Medication errors& how to minimise them!

Kevin GibbsClinical Pharmacy ManagerBristol Royal Infirmary

Aims

To provide an awareness of: Common medication errors How to minimise these The National Patient Safety Agency Resources available to you to aid in safer

prescribing

Objectives

By the end of the session you should be able to:

Define a medication error

List the ‘Five Rights’

Understand the NHS role in safer prescribing

Prescribe safely…………

What is an error?

What is an error ?

Doses omitted Wrong dose Unprescribed drug

given Wrong dosage form

given Wrong route of

administration Wrong rate of

administration

Yes

Yes

Yes

Yes

Yes

Yes

Wrong time of administration time of day in relation to food etc....

Using unstable/expired drug

Wrong administration technique

Incorrect reconstitution Extra dose given

Yes

Yes

Yes

Yes

Error in ….

Prescribing Dispensing Administration Counselling/communication

Adverse events – What is the problem Adverse-events per

admission (%) AE number / year in

UK Cost in additional

hospital stay (£) Cost of clinical

negligence schemes/yr Medication errors = %

of incidents

10%

850,000

£2 billion

£400 million

25%

Incidence

Difficult to estimate due to varying definitions - US/UK

Prescribing errors 3-20 per 1000 prescriptions

Medication errors 1 per patient per day

Been estimated that drug errors account for 1/5 of all deaths due to adverse drug events

Prescribing errors

Process Error Rate Serious Errors

Prescribing errors(Primary Care)

Computer generated

7.9%

Prescribing errors(Primary Care)Hand written

10.2%

Prescribing errors(Hospital)

1.5% 0.4%

Dean B, Schachter M, Vincent C, Barber N. Quality and Safety in Healthcare 2002; 11:340-344Shah SNH, Aslam M and Avery AJ. Pharm J. 2002; 267: 860-862

Dispensing and Admin ErrorsStage of process Error Rate Serious Errors

Dispensing errors (P) 1% 0.18%

Dispensing errorsUndetected (H)

0.0002

AdministrationOral Medicines (H)

3 – 8%

Preparation and admin of parenteral medicines

13%- 49% 1%

UK references 1 – 12 from Building a safer NHS, Medication Safety

The NHS position on error

Avoidable failures occur; Untoward events which could be prevented recur, often

with devastating results Incidents which result from lapses in standards of care in

one hospital do not reliably lead to correction throughout the NHS

Circumstances which predispose to failure are not well recognised

An Organisation with a MemoryDepartment of Health (2000)http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/

PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4006525&chk=wlMQiJ

Patient safety

The process by which an organisation makes patient care safer. This should involve:

risk assessment; the identification and management of patient-related risks;

the reporting and analysis of incidents; and the capacity to learn from and follow-up

on incidents and implement solutions to minimise the risk of them recurring.

National Patient Safety Agency

Collect and analyse information on adverse events

Assimilate other safety-related information Learn lessons and ensure that they are fed back

into practice Where risks are identified, produce solutions to

prevent harm, specify national goals and establish mechanisms to track progress

NPSA: Patient safety incident

any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare.

this is also referred to as an adverse event / incident or clinical error, and includes near misses.

NPSA: Seven steps to patient safety

Step 1 Build a safety culture Step 2 Lead and support your staff Step 3 Integrate your risk management activity Step 4 Promote reporting Step 5 Involve and communicate with patients

and the public Step 6 Learn and share safety lessons Step 7 Implement solutions to prevent harm

Reduce to zero the number of patients dying or being paralysed by maladministered spinal injections by the end of 2001

Reduce by 40% the number of serious errors in the use of prescribed medicines by 2005

Building a safer NHS for patientsDepartment of Health (2001)www.doh.gov.uk/buildsafenhs

NHS action on medication errors

Improving medication safetyJanuary 2004

www. doh.gov.uk/buildsafenhs/medicationsafety

Improving medication safety

1. Medication safety – a worldwide health priority.

2. Medication errors: definition, incidence, causes.

3. The medication process, prescribing, dispensing, administration.

4. Reducing risks for specific patients groups. Patients with allergies Seriously ill patients Children

Improving medication safety5. Reducing the risks for specific medicines

Anaesthetic practice Anticoagulants Cytotoxic drugs Intravenous infusions Methotrexate Opiate analgesics Potassium chloride

6. Organisational and environmental strategies Information management and technology Improved labelling and packaging Interfaces between healthcare settings Education and training for medication safety

Managing medication safety in secondary care

NHS Trusts should have dedicated machinery for organisation wide management of patient safety.

The CNST has developed new standards for

medicines. This requires trusts to have medicines management policies, together with annual reports, improvement programmes with defined objectives and progress.

Prescribing responsibilities

Drug Dose Route Rate of administration Duration of treatment

Checking patient allergies & sensitivities

Providing a prescription that is: Legible Legal Signed Giving all information to allow safe

administration

Internationally

USA 44-98,000 deaths

“To Err is Human” Australia 250,000 adverse events 50,000 permanent disability 10,000 deaths

“Iatrogenic Injury in Australia” Denmark confirmed 9% of admissions

Research says:

Commonest causes of medication errors Lack of knowledge of the drug – 36% Lack of knowledge about the patient “rule” violations – 10% “Slip” or memory loss – 9%

JAMA 1995;274:35-43

Common error types

Wrong patient Contra-indicated medicine

Allergy, medical condition, drug-drug interaction

Wrong drug / ingredient Wrong dose / frequency Wrong formulation Wrong route of administration Wrong quantity

Poor handwriting on Rx Incorrect IV administration calculations or

pump rates Poor record keeping/checking

double doses wrong patient

Paediatric doses Poor administration technique

Complicated prescriptions Calculations Verbal orders Lack of knowledge about drugs Mistakes in identifying drugs

names packaging misreading

Examples

Rx: Insulin 7 stat Erythromycin 500mg IV

in 50ml ISMN 10mg

Vancomycin IV 1g

read as 70 units, given Highly irritant – should

be 250-500 ml ISTIN 10mg given

Isosorbide mononitrate given instead of amlodipine

given as bolus rather than infusion cardiac arrest

Ceftazidime 2g tds IV

Methotrexate 20mg daily (Dx: RA)

Digoxin 125mg IV

Discharged on warfarin loading dose 10mg od

written badly Cefotaxime given

Should be weekly Neutropenia

Should be micrograms given - cardiac arrest

Not referred for dose adjustment to clinic 14days of 10mg od INR 12.3

Weight-related dose for tinzaparin – 80kg body weight estimated

CABG patient, standard therapy

Galantamine re-started after a gap 8ml qds

Patient was 51kg

Thyroxine missed on admission, discovered day 10

Should have been 12mg (2ml) bd PRHO confused over

liquid strength

Anaesthetist adjusted rate of fentanyl syringe pump in Theatre

Rx: Co-amoxiclav Penicillin-alllergic

Rx: morphine 0.4ml 30% sodium chloride

used instead of 0.9% to dilute an epidural

New pump. Increased rate x 1000 Respiratory arrest

Did not realise this is a penicillin – anaphylaxis

4ml given Severe pain

Rx: Ranitidine 50mg

In Theatre: Sodium chloride flush for a central line switched with fentanyl

IV line flushed with sodium chloride 0.9%

Given via epidural line rather than central line

Respiratory arrest. Syringes made up in advance and not labelled

Was in fact Potassium 15% - death. Ampoules look similar in design.

Case study 1 – "Cambridge"

Rx Methotrexate 17.5mg once a week New Rx 10mg once a day 10mg daily dispensed by locum pharmacist Rx error noticed by 2nd GP, but the computer

record was not altered +5/7 patient admitted to ENT ward

Drug chart written for 100mg daily +1/7 Nurse d/w patient – back to 10mg od +1/7 Pharmacist queries and asks nurse to ask Dr

to check dose GP records confirm 10mg od +2/7 blood tests re-checked Haem +5/7 patient dies

Case study 2 – “Nottingham”

Rx Intrathecal methotrexate under GA in theatre by Oncology Reg & intravenous vincristine on ward by specialist nurse

"Outlied" on non-specialist ward Both drugs delivered to theatre from ward Given food pre-op – op postponed

Orignal SpR off-duty now Cover SpR unable to leave ward, anaesthetist to

admin intrathecal drug Aneasthetist had given I/Thecal drugs before but

had never given chemotherapy Methotrexate given intravenously Vincristine given intrathecally Patient died

How to handle errors

Is there an acceptable rate ? Should errors be graded or scored for

severity ?

Blame vs. No blame Analyse why the errors have occurred and

try to prevent reoccurrence

When things go wrong The "patient-centered“ approach

Identify an individual to blame Focus on events surrounding the adverse

event Focus on the human acts or omissions

immediately preceding the event Blame, name & shame

Myths

Perfection myth If people try hard enough they will not make

any errors Punishment myth

If we punish people when they make a errors, ther will make fewer of them

Or/ “Active learning” = Understanding causes of failure

Human error may precipitate

a serious error

but

Deeper, systematic, factors are usually present

Addressing these would have prevented the error

Humans are fallible Errors are inevitable

Change work conditions to make humans less error-provoking Why did the defences fail? What factors contributed to the failure?

CPD

How can we help you?

Clinical

pharmacists

How can we help you?

Medicines

Information

Department

How can we help you?

Formularies

and

Prescribingguidelines

MEDICAL DIRECTORATE ANTIBIOTIC GUIDELINES

1) Don’t use IV antibiotics without good cause 2) Don’t use multiple antibiotics without good indications 3) Don’t give IV therapy for more than 2 days without review (nurses/pharmacists will request new prescription) (IV to Oral policy)

4) Don’t prescribe antibiotics for acute asthma without strong evidence of bacterial infection (usually viral) 5) Review antibiotics when results e.g., urine, blood, sputum cultures etc are available.

Use oral antibiotics for 5-7 days unless otherwise stated.

Doses assume adult with normal renal function

INFECTION COMMENTS DRUG DOSE DURATION OF TX Intravenous Benzylpenicillin should be switched to oral Amoxicillin where appropriate.

Amoxicillin 500mg po 8 hourly Infective Exacerbation of COPD If penicillin allergic Moxifloxacin 400mg po once daily 5 days

Mild Amoxicillin 500mg po 8 hourly

Mild – if atypical suspected or penicillin allergic

Moxifloxacin 400mg po once daily

Severe Benzylpenicillin PLUS Ciprofloxacin

2.4grams (4mu) iv 6 hourly 750mg po 12 hourly

7-10 days

Community Acquired Pneumonia Risk Factors in CAP (CURB-65) C = confusion MTS 8 or less U = Urea >/= 7mmol/l R = Resp. Rate >/= 30/min B = BP Systolic < 90 mmHg +/- Diastolic </= 60 mmHg 65 = age >/= 65 yrs

Severe – penicillin allergic

Levofloxacin Switching to oral

Moxifloxacin

500mg iv 12 hourly 400mg po once daily

7-10 days

Legionella Pneumonia

Ciprofloxacin PLUS Rifampicin

750mg po 12 hourly 300mg-600mg iv/po 12 hourly

2-3 weeks

Suspected Staphylococcal Pneumonia

Flucloxacillin PLUS Gentamicin

2grams iv 6 hourly 4mg/kg/day iv single daily dose (check trough level)

2 weeks 5 days then review

Aspiration Pneumonia

Benzylpenicillin PLUS Metronidazole

2.4grams iv 6 hourly 500mg iv 8 hourly or 1gram pr 8-12 hourly

Amoxicillin 500mg po 8 hourly Mild Nosocomial Chest Infection

If penicillin allergic Moxifloxacin 400mg po once daily

Severe Nosocomial Chest Infection

Benzylpenicillin PLUS Ciprofloxacin (Consider Vancomycin instead of Benpen. – if MRSA colonised)

2.4grams (4MU) iv 6 hourly 750mg po 12 hourly (1gram iv 12 hourly and check levels)

Meningitis All Cases

Initial treatment THEN discuss further management with microbiologists

Ceftriaxone If Over 55yrs ADD

Ampicillin

4grams iv once daily 2grams iv 4 hourly

Benzylpenicillin PLUS Flucloxacillin

2.4grams (4MU) iv 6 hourly 1gram iv 6 hourly

Cellulitis

If penicillin allergic Clindamycin 600mg iv 6 hourly or 450mg po 6 hourly

Cellulitis in Diabetics Co-amoxiclav OR

Ciprofloxacin PLUS Clindamycin

625mg po 8 hourly 750mg po 12 hourly 450mg po 6 hourly

Depends on individual case.

Urinary Tract Infection Trimethoprim 200mg po 12 hourly 3 days Urinary Catheter Infections and Pyelonephritis

Ampicillin PLUS Ciprofloxacin PLUS Stat dose Gentamicin

1gram iv 6 hourly 750mg po 12 hourly 4mg/kg iv single dose

Mild Benzylpenicillin PLUS Ciprofloxacin

2.4grams (4MU) iv 6 hourly 750mg po 12 hourly

Sepsis of unknown source Severe

(Life Threatening) Ceftriaxone PLUS Gentamicin

4grams iv once daily 4mg/kg/day iv single daily dose (check trough)

How can we help you?

Resources

BNF

Medicines

for Children

Safe prescribing: A summary

Clear and unambiguous

Approved name

No abbreviations

Care with IVs

Care with units

Legal

Is it weight/BSA-related dosing. Is weight accurate?

Clear decimal points0.5ml not .5ml

Rewrite charts regularly

Take time, eg to read labels

***** In English If abbreviate use

‘standard’ ones

od / bd / tds / qds

NOT 250mg3

Care if: Impaired renal function (NB: GFR) Hepatic dysfunction Children The elderly Drug unknown to you Very new drug

The “5 Rights”

• the right patient• the right drug• the right time• the right dose• the right route

If in doubt ……..

Please ask

Further reading/references

Naylor, R. Medication Errors. Radcliffe Press. ISBN 1857759567

Department of Health. (2004). Building a safer NHS. Improving patient safety.

National Patient Safety Agency (NPSA) (UK) Website: http://www.npsa.nhs.uk/

Institute for Safe Medication Practices (ISMP) (American) Website: http://www.ismp.org/