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Medication errors & how to minimise them! Kevin Gibbs Clinical Pharmacy Manager Bristol Royal Infirmary Slide 2 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 Slide 3 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 Slide 4 What is an error? Slide 5 Doses omitted Wrong dose Unprescribed drug given Wrong dosage form given Wrong route of administration Wrong rate of administration Yes Slide 6 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 Slide 7 Error in . Prescribing Dispensing Administration Counselling/communication Slide 8 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% Slide 9 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 Slide 10 Prescribing errors ProcessError RateSerious 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; 11:340-344 Shah SNH, Aslam M and Avery AJ. Pharm J. 2002; 267: 860-862 Slide 11 Dispensing and Admin Errors Stage of processError RateSerious Errors Dispensing errors (P)1%0.18% Dispensing errors Undetected (H) 0.0002 Administration Oral Medicines (H) 3 8% Preparation and admin of parenteral medicines 13%- 49%1% UK references 1 12 from Building a safer NHS, Medication Safety Slide 12 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 Memory Department of Health (2000) ceArticle/fs/en?CONTENT_ID=4006525&chk=wlMQiJ Slide 13 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. Slide 14 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 Slide 15 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. Slide 16 NPSA: Seven steps to patient safety Step 1Build a safety culture Step 2Lead and support your staff Step 3Integrate your risk management activity Step 4Promote reporting Step 5Involve and communicate with patients and the public Step 6Learn and share safety lessons Step 7Implement solutions to prevent harm Slide 17 Slide 18 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 patients Department of Health (2001) NHS action on medication errors Slide 19 Improving medication safety January 2004 www. Slide 20 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 Slide 21 Improving medication safety 5. 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 Slide 22 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. Slide 23 Prescribing responsibilities Drug Dose Route Rate of administration Duration of treatment Checking patient allergies & sensitivities Slide 24 Providing a prescription that is: Legible Legal Signed Giving all information to allow safe administration Slide 25 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 Denmarkconfirmed 9% of admissions Research says: Slide 26 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 Slide 27 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 Slide 28 Poor handwriting on Rx Incorrect IV administration calculations or pump rates Poor record keeping/checking double doses wrong patient Paediatric doses Poor administration technique Slide 29 Complicated prescriptions Calculations Verbal orders Lack of knowledge about drugs Mistakes in identifying drugs names packaging misreading Slide 30 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 Slide 31 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 Slide 32 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 Slide 33 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 Slide 34 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. Slide 35 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 2 nd GP, but the computer record was not altered +5/7 patient admitted to ENT ward Slide 36 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 Slide 37 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 Slide 38 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 Slide 39 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 Slide 40 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 Slide 41 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 Slide 42 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