safe prescribing: how to avoid prescribing errors

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Safe prescribing: How to avoid prescribing errors. Maggie Allen UHCW/CWFS. 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 - PowerPoint PPT Presentation


  • Safe prescribing:How to avoid prescribing errorsMaggie AllenUHCW/CWFS

  • AimsTo provide an awareness of:Common medication errorsHow to minimise theseNational and local resources available to you to aid in safer prescribingTo give you some prescribing pointers to look out for in posts

  • By the end of the session you should be able to:Define a medication errorList the Five RightsIdentify common types of medication errorsBegin to think about how to minimise errors by using your knowledge, skills and available resources

  • During your placementsThink about:What do I need to prescribe in a safe way?Patient informationCo-morbid conditionsDrug informationPharmacologyPharmacokinetics and pharmacodynamicsTherapeuticsSystemsPolicies, guidelines, prescribing aids etc

  • What is an error?

  • What is an error ?Doses omittedWrong doseUnprescribed drug givenWrong dosage form givenWrong route of administrationWrong rate of administrationWrong time of administrationtime of dayin relation to food etc....Using unstable/expired drugWrong administration techniqueIncorrect reconstitutionExtra dose given

  • Where do errors occur in the process of giving a drug?PrescribingDispensingAdministrationCounselling/communication

  • Adverse events in hospitalsWhat is the size of the problem?An organisation with a memory. Dept of Health 2001

    Adverse events per admission (%)10%

    AE number / year in UK850,000Cost in additional hospital stay ()2 billion

    Cost of clinical negligence schemes/yr400 million

    Medication errors = % of incidents25%

  • Reported incidencesDifficult to estimate due to varying definitions - US/UK

    Prescribing errors3-20 per 1000 prescriptionsMedication errors1 per patient per dayBeen estimated that drug errors account for 1/5 of all deaths due to adverse drug events

  • OutcomesData collated by US National Co-ordinating council for Medication Error Reporting and Prevention 1993-98Performance deficit 29.8%Communication problem 15.8%Knowledge deficit 14.2%Dose miscalculation 13%

    5366 reports68.2%- Serious patient outcomes9.8% - fatalImproper doseWrong drugWrong route of administrationPhillips, J etal. Am J Health Syst Pharm 2001;58: 1835-41

  • Prescribing errors

    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

    ProcessError RateSerious ErrorsPrescribing errors(Primary Care)Computer generated7.9%Prescribing errors(Primary Care)Hand written10.2%Prescribing errors(Hospital)1.5% 0.4%

  • Handwriting

  • Errors in medication history takingLiterature review22 studies, 3755 patientsErrors in medication historiesIn up to 67% of cases10-61% had at least 1 omission error54% of patients had at least 1 medication history errorClinically important errors in 11-59%Tam et at Canadian Medical Association Journal 2005;173(5):510-15

  • Dispensing and adminn errorsUK references 1 12 from Building a safer NHS, Medication Safety

    Stage of processError RateSerious ErrorsDispensing errors (P)1%0.18%Dispensing errorsUndetected (H)0.0002AdministrationOral Medicines (H)3 8%Preparation and admin of parenteral medicines13%- 49%1%

  • Similar packagingSame drug different manufacturers

  • Similar packaging

    Same drug several strengthsMay be colour-coded but DO NOT rely on colour

  • Similar packagingSimilar sounding names / similar spelling / same strengthCeftazidime Cefotxime

  • Similar packagingIf in a hurry These look similar Water for injection, Sodium Chloride injectionSo does Potassium 15% injection = Why there are NPSA/Trust policy on restricting this

  • Summary:Common error typesWrong patientContra-indicated medicineAllergy, medical condition, drug-drug interactionWrong drug / ingredientWrong dose / frequencyWrong formulationWrong route of administrationWrong quantity

  • Poor handwriting on RxIncorrect IV administration calculations or pump ratesPoor record keeping/checkingdouble doseswrong patientPaediatric dosesPoor administration technique

  • Complicated prescriptionsCalculationsVerbal ordersLack of knowledge about drugsMistakes in identifying drugsnamespackagingmisreading

  • National & local examples

    Discharged on warfarin loading dose 10mg odNot referred for dose adjustment to clinic14days of 10mg odINR 12.3Admitted with frank haemorrhageWeight-related dose for tinzaparin 80kg estdPatient was 51kg, risk of haemorrhageRx: Ranitidine 50mgGiven via epidural line rather than central line

  • Discharged on warfarin loading dose 10mg odNot referred for dose adjustment to clinic14days of 10mg odINR 12.3Admitted with frank haemorrhageWeight-related dose for tinzaparin 80kg estdPatient was 51kg, risk of haemorrhageRx: Ranitidine 50mgGiven via epidural line rather than central line

  • CABG patient, standard therapyThyroxine missed on admission, discovered day 10Galantamine re-started after a gap, Rx; 8ml qdsShould have been 12mg (2ml) bdprescriber confused over liquid strengthRx: Co-amoxiclavPenicillin-alllergicDid not realise this is a penicillinanaphylaxis

  • Anaesthetist adjusted rate of fentanyl syringe pump in TheatreNew pump. Increased rate x 1000Respiratory arrest - deathRx: morphine 0.4ml4ml given30% sodium chloride used instead of 0.9% to dilute an epiduralSevere pain

  • In Theatre: Sodium chloride flush for a central line switched with fentanylRespiratory arrest. Syringes made up in advance and not labelled

    IV line flushed with sodium chloride 0.9%Was in fact Potassium 15% deathAmpoules look similar in design

  • Case study 1 "Cambridge"Rx Methotrexate 17.5mg once a weekNew Rx 10mg once a day10mg daily dispensed by locum pharmacistRx 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 doseGP records confirm 10mg od+2/7 blood tests re-checked } Haem+5/7 patient dies

  • Case study 2 NottinghamRx Intrathecal methotrexate under GA in theatre by Oncology Reg & intravenous vincristine on ward by specialist nurse "Outlied" on non-specialist wardBoth drugs delivered to theatre from wardGiven food pre-op op postponed

  • Orignal SpR off-duty nowCover SpR unable to leave ward, anaesthetist to admin intrathecal drugAnaesthetist had given I/Thecal drugs before but had never given chemotherapyMethotrexate given intravenouslyVincristine given intrathecallyPatient died

  • Improving medication safetyDepartment of Health. Jan 2004

  • Improving medication safety:Main areas of medication error

    Anaesthetic practiceAnticoagulantsCytotoxic drugsIntravenous infusionsMethotrexateOpiate analgesicsPotassium chloride

  • Causes SolutionsLack of knowledge of the drug 31%Wrong dose, choice, drug. InteractionAllergy checking

    rule violations 10%Incl. communication problems

    Slip or memory loss 9%

    Drug informationEg: InteractionsResources availablePatient conditionRenal / liver function

    Guidelines, formularyLeape et al. JAMA 1995;274:35-43

  • Avoiding errorsPatient knowledgeHave a therapeutic goalIs prescribing the right answer?Have you included the patient in this decision?Knowledge about the drugMonitor for effects and adverse effectsUse your resourcesGood communication

  • Taking a good medication historyHow reliable is your source does it have enough detail?Patient, patients repeat prescription, own drugs, GP admission letter, on-call serviceDrug detailsdose, frequency, formulation (eg modified release), start date, indicationInclude: Prescribed drugs, OTC drugs, complementary medicines, vitamins, ? Recreational drugsAllergies including severityComplianceTherapeutic failures

  • Factors affecting a drugs pharmacodynamics or pharmacokineticsChildrenThe elderlyRenal impairmentHepatic impairmentPrescribing in pregnancy or breast feedingDrug interactions

    More later..

    Further references:Clinical Pharmacology textbook use course recommendationBasic Clinical Pharmacokinetics. 4th edn. ME Winter. Covers Drug-specific kinetics eg Digoxin, gentamicin

  • Drug dosing in renal impairmentBased on estimation of renal function using creatinine clearanceCockcroft-Gault equationCrcl = F x (140-age)x wt in kgS.Cr in micromol/LWhere F = 1.23 for males, 1.04 for femalesOr use an on-line calculator such as

  • Drug-drug interactionsdrug-food interactionsResourcesBNF Appendix 1Pharmacy Medicines Information DepartmentsHave specialists texts and other resources to help

  • Resources available to youSummary of Product Characteristics for each medicine - eMCPharmacy Medicines InformationOn-lineNationalElectronic prescribingOther medical and non-medical prescribers

  • PharmacyAvaliable for help and adviceWard PharmacistLocal Medicines Information departmentRegional medicines InformationMainly Community sector enquiriesOut-of-hours: On-call or resident pharmacist

  • Electronic Medicines Compendium (eMC)The eMC provides up-to-date information on licensed UK medicines 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.

  • In summary

  • Prescribing responsibilitiesDrugDoseRouteRate of administrationDuration of treatment

    Checking patient allergies & sensitiviti

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