medication errors & how to minimise them! kevin gibbs clinical pharmacy manager bristol royal...
TRANSCRIPT
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 ?
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
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 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
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)
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
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/