Minutes of meeting no. 2 of the Network for the Prevention of Medication Errors held on 30 October 2008

19 May 2009

The meeting was held on 30 October 2008 at 13:00-15.30 at the Danish Medicines Agency.

Agenda
Minutes
Participants

Agenda


  1. Welcome
  2. Challenges posed by EPM – a nurse's perspective - by Gunilla Svensmark, Danish Nurses' Organization
  3. Status on the High-Risk Medicines Working Group - presentation by the chairman
  4. Medicine room project and introduction to Global Trigger Tool in Denmark - by Marie Lund Nielsen, Region of Southern Denmark
  5. Situation report on identification of medicinal products (cancelled) - by Ulla Høegh, Danish Association of the Pharmaceutical Industry
  6. Capital Region of Denmark's medicine mix-up working group- by Majken Petersen, Capital Region of Denmark Pharmacy, and Annemarie Hellebek
  7. Next meeting
  8. Any other business

Minutes

Re item 1 Welcome
Anne-Marie Vangsted welcomed members to the meeting. Charlotte Mortensen reported that problems sending out e-mails to the last meeting's participants had meant that fewer participants had signed up for this meeting. Marie Melskens gave a brief account of the actions taken by the Danish Medicines Agency in the area of patient safety since the last network meeting, see the attached presentation (in Danish only).

Re item 2 Challenges posed by EPM – a nurse's perspective
Gunilla Svensmark (GS) presented the challenges experienced by the nurses in the secondary sector. See the attached presentation (in Danish only).
The issue of missing barcodes was mentioned by GS. GS explained the difficulties that nurses are faced with when barcodes are missing or only appear on the outer packaging of a product. The Danish Association of the Pharmaceutical Industry (Lif), the Danish Generic Medicines Industry Association (IGL), the Danish Association of Parallel Importers of Medicine and Amgros have joined forces to find a solution involving barcodes on inner and outer packaging. It was commented that the pharmacies also use barcodes as a second control method.
GS asked if any reports had been made identifying whether the introduction of an Electronic Patient Module (EPM) had led to increased patient safety. The introduction of EPM has reduced the number of errors that were related to poor readability, but the new electronic system has probably provoked new errors.
At present, EPM is not certified. It was discussed, in general terms, whether quality management of hospital processes, including EPM certification, should be part of the certification of hospitals. The Danish Society for Patient Safety would focus on this topic in 2009.
GS considered it necessary to prepare a list of medication incidents that ought to be reported to the Danish Patient Safety Database. The National Board of Health replied that significant events must be reported, and that in some cases the event is communicated locally, and in other cases regionally or nationally. At some hospitals, IT events are forwarded to IT departments and put on the agenda of drug committee meetings.

Re item 3 Status of the High-Risk Medicines Working Group
Annemarie Hellebek (AMH) introduced the members of the working group and explained how the group intends to approach the task. See the attached document (in Danish only).

Marie Lund Nielsen (MLN) added that the Region of Southern Denmark had formed a regional working group on high-risk medicines. It was agreed to invite a representative to join the network's working group on "High-Risk Medicines".

Re item 4 Medicine room project and introduction to Global Trigger Tool in Denmark
MLN gave a presentation of the Region of Southern Denmark's project on optimisation of the medicine room and the Global Trigger Tool (GTT). GTT is a tool that can be used by everyone to learn from mistakes, e.g. the hospital departments concerned with quality or the individual ward.

Re item 5 Situation report on identification of medicinal products (cancelled)
The presentation was postponed until the next network meeting since Ulla Høegh had sent her apologies.

Re item 6 Capital Region of Denmark's medicine mix-up working group
AMH explained the background to the Capital Region of Denmark's medicine mix-up working group.
Majken N. Pedersen reported on the processing of cases involving medicine mix-ups. The cases involving mix-ups are categorised on the basis of harmfulness associated with product mix-ups with the assistance of a clinical pharmacologist. The clinical pharmacologist has worked out the categories single-handedly. It was commented that experience ought to be exchanged between risk managers and the Danish Medicines Agency because it sometimes occurs that cases have already been dealt with regionally or nationally. The Danish Medicines Agency will investigate whether it is possible to brief risk managers when a case is opened based on an adverse event. A question was raised whether it would be possible for the medicine mix-up working group to communicate its initiatives on a more national level.

Re item 7 Next meeting
The next meeting was scheduled for Thursday 2 April 2009 at 13:00-16:00

Re item 8 Any other business
AMH announced that the Danish Society for Patient Safety is addressing the topic of pharmaceutical evaluation (medicinafstemning) on 3 December 2008 at 13:00 to 16:00.
Marianne Møller asked for the network's opinion about the fact that it is not the same person that is represented in the network and the working group. Anne-Marie Vangsted replied that it did not necessarily have to be the same person, since the working group should be joined by participants with specific knowledge or qualifications.


Participants

  • Amgros: Bente Dam
  • Association of Danish Pharmacies: Linda Aagaard Thomsen
  • Danish Drug Information: Louise Thrane, Christianna Marinakis
  • Danish Society for Patient Safety: Annemarie Hellebek
  • Association of Hospital Pharmacies in Denmark: Majken Nørskov Petersen, Lene Stenbek
  • Danish Nurses’ Organization: Gunilla Svensmark, Janne Due Sommerset
  • FOA – Trade and Labour: Ulla Rosenkvist
  • Danish Generic Medicines Industry Association: Lena Storm, Hospira
  • Institute for Rational Pharmacotherapy: Marianne Møller
  • The Danish Medicines Agency: Anne-Marie Vangsted, Charlotte Mortensen, Lene Havsteen, Marie Melskens
  • Pharmadanmark: Sonja Paltoft
  • Region of Southern Denmark, Centre for Quality: Marie Lund Nielsen
  • National Board of Health: Marianne Søborg Nielsen, Karin Povlsen

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