, ETHICS AND MEDICINES TEACHING WEEK 11 : OLT MANAGEMENT OF CLINICAL ERRORS

On-Line Learning Task Patient safety is of paramount importance, and one way such safety is assured is via the design of services informed by robust investigations when things go wrong. This OLT is designed to introduce you to some of the management strategies used to learn from medication incidents. Prior to undertaking this OLT, use the following webquest to familiarise yourself with many of the basic principles : Read the web page outlining how to avoid medication errors by using simple strategies at http://www.aafp.org/fpm/2007/0200/p41.html Read the file Dispensary design from the NPSA Read the NPSA Root cause analysis summary sheet Read the Dex investigation report, based on the dexamethasone case you covered in the week 9 OLT. This is a completed initial incident report which has been written on the NPSAs template available off the internet. Open the document Dex Action Plan. Using the details of the case, and the facts uncovered in the investigation process, complete THREE actions of the Action Plan as if you were the Safety Officer for the company LondonPharmacy charged with ensuring that a repeat of the dexamethasone overdose would be avoided in future. Submit your completed action plan to your PebblePad on-line portfolio by midnight on Sunday 9th December.

These tasks and lectures in this module should have given you an appreciation of the importance of managing errors appropriately. Hopefully, you will never be exposed to any of these issues in your actual working life, but by being aware of these issues you will be able to practice more safely and play your part in ensuring patient safety in relation to dispensed medicines. Mike Daly 17th September 2012