Medicine Management Risk Register

Assurance on Risk Grading Assurance Gaps

Risk Ref Number Risk Description Controls Against Risk Controls/Evidence they are Sources Gaps in Control in Reviews
working S L R (Types) Assurance
Risk Assessment Title: Homecare Version No: 3 Owner: William Glendinning Title: Pharmacist
1 MM14/14 Clinical and financial risk Clinical pharmacists review of HIV Commisisoning engagement via Initial Risk:
Lack of -ve No Homecasre Nothing substantial Last Review:
from use of homecare prescriptions. Adoption of Blueteq for Blueteq. 4 4 16 feedback from policy. No effective in place to satisfy 17/11/2014
Department: medicines without effective rhuematology prescriptions Homecare Business case commisioners. system for requirements.
Frequency:
controls (as stated in approved by Trust Nov-14 Current Risk: reconciling
Pharmacy Hackett Report 2012). medicines with Quarterly
4 4 16
invoices. No Next Review:
Sub Division:
Target Risk: identified staff to
Mar 2015
Pharmacy 4 2 8 manage Homecare.
Failure to adopt
Date Opened: recomnedations
from Hackett report.
22/04/2014
Risk Assessment Title: Education and training of workforce wrt safe medicines use Version No: 3 Owner: William Glendinning Title: Pharmacist
2 MM14/15 Patients will be at harm if Insulin prescribing sheet. GKI Metrics exist for the limited Initial Risk:
Error/near miss data Trust needs a Learning is limited. Last Review:
staff are not trained and guidelines; junior doctor training on training that is offered/available. 4 4 16 reported to SMPG. comprehensive 17/11/2014
Department: competent in handling safe prescribing of insulin; limited Metrics now reported on process to provide
Frequency:
medicines (prescribing, pharmacy service to support safe completion of training via SMPG Current Risk: adequate training to
Pharmacy administration etc). use of medicines. TNA reviewed against all clinical staff. Bi-Monthly
4 4 16
Northumbria TNA Next Review:
Sub Division:
Target Risk:
Jan 2015
Pharmacy 4 2 8

Date Opened:

22/04/2014
Risk Assessment Title: Pharmacy services Version No: 2 Owner: William Glendinning Title: Pharmacist
3 MM14/17 Patients at risk if Pharmacy Management and leadership capacity Details provided throughout this Initial Risk:
Details provided Inadequate No Service Line Last Review:
service fails to deleiver the is limited. Depth of clinical and Risk Register. Also CQC 4 4 16 throughout this Risk management/ Reporting/inadequa 17/11/2014
Department: necessary leadership and operational service provided is also outcomes measures report. Register. leadership te KPIs to
Frequency:
operational/clinical support limited. Current Risk: capacity/resources demonstrate where
Pharmacy that is required. Operational plan drafted to support to ensure timely and service is failing. Monthly
4 4 16
Medicines Optimisation strategy to appropriate delivery Trust's inadequate Next Review:
Sub Division:
address gaps. Target Risk: of safety governance
Dec 2014
Pharmacy 4 1 4 improvement reporting
actions. The TDA's arrangements
Date Opened: Medicines compound the
Optimisation and problems.
22/04/2014 Pharmaceutical

18/11/2014 Page 1 of 6
 Medicine Management Risk Register
Assurance on Risk Grading Assurance Gaps
Risk Ref Number Risk Description Controls Against Risk Controls/Evidence they are Sources Gaps in Control in Reviews
working S L R (Types) Assurance

Services
Framework
provides details of
gaps.
Risk Assessment Title: Medicines reconciliation at point of admission Version No: 3 Owner: William Glendinning Title: Pharmacist
4 MM14/01 Errors in Medicines policy. Standard procedure Limited error/near miss data Initial Risk:
Monthly time series Clinical pharmacy Limited intervention Last Review:
prescribing/recording at for medicines reconciliation. Training reported to SMPG. Medicines 5 3 15 reported to SMPG. service only recording and 17/11/2014
Department: point of admission which for nursing and medical staff. Clinical reconciliation rate at point of Target = 80% available 'office feedback
Frequency:
follow patient throughout pharmacy service provided to admission. Medication safety Current Risk: (2014/5) hours'/limited mechanism linked to
Pharmacy their inpatient stayleading to admissions, targeted at the medicines thermometer reporting and service to the Trust's risk Monthly
5 3 15
potential for harm (ref: reconciliation process. Involvement independent CPFT audit reporting pre-admission. management Next Review:
Sub Division:
NPSA alert which defines a of Pharmacy staff in pre-admission rate above 80%(Nov14) Target Risk: Many patients are system. Under
Dec 2014
Pharmacy target of review by pathway for elective patients. 5 1 5 not seen and reporting of
Pharmacist within 24 hours cannot easily be medicines related
Date Opened: of admission). tracked. incidents through
Ulysses.
22/04/2014
Risk Assessment Title: Medicines reconciliation at point of discharge Version No: 3 Owner: William Glendinning Title: Pharmacist
5 MM14/02 Errors in prescribing at System for reconciling medicines at Limited error/near miss data Initial Risk:
Error/near miss data Limited clinical Errors are under Last Review:
discharge or in the point of discharge (when reported to SMPG. Audit of 5 3 15 reported to SMPG. pharmacy service reported. No 17/11/2014
Department: communication with GP at pharmacy involved). discharge reconciliation from available (best routine monitoring
Frequency:
point of discharge are not CPFT demonstrates rate of 54% Current Risk: place to undertake data so % patients
Pharmacy identified leading to (Nov-14) check is at ward in whom no check Monthly
5 3 15
potential for harm. level with access to is done is limited Next Review:
Sub Division:
Target Risk: notes and patient).
Dec 2014
Pharmacy 5 1 5 Many patients'
discharges are not
Date Opened: seen. Discharges
received through
22/04/2014 Pharmacy receive
minimum
countercheck only.

18/11/2014 Page 2 of 6
 Medicine Management Risk Register
Assurance on Risk Grading Assurance Gaps
Risk Ref Number Risk Description Controls Against Risk Controls/Evidence they are Sources Gaps in Control in Reviews
working S L R (Types) Assurance
Risk Assessment Title: Electronic Prescribing and Medicines Administration (EPMA) Version No: 3 Owner: William Glendinning Title: Pharmacist
6 MM14/05 Patients at risk of harm of System of near miss and error Limited error/near miss data Initial Risk: See risk number Limited pharmacy Limited reports via Last Review:
medicine related errors due reporting. Pilot agreed for use of reported to SMPG. Progress 3 5 15 MM14/03 service so risk SMPG. In absence 17/11/2014
Department: to frequent non compliance Medicines Safety Thermometer as reports (verbally) of cannot be mitigated. of reliable
Frequency:
with policy where means of providing good quality implementation of MST according Current Risk: No active clinical information,
Pharmacy technological solutions information about medicines safety. to timescale. decision support assurance of a Monthly
3 5 15
could reduce. Need clinical AuditR in use. Project initiated and embedded within safe/appropriate Next Review:
Sub Division:
decision support to help agreed with Cancer centre to deliver Target Risk: processes. system of
Dec 2014
Pharmacy doctors and nurses to do chemotherapy prescribing by end of 3 2 6 medicines use is
the right thing and make the 2015. low. Learning is
Date Opened: right decisions when it limited.
comes to medicines use.
22/04/2014 Lack of solution for
chemotherapy raised as a
serious risk by Peer
review.

Risk Assessment Title: Controlled Drug Supply Licence Version No: 3 Owner: William Glendinning Title: Pharmacist
7 MM14/06 Trust operating illegally Raised with Chief Pharmacist for n/a Initial Risk: n/a "No licences in n/a Last Review:
without appropriate Home England through Chief Pharmacists' 3 4 12 place and 17/11/2014
Department: Office licence when network to discuss with Home Office application process
Frequency:
supplying Controlled Drugs and MHRA. Current Risk: can take 16 weeks.
Pharmacy to 3rd parties. Application made for licences for CIC No SLA signed Bi-Monthly
3 4 12
and WCH Pharmacy departments between Trust and Next Review:
Sub Division:
30-12-2013. SLA negotiations with Target Risk: Cumbria Partnership
Jan 2015
Pharmacy Partnership ongoing for ~2 years 3 1 3 Trust for supply of
medicines.
Date Opened: "

22/04/2014

18/11/2014 Page 3 of 6
 Medicine Management Risk Register
Assurance on Risk Grading Assurance Gaps
Risk Ref Number Risk Description Controls Against Risk Controls/Evidence they are Sources Gaps in Control in Reviews
working S L R (Types) Assurance
Risk Assessment Title: Wholesale Dealer's Licences Version No: 3 Owner: William Glendinning Title: Pharmacist
8 MM14/07 Trust operating illegally Ditto n/a Initial Risk: n/a No licence in place - n/a Last Review:
without appropriate MHRA 3 4 12 note would require 17/11/2014
Department: licence when supplying changes to staff
Frequency:
medicines to 3rd parties. Current Risk: roles, fabric of
Pharmacy department and Bi-Monthly
3 4 12
internal processes Next Review:
Sub Division:
Target Risk: to operate with a
Jan 2015
Pharmacy 3 1 3 wholesale dealer's
licence GDP
Date Opened: requirement)

22/04/2014
Risk Assessment Title: Medicine storage in bedside lockers Version No: 3 Owner: William Glendinning Title: Pharmacist
9 MM14/08 Defects in lockers. Regular inspection by pharmacy No reported thefts of medicines Initial Risk:
Medicine Inconsistent checks Limited reports via Last Review:
Medicines are not held staff. from a patient bedside locker. 3 4 12 management risk on lockers to SMPG. In absence 17/11/2014
Department: securely. assessment. ensure they are of reliable
Frequency:
Current Risk: Regular ward empty when information,
Pharmacy Quarterly
3 4 12 checks by patients move on. assurance of a
pharmacy staff, IR1 reports of safe/appropriate Next Review:
Sub Division:
Target Risk: Ulyssesreporting previous patient's system of
Mar 2015
Pharmacy 3 1 3 medicines left in medicines use is
lockers on low. Learning is
Date Opened: handover to new limited.
patients.
22/04/2014
Risk Assessment Title: High risk injectable medicines Version No: 3 Owner: William Glendinning Title: Pharmacist
10 MM14/09 Potential for harm to Some prefilled bags and syringes Limited error/near miss data Initial Risk: Error reporting No regular audits. Limited reports via Last Review:
patients and staff bought in. Injectable database held reported to SMPG. Progress 3 4 12 system. Some products are SMPG. In absence 17/11/2014
Department: associated with the on ward with risk assessment reports (verbally) of made at ward level of reliable
Frequency:
assemby and administration included. Aseptic unit makes up implementation of MST according Current Risk: that should not be. information,
Pharmacy of high risk injectable some products (i.e. no cytotoxic to timescale assurance of a Monthly
4 3 12
medicines (e.g. infliximab) drugs made up on wards). Training safe/appropriate Next Review:
Sub Division:
available for nurses. Target Risk: system of
Dec 2014
Pharmacy 4 2 8 medicines use is
low. Learning is
Date Opened: limited.

22/04/2014

18/11/2014 Page 4 of 6
 Medicine Management Risk Register
Assurance on Risk Grading Assurance Gaps
Risk Ref Number Risk Description Controls Against Risk Controls/Evidence they are Sources Gaps in Control in Reviews
working S L R (Types) Assurance
Risk Assessment Title: Insulin Version No: 3 Owner: William Glendinning Title: Pharmacist
11 MM14/12 Potential for harm to Insulin prescribing sheet. GKI Subcutaneous Insulin prescription Initial Risk: Error reporting No up to date Limited reports via Last Review:
patients associated with guidelines; junior doctor training on chart implemented and training 3 4 12 system. prescribing SMPG. In absence 17/11/2014
Department: the use of insulin safe prescribing of insulin; limited rolled out to all areas on its use. documentation for iv of reliable
Frequency:
pharmacy service to support safe Current Risk: insulin No use of IT information,
Pharmacy use of medicines. (clinical decision assurance of a Monthly
3 4 12
support) to mitigate safe/appropriate Next Review:
Sub Division:
Target Risk: risk; lack of system of
Dec 2014
Pharmacy 3 2 6 pharmacy service medicines use is
to mitigate risk. low. Learning is
Date Opened: limited.

22/04/2014
Risk Assessment Title: Heparin and other anticoagulants Version No: 3 Owner: William Glendinning Title: Pharmacist
12 MM14/10 Potential for harm to Prescribing sheet in place; Feedback from users that Initial Risk: Error reporting Limited reports via Last Review:
patients associated with standardised heparin preparations. paperwork is used and process 2 5 10 system. SMPG. In absence 17/11/2014
Department: the use of heparin and followed of reliable
Frequency:
other anticoagulants Current Risk: information,
Pharmacy assurance of a Monthly
5 2 10
safe/appropriate Next Review:
Sub Division:
Target Risk: system of
Dec 2014
Pharmacy 5 2 10 medicines use is
low. Learning is
Date Opened: limited.

22/04/2014
Risk Assessment Title: Capacity for improvement with medicines safety agenda Version No: 2 Owner: Jeremy Rushmer Title:
13 MM14/13 Failure to deliver Honorary contract for David Campbell Changes made to Clinical Initial Risk:
SMPG minutes, Inadeqaute Limited capacity to Last Review:
improvement against as Medicines Safety Lead (one day Guidelines with involvement of 5 4 20 Clinical Guidelines management/leade deliver full changes 17/11/2014
Department: medicines safety priorities. per week). Executive Director MSO published rship required.
Frequency:
Failure to demonstrate support from Medical Director and Current Risk: capacity/resources
Pharmacy satisfactory assurance of Director of Nursing on Safe to ensure timely and Bi-Monthly
5 2 10
safe/quality system. Medicines Practice Group(SMPG). appropriate delivery Next Review:
Sub Division:
Medicines Safety Officer(MSO) Target Risk: of safety
Jan 2015
Pharmacy appointed. Representation from all 5 2 10 improvement
Business units achieved at SMPG. actions.
Date Opened:

22/04/2014

18/11/2014 Page 5 of 6
 Medicine Management Risk Register
Assurance on Risk Grading Assurance Gaps
Risk Ref Number Risk Description Controls Against Risk Controls/Evidence they are Sources Gaps in Control in Reviews
working S L R (Types) Assurance
Risk Assessment Title: Medicines safety Intelligence Version No: 4 Owner: William Glendinning Title: Pharmacist
14 MM14/03 Lack of assurance; Trust System of near miss and error Limited error/near miss data Initial Risk:
Error/near miss data Under reporting Limited reports via Last Review:
unable to identify where its reporting. Pilot agreed for use of reported to SMPG. Progress 4 3 12 reported to SMPG. levels via Ulysses SMPG. In absence 17/11/2014
Department: medicines safety concerns; Medicines Safety Thermometer as reports (verbally) of Ad hoc audit system. of reliable
Frequency:
unable to target means of providing good quality implementation of MST according Current Risk: results. information,
Pharmacy improvement action without information about medicines safety. to timescale assurance of a Monthly
4 2 8
(a) a robust system of AuditR in use. Access to NRLS data safe/appropriate Next Review:
Sub Division:
error and near miss by MSO now in place Target Risk: system of
Dec 2014
Pharmacy reporting and (b) system of 4 1 4 medicines use is
monitoring/reporting of high low. Learning is
Date Opened: risk processes or limited.
medicines; no effective
22/04/2014 system of demonstarting
impact of improvement
actions.
Risk Assessment Title: Medicines management/optimisation strategy Version No: 5 Owner: William Glendinning Title: Pharmacist
15 MM14/11 Trust Board not aware of Strategy drafted and circulated Strategy approved by S&Q in Initial Risk: n/a n/a Strategy not yet Last Review:
extent of risk or long term around Business units and November-14 4 4 16 approved by Trust 17/11/2014
Department: plan to mitigate. assurance committees Board
Frequency:
Consequential impact on Current Risk:
Pharmacy patient safety of ineffective Bi-Monthly
4 2 8
controls, systems and Next Review:
Sub Division:
services. Target Risk:
Jan 2015
Pharmacy 4 1 4

Date Opened:

22/04/2014

18/11/2014 Page 6 of 6