mediation safety - first lecture

Safer prescribing and Safer prescribing and avoiding medication erroravoiding medication error

University of Manchester

Background

Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patientsBMJ. 2004; 329:15-19

Friday, 2 February, 2001, 18:43 GMTDrug blunder patient dies

BBC NEWS / NEWS FRONT PAGE

“My clients have been appalled to learn that so many other families have suffered as a result of similar mistakes”Family solicitor

•A teenager has died after a cancer drug was injected into his spine by mistake…

•The leukaemia treatment should have been injected into his vein…

•Two junior doctors have been suspended. Wayne had been unconscious since the incident last month. He was killed by a slow, creeping paralysis that eventually stopped his heart.

Background

Prevalence, Incidence and Nature of Prescribing Errors in Hospital Inpatients: A Systematic Review. Drug Safety 2009;32(5):379-389

7%

93%

What do we think?

Prescribing should not endanger patient care:Inappropriate prescribing Poor communication

Getting you all involved

Voting sheets

Voting Instructions: Please ring the letter which corresponds to the option you want to vote for. A brief overview of the option follows each letter. Do not ring more than one letter.

VOTE

A B C D

Confidence in your vote Instructions: Please ring the number which corresponds to your confidence that you have voted for the best option. Do not ring more than one number. Description of options:

1 I am not at all confident that I have voted for the most appropriate option

2 I am not overly confident that I have voted for the most appropriate option.

3 I am quite confident that I have voted for the most appropriate option.

4 I am very confident that I have voted for the most appropriate option

Confidence

1 2 3 4

How would I deal with this?

How would I deal with this?

A - Turn off the sink tap?

B - Turn off the water supply to the house?

C - Contact a local plumbing company and ask a plumber to attend immediately?

How would I deal with this?

A

B

CD

Discuss with the person next to you

Which drugs are likely to lead to a hospital admission?

Which drugs are likely to lead to a hospital admission?

Most common medications causing admission include:

Low dose aspirinWarfarinNon steroidal anti-inflammatory drugsDiuretics

Most common reaction: Gastrointestinal bleeding

Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patientsBMJ. 2004; 329:15-19

Which drugs are mostly implicated in medication error in hospitals?

Medications involved in error

At what point could error occur during the provision of medication in hospitals?

At what point could error occur during the provision of medication in hospitals?

At what point could error occur during the provision of medication in hospitals?

‘ A 600- bed teaching hospital with 99.9% error-free drug ordering, dispensing and administration will experience 4,000 drug errors a year’

Organisation with a memory, DH 2000

So…. A 1000-bed teaching hospital (e.g. Hope) will experience at least 6500 errors per year!!

Prescribing- What information is required to make a prescription legal? And safe?

Prescribing- What information is required to make a prescription legal? And safe?

Correct prescription form required (green FP10, hospital chart etc.)

Patient name and address (or hospital number and ward/clinic)

Drug name, dose, frequency, route (+ formulation and administration information where appropriate)

Date and signature

What about “controlled” medication?

Prescribing errors- what kinds of mistakes are made?

Prescribing errors- what kinds of mistakes are made?

Prescription illegal, illegible or incomplete

Incorrect/inappropriate route or formulation

Incorrect/inappropriate dose, frequency or duration

Drug Interactions

Prescribing errors- what kinds of mistakes are made?

Incorrect/inappropriate choice of therapy

Lack of monitoring

Discharge prescriptions/Transcription error

“A man suffered irreversible brain damage after a pharmacist misread hisdoctor’s prescription. The patient had been prescribed the antibiotic Amoxil®(amoxicillin) for a chest infection. The prescription was badly written and thepharmacist misread the drug name as Daonil® (glibenclamide) a drug used tolower blood sugar in people with diabetes. As a result of taking the wrongmedicine the patient went into a coma and was hospitalised for 5 months…”

Dispensing errors- what kinds of mistakes are made?

Dispensing errors- what kinds of mistakes are made?

Dispensing errors- what kinds of mistakes are made?

Dispensing errors- what kinds of mistakes are made?

Right label / wrong drug or vice versa

Right drug; wrong strength

Drugs with similar generic namesprocylidine/prochlorperazinechlorpromazine/chlorpropamide

Drugs with similar packaging (manufacturer branding)

Dispensing errors- what kinds of mistakes are made?

Wrong quantity (calculation error)

Wrong concentration (extemporaneous calculation error)

Compliance aid errorlabels don't match drugsdrugs dispensed at wrong timesdrugs omitted

“A man suffered irreversible brain damage after a pharmacist misread hisdoctor’s prescription. The patient had been prescribed the antibiotic Amoxil®(amoxicillin) for a chest infection. The prescription was badly written and thepharmacist misread the drug name as Daonil® (glibenclamide) a drug used tolower blood sugar in people with diabetes. As a result of taking the wrongmedicine the patient went into a coma and was hospitalised for 5 months…”

Administration errors- what kinds of mistakes are made?

Administration errors- what kinds of mistakes are made?

Wrong route e.g. prescribed oral but given IV

Wrong formulation e.g. prescribed MR but given as standard immediate release preparation

Wrong drug (similar names as per prescribing and dispensing errors)

Wrong rate - too slow or rapid (calculation error or device failure)

Administration errors- what kinds of mistakes are made?

Omissiondrug "not available”human error; nurse did not see prescription

Timing errorgiven at wrong time e.g. Parkinsons diseasedelayed administration e.g. IV antibioticcontinued past stop date

Compatibility errordrugs mixed inappropriately

✓NO!

Post-operative pain

ANNE SMITH DCU 135852 1/9/09

1/91200

1/9/09

96%

8

132/68

82

7/10

V

896%

Post-operative painVOTE:

A 50MG ORAL DICLOFENAC

B 25 MICROGRAM TOPICAL FENTANYL PATCH

C 10MG INTRAMUSCULAR MORPHINE

D 1000MG RECTAL PARACETAMOL

A 50MG ORALDICLOFENAC

B 25 MICROGRAM TOPICAL FENTANYL PATCH

C 10MGINTRAMUSCULAR MORPHINE

D 1000MG RECTALPARACETAMOL

A 50MG ORALDICLOFENAC

B 25 MICROGRAM TOPICAL FENTANYL PATCH

C 10MGINTRAMUSCULAR MORPHINE

D 1000MG RECTALPARACETAMOL

Patient name: Anne Smith

Patient hospital number: 135852

Patient date of birth: 01/08/72

Patient weight: 66Kg

Ward: Day case unit

Consultant: BJH

Here are some further details you will need:

Post-operative painHIS CHOICE:

A 50MG ORAL DICLOFENAC

B 25 MICROGRAM TOPICAL FENTANYL PATCH

C 10MG INTRAMUSCULAR MORPHINE

D 1000MG RECTAL PARACETAMOL

Post-operative pain

IBUPROFEN SMITH

BJH DCU ANNE 1/8/72 66Kg

IBUPROFEN135852SMITH

BJH DCU ANNE 1/8/72 66Kg

Post-operative pain

VOTE:A ADVISE NURSE TO GIVE

DICLOFENAC

B PRESCRIBE OPIATE

C PRESCRIBE RECTAL PARACETAMOL

D RING COLLEAGUES FOR ADVICE

System changes?

System changes?VOTE:

A DEVELOP AN ALGORITHM FOR POST-OPERATIVE PAIN

B ENSURE ALLERGY BOX ON PRESCRIPTION FORM IS MORE VISIBLE

C ORGANISE TEACHING SESSIONS FOR JUNIOR DOCTORS REGARDING PAIN MANAGEMENT

D TRAIN NURSES TO PRESCRIBE AND ADMINISTER POST-OPERATIVE ANALGESIA

What have we looked at today?

Background around medication safety

Voting and confidence

Where errors occur

Considered a ‘real’ case

Voting Instructions: Please ring the letter which corresponds to the option you want to vote for. A brief overview of the option follows each letter. Do not ring more than one letter.

VOTE

A B C D

Confidence in your vote Instructions: Please ring the number which corresponds to your confidence that you have voted for the best option. Do not ring more than one number. Description of options:

1 I am not at all confident that I have voted for the most appropriate option

2 I am not overly confident that I have voted for the most appropriate option.

3 I am quite confident that I have voted for the most appropriate option.

4 I am very confident that I have voted for the most appropriate option

Confidence

1 2 3 4

What will we look at next time?

Agenda:Results of your votingSee how the pharmacy students voted when

confronted with the same dilemmasConsider a more complex case and have the

opportunity to vote againThink about future aims following the lecture

series

See you all next time.