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Medication errors & how to minimise them! Kevin Gibbs Clinical Pharmacy Manager Bristol Royal Infirmary

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& how to minimise them! Kevin Gibbs Clinical Pharmacy Manager Bristol Royal Infirmary Aims To provide an awareness of: Common medication errors How to minimise these ... – PowerPoint PPT presentation

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Title: Medication errors & how to minimise them! Kevin Gibbs Clinical Pharmacy Manager Bristol Royal Infirmary


1
Medication errors how to minimise them! Kevin
Gibbs Clinical Pharmacy Manager Bristol Royal
Infirmary
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

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

4
What is an error?
5
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

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
  • Yes
  • Yes
  • Yes

7
Error in .
  • Prescribing
  • Dispensing
  • Administration
  • Counselling/communication

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

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

10
Prescribing errors
Dean B, Schachter M, Vincent C, Barber N.
Quality and Safety in Healthcare 2002
11340-344 Shah SNH, Aslam M and Avery AJ. Pharm
J. 2002 267 860-862
11
Dispensing and Admin Errors
UK references 1 12 from Building a safer NHS,
Medication Safety
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)
  • http//www.dh.gov.uk/PublicationsAndStatistics/Pub
    lications/PublicationsPolicyAndGuidance/Publicatio
    nsPolicyAndGuidanceArticle/fs/en?CONTENT_ID400652
    5chkwlMQiJ

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.

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

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.

16
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

17
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18
NHS action on medication errors
  • 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)
  • www.doh.gov.uk/buildsafenhs

19
Improving medication safety January 2004
www. doh.gov.uk/buildsafenhs/medicationsafety
20
Improving medication safety
  • Medication safety a worldwide health priority.
  • Medication errors definition, incidence, causes.
  • The medication process, prescribing, dispensing,
    administration.
  • Reducing risks for specific patients groups.
  • Patients with allergies
  • Seriously ill patients
  • Children

21
Improving medication safety
  • Reducing the risks for specific medicines
  • Anaesthetic practice
  • Anticoagulants
  • Cytotoxic drugs
  • Intravenous infusions
  • Methotrexate
  • Opiate analgesics
  • Potassium chloride
  • Organisational and environmental strategies
  • Information management and technology
  • Improved labelling and packaging
  • Interfaces between healthcare settings
  • Education and training for medication safety

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.

23
Prescribing responsibilities
  • Drug
  • Dose
  • Route
  • Rate of administration
  • Duration of treatment
  • Checking patient allergies sensitivities

24
  • Providing a prescription that is
  • Legible
  • Legal
  • Signed
  • Giving all information to allow safe
    administration

25
Internationally
Research says
  • 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

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 199527435-43

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

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

29
  • Complicated prescriptions
  • Calculations
  • Verbal orders
  • Lack of knowledge about drugs
  • Mistakes in identifying drugs
  • names
  • packaging
  • misreading

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

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

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

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

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.

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 2nd GP, but the computer
    record was not altered
  • 5/7 patient admitted to ENT ward

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

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

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

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

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

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

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

43
  • 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

44
How can we help you?
  • Clinical
  • pharmacists

45
How can we help you?
  • Medicines
  • Information
  • Department

46
How can we help you?
  • Formularies
  • and
  • Prescribing
  • guidelines

47
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48
How can we help you?
  • Resources
  • BNF
  • Medicines
  • for Children

49
Safe prescribing A summary
  • Care with units
  • Legal
  • Is it weight/BSA-related dosing. Is weight
    accurate?
  • Clear and unambiguous
  • Approved name
  • No abbreviations
  • Care with IVs

50
  • Clear decimal points
  • 0.5ml not .5ml
  • Rewrite charts regularly
  • Take time, eg to read labels
  • In English
  • If abbreviate use standard ones
  • od / bd / tds / qds
  • NOT 250mg3

51
  • Care if
  • Impaired renal function (NB GFR)
  • Hepatic dysfunction
  • Children
  • The elderly
  • Drug unknown to you
  • Very new drug

52
The 5 Rights
  • the right patient
  • the right drug
  • the right time
  • the right dose
  • the right route

53
If in doubt ..
  • Please ask

54
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/
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