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• A more formal process for involving educational • Monthly reports for nursing staff regarding medication
supervisors in follow up of prescribing errors by junior errors and specific medication reports are provided
doctors has been well received. This is supported by to each Division and also the education department
circulation of a monthly summary of incidents caused for prescribers.
by prescribing errors.
• An intranet page dedicated to medication safety has
• Developed a medication safety mandatory training been developed which includes recent alerts and
workbook. This has been approved by MMC and was lessons learned.
implemented in April 2017.
• We have publicised the need to report more adverse
• Line managers are offered support when investigating drug reactions via the Yellow Care Scheme by
incidents by MSOs. This has improved the response running a competition between the doctors and the
time for investigations following an incident. pharmacists. Since this was set up, the number of
adverse drug reactions reported to the MHRA via
• ‘Medication Safety Surgeries’ have been set up for
the Yellow card scheme has increased from 19 to 43
managers needing support to complete or review
(126% increase from 2014/15).
incidents. This has improved timeliness of reports and
ensured reporters know their incidents are followed • A TPN errors reduction working group and workshop
and should reduce the risk of a similar error recurring. has highlighted 3 key areas for improvement:
• Ensuring any medication errors involving Meditech • Developing criteria for when TPN is appropriate to
(our Electronic Prescribing and Medication start.
Administration (EPMA) system) are fed back to the
• Develop a training package on TPN for nurses and
Meditech team and used to shape and prioritise
doctors.
developments and training programmes.
• Develop a new TPN prescription form
• Developed links with universities which have
increased the delivery of medication safety training to • A MSO dashboard is used to monitor progress and
student nurses who are placed within the Alder Hey. training activity

• Showcased our successes at the Sign up to Safety • The Medication Safety Committee have led the Trust
event held at Alder Hey to re-iterate to staff to follow response to appropriate national medication safety
the “Five rights for medication safety” and encourage alerts.
reporting of near misses and actual medication errors
• A new Pharmacy Medication Safety Officer, has been
• The Nurse MSO was a speaker at the Medication appointed.
Safety Summit in London in June 2017 and ran a
workshop on safe administration of medicines at the Future Goals and Plans:
Neonatal and Paediatric Pharmacists Group annual
• A WhatsApp group for Junior Doctors was initiated
conference in November 2017
to communicate medication alerts. Currently we are
not utilising this service as intended and is to be re-
evaluated for the following year.
• To improve the process of involving prescribers in
the incident by forging closer links with the Medical
Leads.

• Developing close working links with the new MDSO.
• Assist with the development of an app with the
innovation team. This app will allow the patients to
have a better understanding of their medications.
This is being driven by feedback from children, young
people and parent’s workshop.
• Decreasing the incidents that involve TPN and
Heparin. To embed the work from the workshops that
has been done.
• Develop more medication safety audits including
• MSOs continue to provide regular training on many TPN, controlled drugs and critical medicines and
aspects of prescribing, administering and dispensing involve more staff in undertaking these audits and
medicines to medical, theatre, nursing and pharmacy taking ownership for resulting actions
staff. • Furthering links with ward-based Patient Safety
Champions and the newly appointed practice
education facilitators

Alder Hey Children’s NHS Foundation Trust 131 Annual Report & Accounts 2017/18