Identifying and Reducing Avoidable Drug-associated Bleeds

Janet Thomas

Betsi Cadwaladr University Health Board

This Betsi Cadwaladr University Health Board (BCUHB) pharmacovigilance/quality improvement project is about finding out more about just one fraction of medication-related harm; that of drug-associated bleeds (DaBs). It seeks to improve local/national data capture of DaBs, in order to learn lessons and reduce future occurrences.

Project Scope

Stakeholders include the local Endoscopy Steering Group and the Welsh Medical Imaging Sub-Committee of the Welsh Scientific Advisory Committee, local / national Clinical Coding departments, external Gastro-intestinal (GI) Reporting tool commercial software companies, NHS Wales Informatics Service (NWIS), the Medicines and Healthcare Products Regulatory Agency (MHRA) and its associates, BCUHB’s Drug and Therapeutics Group, finance department and cross-sector healthcare professionals.

The project, in time, will be a Wales-wide project impacting on the wider UK and beyond.

Initially, the Bevan Exemplar is working with stakeholders to refine the processes involved in identification of and capturing clinical coding of DaBs.

Another aspect is the collection of pharmacovigilance data regarding DaBs in the form of yellow MHRA cards. All drugs, whether new or long established therapies, have an inherent risk of Adverse Drug Reactions (ADRs). Identifying and reporting ADRs to the MHRA is an important part of drug surveillance. With time, root cause analysis of individual DaB cases should highlight avoidable DaBs and reveal potentially rectifiable contributory factors.

With improved clinical coding and identification, more accurate DaBs data should reflect a truer picture of both patient harm and NHS resource consumption.

Ultimately, national standards for the software companies engaged in gastro-intestinal (GI) reporting tools are strived for with parallel development of Bronchoscopy reporting tools for collecting drug-associated harm to lungs.

This project seeks to make a positive difference to reducing DaB harm and costs.

Why this Project?

Anticipated Benefits

Within BCUHB & ultimately across Wales

Make it safer:

Make it sound:

Make it happen:

Make it sustainable:

Within the UK

This Project Supports Prudent Healthcare

Part of Cohort Bevan Exemplars 2015-16