Reducing Medication Errors findings of the National Clinical Governance Protected Time Project

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Reducing Medication Errorsfindings of the
National Clinical Governance Protected Time
Project
Paul Moore
Clinical Governance Manager
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Introduction

• The protected time project
• Why medication errors?
• What did we learn?
• Main developments
• Are we safer?

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Protected Time Project

• Developed by NHS Clinical Governance Support Team
• SMUHT one of 20 NHS Trust involved
• accelerated service improvement
• enables frontline staff to develop effective
  systems and processes
• our approach involved representatives of all
  stakeholders
• our approach identified and acknowledged problems
  up front

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Protected Time Programme methodology

• define the problem and significance
• stakeholder analysis and recruitment
• process map
• identifying problems
• identifying / analysing controls and gaps
• identify opportunities
• redesigning the process
• action planning for change
• monitor performance

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Why medication errors?

• Problem
• our web-enabled incident reporting system,
  launched in June 2001, immediately highlighted
  that one of the largest areas of adverse events
  was the prescription and administration of drugs
• Significance
• Patients at risk of harm - potentially very high
• writing prescription most common therapeutic
  intervention
• high associated mortality and litigation costs
• reduce by 40 the number of serious errors in the
  use of prescribed drugs by 2005

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Aims

• Develop a whole systems approach to reducing
  medication errors
• Reporting medication errors
• Drug administration process
• Capturing, validating disseminating lessons
  for learning
• Implementing change
• Monitoring performance

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What did we learn from participants?

• Staff are motivated to keep patients safe
• Staff do not routinely share their experience of
  adverse events with each other
• Systems for actively managing and learning from
  adverse events were inadequate
• Disciplinary action following medication errors
  varies amongst professionals and
• makes doctors less likely to report formally
• introduces reporting bias within HIRS

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What did we learn from participants?

• System is flawed
• training in isolation
• patients - passive recipients not active
  participants
• use of multidisciplinary team - ward rounds
• pharmaceutical packaging
• inadequate trust policy
• varying use of disciplinary action against
  individuals
• no formal process for reviewing and learning from
  error
• no mechanism for disseminating learning

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Main developments

• Development of HIRS
• improved web-enabled electronic data capture
• error reporting throughout the process of drug
  administration
• Supply / Prescription / Delivery (to clinical
  areas) / Administration
• Development of integrated training informed by
  medication errors
• Revised mandatory clinical training programme
  driven by incident reporting system output
• Set up learning group to capture, validate and
  disseminate lessons for learning
• Targeted clinical audit
• Empowerment initiatives to encourage greater
  patient participation
• Reading prescriptions
• Identification name bands

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Are we safer?
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Examples of incidents reported

• Heparin injection given in theatres - adrenaline
  intended
• High dose Gentamicin prescribed once daily
  (Patient in Renal Failure)
• Morphine diluted in lignocaine not water
• Enoxaparin overdoses (several)
• Flumazenil given pre-endoscopy instead of
  Midazolam

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Examples of incidents reported

• Suxamethonium given instead of Midazolam
• Beta blocker given to asthmatic
• 24 hour Diamorphine infusion given over 9 hours
• Potassium Chloride not available during cardiac
  arrest

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Quick wins

• 61 increase in reported adverse events
• Profile the need to weigh patients on admission
• Targeted staff training to areas of identified
  high risk
• low molecular weight heparin prescribing
• insulin sliding scale administration
• documentation of allergies and medication
  intolerance
• Established multidisciplinary error review group
• Updated and revised mandatory clinical training
  driven by incident reporting system output

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Quick wins

• Removal of manufacturers packs known to have
  contributed to administration error
• Morphine Sulphate 30mgs/ml
• Lignocaine ampoules

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Quick wins

• New medicines policy with safer procedures and
  much wider target audience
• Relationship between incident reporting and
  disciplinary action defined for all staff

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Examples of safer practice
Would you administer Augmentin to a patient with
a penicillin allergy?

• Answer No - as it contains Amoxycillin
• reports of poor records of medication intolerance
  led to an audit. 39 of nurses and 13 of doctors
  did not recognize this error potential. Now
  included in training.

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Examples of safer practice

• Combination products
• Patient received 5 x overdose of Co-beneldopa.
  Was prescribed 62.5 mg dose.
• Bottle labelled as12.5/50 and interpreted as 12.5
  dose and 50 tablets in bottle, so 5 tablets
  given.
• Labels changed and now read
• Co-beneldopa 12.5/50 (62.5mg) dispersible tablets

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Summary

• The protected time project has accelerated the
  development of a web-enabled incident reporting
  and learning system for medication errors.
• More medication errors are reported than ever
  before.
• Data is used to influence training and shared
  with staff for learning
• The project has improved patient safety within
  the Trust