safe prescribing: how to avoid prescribing errors kevin gibbs clinical pharmacy manager united...

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Safe prescribing: How to avoid prescribing errors Kevin Gibbs Clinical Pharmacy Manager United Bristol Healthcare Trust Slide 2 Aims To provide an awareness of: Common medication errors How to minimise these National and local resources available to you to aid in safer prescribing To give you some prescribing pointers to look out for in your clinical placements Slide 3 By the end of the session you should be able to: Define a medication error List the Five Rights Identify common types of medication errors Begin to think about how to minimise errors by using your knowledge, skills and available resources Slide 4 During your placements Think about: What do I need to prescribe in a safe way? Patient information Co-morbid conditions Drug information Pharmacology Pharmacokinetics and pharmacodynamics Therapeutics Systems Policies, guidelines, prescribing aids etc Slide 5 What is an error? Slide 6 Doses omitted Wrong dose Unprescribed drug given Wrong dosage form given Wrong route of administration Wrong rate of administration Wrong time of administration time of day in relation to food etc.... Using unstable/expired drug Wrong administration technique Incorrect reconstitution Extra dose given Slide 7 Where do errors occur in the process of giving a drug? Prescribing Dispensing Administration Counselling/communication Slide 8 Adverse events in hospitals What is the size of the problem? Adverse events per admission (%) 10% AE number / year in UK 850,000 Cost in additional hospital stay () 2 billion Cost of clinical negligence schemes/yr 400 million Medication errors = % of incidents 25% An organisation with a memory. Dept of Health 2001 Slide 9 Reported incidences 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 Outcomes Data collated by US National Co-ordinating council for Medication Error Reporting and Prevention 1993-98 Performance deficit 29.8% Communication problem 15.8% Knowledge deficit 14.2% Dose miscalculation 13% 5366 reports 68.2%- Serious patient outcomes 9.8% - fatal Improper dose Wrong drug Wrong route of administration Phillips, J etal. Am J Health Syst Pharm 2001;58: 1835-41 Slide 11 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 12 Slide 13 Handwriting Slide 14 Errors in medication history taking Literature review 22 studies, 3755 patients Errors in medication histories In up to 67% of cases 10-61% had at least 1 omission error 54% of patients had at least 1 medication history error Clinically important errors in 11-59% Tam et at Canadian Medical Association Journal 2005;173(5):510-15 Slide 15 Dispensing and admin n 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 16 Similar packaging Same drug different manufacturers Slide 17 Similar packaging Same drug several strengths May be colour-coded but DO NOT rely on colour Slide 18 Similar packaging Similar sounding names / similar spelling / same strength Ceftazidime Cefotxime Slide 19 Similar packaging If in a hurry These look similar Water for injection, Sodium Chloride injection So does Potassium 15% injection = Why there are NPSA/Trust policy on restricting this Slide 20 Summary: 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 21 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 22 Complicated prescriptions Calculations Verbal orders Lack of knowledge about drugs Mistakes in identifying drugs names packaging misreading Slide 23 National & local examples Discharged on warfarin loading dose 10mg od Not referred for dose adjustment to clinic 14days of 10mg od INR 12.3 Admitted with frank haemorrhage Weight-related dose for tinzaparin 80kg est d Patient was 51kg, risk of haemorrhage Rx: Ranitidine 50mgGiven via epidural line rather than central line Slide 24 Discharged on warfarin loading dose 10mg od Not referred for dose adjustment to clinic 14days of 10mg od INR 12.3 Admitted with frank haemorrhage Weight-related dose for tinzaparin 80kg est d Patient was 51kg, risk of haemorrhage Rx: Ranitidine 50mgGiven via epidural line rather than central line Slide 25 CABG patient, standard therapy Thyroxine missed on admission, discovered day 10 Galantamine re- started after a gap, Rx; 8ml qds Should have been 12mg (2ml) bd prescriber confused over liquid strength Rx: Co-amoxiclav Penicillin-alllergic Did not realise this is a penicillin anaphylaxis Slide 26 Anaesthetist adjusted rate of fentanyl syringe pump in Theatre New pump. Increased rate x 1000 Respiratory arrest - death Rx: morphine 0.4ml4ml given 30% sodium chloride used instead of 0.9% to dilute an epidural Severe pain Slide 27 In Theatre: Sodium chloride flush for a central line switched with fentanyl Respiratory arrest. Syringes made up in advance and not labelled IV line flushed with sodium chloride 0.9% Was in fact Potassium 15% death Ampoules look similar in design Slide 28 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 29 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 30 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 31 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 32 Improving medication safety Department of Health. Jan 2004 Slide 33 Improving medication safety: Main areas of medication error Anaesthetic practice Anticoagulants Cytotoxic drugs Intravenous infusions Methotrexate Opiate analgesics Potassium chloride Slide 34 Causes Solutions Lack of knowledge of the drug 31% Wrong dose, choice, drug. Interaction Allergy checking rule violations 10% Incl. communication problems Slip or memory loss 9% Drug information Eg: Interactions Resources available Patient condition Renal / liver function Guidelines, formulary Leape et al. JAMA 1995;274:35-43 Slide 35 Avoiding errors Patient knowledge Have a therapeutic goal Is prescribing the right answer? Have you included the patient in this decision? Knowledge about the drug Monitor for effects and adverse effects Use your resources Good communication Slide 36 Taking a good medication history How reliable is your source does it have enough detail? Patient, patients repeat prescription, own drugs, GP admission letter, on-call service Drug details dose, frequency, formulation (eg modified release), start date, indication Include: Prescribed drugs, OTC drugs, complementary medicines, vitamins, ? Recreational drugs Allergies including severity Compliance Therapeutic failures Slide 37 Factors affecting a drugs pharmacodynamics or pharmacokinetics Children The elderly Renal impairment Hepatic impairment Prescribing in pregnancy or breast feeding Drug interactions More later.. Further references: Clinical Pharmacology textbook use course recommendation Basic Clinical Pharmacokinetics. 4 th edn. ME Winter. Covers Drug-specific kinetics eg Digoxin, gentamicin Slide 38 Drug dosing in renal impairment Based on estimation of renal function using creatinine clearance Cockcroft-Gault equation Crcl = F x (140-age)x wt in kg S.Cr in micromol/L Where F = 1.23 for males, 1.04 for females Or use an on-line calculator such as alculator.cfm alculator.cfm Slide 39 Drug-drug interactions drug-food interactions Resources BNF Appendix 1 Pharmacy Medicines Information Departments Have specialists texts and other resources to help mOre in a leter talk Slide 40 Resources available to you Summary of Product Characteristics for each medicine - eMC Pharmacy Medicines Information On-line National Electronic prescribing Other medical and non-medical prescribers Slide 41 Pharmacy Avaliable for help and advice Ward Pharmacist Local Medicines Information department Regional medicines Information Mainly Community sector enquiries Out-of-hours: On-call or resident pharmacist Slide 42 Electronic Medicines Compendium (eMC) The eMC provides up-to-date information on licensed UK medicines Summary of Product Characteristics (SPCs) Patient Information Leaflets (PILs). SPCs are legal & technical documents with information to help guide on the best way to use a medicine. Slide 43 Slide 44 Slide 45 Slide 46 Slide 47 Slide 48 In summary Slide 49 Prescribing responsibili