medication safety -wa style delivering a healthy wa kerry fitzsimons medication safety pharmacist...

Medication Safety

-WA Style

Delivering a Healthy WA

Kerry Fitzsimons

Medication Safety Pharmacist

Office of Safety and Quality in Healthcare

Medication Safety Standard 4“…“…..reduce the occurrence of medication ..reduce the occurrence of medication incidents and improve the safety and quality of incidents and improve the safety and quality of medicines use.” medicines use.”

Prescribing

Dispensing Administration

Monitoring 39%39%

Transcribing12%12%

11%11%38%38%

52% of prescribing errors 52% of prescribing errors reach the patient reach the patient

Prescription review by Prescription review by pharmacist and nurses pharmacist and nurses minimise errors which minimise errors which reach patient.reach patient.

Only 2% of administration Only 2% of administration errors are intercepted.errors are intercepted.

Kerry Fitzsimons Sept 2013

Medication Safety Standard

Medication Safety 5 Criterion

1 Systems and governance for medication safety

2 Documentation of patient information.

3 Medication management processes

4 Continuity of medication management

5 Communicating with patients and carers


Develop strategies for reducing risk of patient harm and plan ongoing system improvement (4.5.2)

1. Implement national recommendations and safety alerts national recommendations and safety alerts– National Recommendations for User-Applied Labelling of Injectable Medicines

Fluids and Lines– Intravenous potassium chloride and vincristine alerts– Standardised abbreviations for prescribing and administration of medicines

2.2. Standardisation of work practices and products: Standardisation of work practices and products: – NIMC, premix bags, standardised dosing protocols, standardised

medication checking times, WA Anticoagulation Chart… etc

3. Implement Patient ID Patient ID processes consistent with Standard 5 throughout medication management cycle

4. Implement barcode checking barcode checking in the pharmacy dispensing process

5. QI activities to address gaps in practice etc…..

Governance and systems for medication safety


4.4 Medication incidents are regularly monitored, reported and investigated:

• Action taken to reduce errors

• Encourage clinicians to utilise Clinical Incident Monitoring System (CIMS)

• Review reports to identify trends, causes (4.4.1)

– Involve clinical staff, medication sub-committee

• Identify actions to reduce risk of recurrence (4.4.2)

– Medication safety risk register with actions– Safety and/or quality improvement plan– Report to quality/patient safety committee– Feedback to staff



•“Drug therapy errors occur in 5-20% of drug administrations in Australian hospitals”

•3% result in significant harm.

•“43% of adverse drug events are preventable”

•“Medication interventions save lives, reduce length of stay, reduce admissions and reduce costs”

•January 2010

- estimated 190,000 medication related hospital admissions occur per year in Australia with an estimated cost of $660 million.

•Medication related incidents remain 22ndnd most reported incident in most reported incident in Australian hospitals.Australian hospitals.Lowinger et al. Medical Journal of Australia. 2010: 192 (4).


What do you think is the most common What do you think is the most common cause of medication incidents?cause of medication incidents?

A. Failing to read or misreading the medication chart

B. Failing to consider the patient’s renal function

C. Similar sounding drug names

D. Similar looking packaging or different medications

E. Prescription or order errors

2nd2nd


Medication Incidents – 2012


Types of Medication IncidentsTypes of Medication IncidentsTypes of Medication Incidents


Medication Incidents Outcome Severity2012-2013


Top Five Medication Contributory Factors


Tip of the IcebergTip of the Iceberg

CIMS is a Voluntary Reporting System

Tip of the Iceberg


BLANKBLANKSS

NOT NOT AVAILABLAVAILABLEE

NIMC AUDIT 2012NIMC AUDIT 2012

Medication omission rate for WA patients was 11%11% of all prescription orders

Medication Omissions


Medication OmissionsMedication OmissionsReasons why a necessary medication may not be prescribed

include:• Incomplete or inaccurate medication history• Lack of knowledge / awareness of best practice guidelines or

overlooking guidelines in practice• Transcription errors

Reasons why a medication may not be administered as intended include:

• Oversight• Nurse is unaware of the order• The medication can not physically be administered• No stock available

Medication Omissions


• Mrs Green was prescribed 120mg of sustained release gliclazide ( 2 x 60mg tablets) in the morning.

• The nurse administered immediate release gliclazide ( 1½ x 80mg).

Later that day the nurse realised the error when searching through the patient’s medication draw but did not act upon it as the patient’s blood sugar levels were stable.

The error was not reported…………………

Learning from Errors



• The following week, the same nurse administered 3 x 60mg immediate release diltiazem to Mrs White

- the patient should have had diltiazem 180mg SR.

An hour later, the patient had a fall in the shower and suffered a fractured neck of femur.

At the time the patient’s BP was 65/40 mm/Hg.

Mrs White spent a week on the orthopaedic ward and a further 6 weeks in rehabilitation.



Wrong parenteral route mix ups can be Wrong parenteral route mix ups can be prevented prevented through through clear labellingclear labelling of all of all lines and medication containers (syringes lines and medication containers (syringes and infusion bags) in accordance with the and infusion bags) in accordance with the National Labelling Recommendations for National Labelling Recommendations for User Applied Labelling of Injectable User Applied Labelling of Injectable Medicines, Fluids and LinesMedicines, Fluids and Lines

Lines should be clearly labelled to identify the route of Lines should be clearly labelled to identify the route of administrationadministration

Syringes should be clearly labelled to identify their contents Syringes should be clearly labelled to identify their contents using colour codes labels to indicate the intended routeusing colour codes labels to indicate the intended route

Preventing Wrong Injectable Route Errors


Labelling SyringesLabelling Syringes

A patient suffering an asthma attack was prescribed nebulised salbutamol (Ventolin), ipatropium bromide (Atrovent ) and intravenous hydrocortisone.

• All three medications were drawn up into syringes and placed in a kidney dish to be taken to the patient.

• As the syringes were not labelled, the patient was administered the salbutamol and ipatropium bromide intravenously and experienced atrial flutter.

This would not have occurred if:• Each drug was prepared and administered individually.• Each syringe was labelled appropriately.• Nebules were used instead of nebuliser solutions

Preventing Wrong Route Errors

Oral Liquids and Oral SyringesOral Liquids and Oral SyringesAny product administered into a patient’s vein must be:

□ Non-irritant

□ Particle free

□ Sterile

Oral doses are not equivalent to IV doses.

Oral syringes must be used to measure liquids for oral administrationOral syringes must be used to measure liquids for oral administration

Preventing Wrong Route Errors


Adverse Drug Reaction Documentation

Responsibility of Clinician to:

Ensure that the nature of each ADR is clarified.

Ensure clinically important ADRs are appropriately documented on/in:

all medication charts, the current medical notes, the cover of the medical notes, and in the discharge summary (as per Operational Directive 2079/06)

Patient should wear a red alert bracelet

Adverse Drug Reaction Documentation 4.7


Adverse Drug Reaction Documentation• Ensure patient has not had a previous reaction documentednot had a previous reaction documented to a

medication prior to administration

• Ensure that the medication is not in the same class of medicinesnot in the same class of medicines that the patient has had a prior reaction.

• Be aware of cross-sensitivity cross-sensitivity between classes i.e. Cephalosporins have a 10% cross-sensitivity with penicillins

• Check for products containing multiple medicationsmultiple medications i.e. Tazosin - Piperacillin (a penicillin) and tazobactam

Amoxycillin Amoxycillin 250mg/5mL250mg/5mL

Chest Chest infectioninfection

Adverse Drug Reaction Documentation 4.7


Acceptable Prescribing Abbreviations

What can go wrong….12 U of insulin misinterpreted as 124 Units of insulin and given to patient.

Should be written Should be written as 12 unitsas 12 units

Standardised Abbreviations for Safety


SQuIRe Medication ReconciliationSQuIRe Medication ReconciliationImprove medication reconciliation processes:

• Best possible medicationBest possible medication history documented

• ConfirmationConfirmation of medications with a second source

• Reconciling differencesReconciling differences identified with doctor

• Ensuring clinical handoverclinical handover of a patient’s medications between the patient, doctor, nurse, pharmacist and community clinicians at discharge

(GP/ Nursing Home/Community Pharmacist)

Medication Reconciliation 4.6, 4.8, 4.12


WA Medication History and Management Plan (WA MMP)WA MMP was developed by the WA Medication Safety Network to meet WA Health requirements for medication reconciliation.

The Medication History and Management Plan is designed to meet the requirements of:

• The APAC Guidelines

• The WA Pharmaceutical Review Policy –Std 2,

• The NSQHS Standard 4 Medication Safety

• 4.64.6 (BPMH), 4.74.7 (ADR), 4.84.8 (Reconciliation),

4.12 4.12 (Communication to patient and community

clinician), & 4.154.15 (Patient information provision)

• The Australian Safety &Quality Goals for

Health Care Priority Area 1.1- Medication Safety Medication Safety


Medication Reconciliation Audit Tools


Criterion 3 achieved by:

4.11 High risk medicines High risk medicines identifiedidentified are

• stored,

• prescribed,

• dispensed, and

• administered safely.

• Also high risk processes

(4.11.1 and 4.11.24.11.1 and 4.11.2)

Health service has list of high risk medicines

ResourceMedication Safety Alerts webpagehttp://www.safetyandquality.gov.au/our-work/medication-safety/medication-alerts/

A Antimicrobials and Antipsychotics

P Potassium and conc. electrolytes

I Insulins

N Narcotic analgesics and sedatives

C Chemotherapeutic agents

H Heparins and other anticoagulants

Medication management processes


Top 10 Most Frequently Reported Medications Involved in Medication Incidents (2012)


High Risk MedicationsDefinition

“Medications which have a heightened risk of causing significant or catastrophic harm when used in error.”

A list of high risk medications should be determined by each health site.

This list may include;• “A PINCH” medications • Medicines with a low therapeutic index • Medicines that present a high risk when administered via the wrong formulation or route.

Risk Reduction strategies1) Prevent errors from occurring2) Encourage transparency when errors are made, and 3) Mitigate harm.


Key Strategies for Safeguarding High Risk Medications

• Reducing or eliminating the risk of error

• Making errors visible

• Minimising the consequence of error

• Monitor patients receiving high risk medicines

• Reviewing and learning from improvement


The Patient• Majority of hospitalised patients are aged

between 75-85 years.

• High Risk Patients are defined as

– >55 years of age– > 5 regular medications– > 2 co-morbidities– Prescribed High Risk Medications– Difficulty managing medications – (vision & cognition impairment, literacy &

language difficulties)

• The more medications a patient is taking….

→ The Higher Risk of Adverse Drug EventsKerry Fitzsimons Sept 2013

Training programs for staff• medication safety risks, strategies to reduce the risks

• NIMC on line learning module

• Antimicrobial prescribing modules

• Medication reconciliation training resources

National Prescribing Service (NPS)

• Medication Safety Modules

• NIMC Online Training Course

• Antimicrobial Prescribing Modules



ContactFor further information:

Visit

OSQH Medication Safety Website

http://www.safetyandquality.health.wa.gov.au/medication/index.cfm

OSQH Accreditation Website

http://www.safetyandquality.health.wa.gov.au/initiatives/accreditation.cfm

Kerry Fitzsimons (Medication Safety Pharmacist) [email protected]

Going to Hospital and Managing your Medicines – Consumer DVDs

Available : http://www.safetyandquality.health.wa.gov.au/hospital/medication.cfm

Further information


Priority 1 - Medication Safety

• Reduce risk of older consumers experiencing Adverse Medication EventsReduce risk of older consumers experiencing Adverse Medication Events

– Annual medicines reviews eg HMRs– Medication reconciliation on admission to & discharge from hospital

• Reduce risk of paediatric patients experiencing dose related Adverse Reduce risk of paediatric patients experiencing dose related Adverse Medication EventsMedication Events

– Dose calculation documented on Paed NIMC

• Reduce risk of adults experiencing VTE when hospitalisedReduce risk of adults experiencing VTE when hospitalised

– Risk assessment for all patients admitted to hospital, – appropriate prescription for prophylaxis

• Reduce risk of consumers in community on warfarin experiencing Adverse Reduce risk of consumers in community on warfarin experiencing Adverse Medication EventsMedication Events

– Risk/benefit assessment– Improved clinical handover from hospital to GP– Documentation accessible to patient and all care providers

National Safety & Quality Goals


Intravenous Medicines Given Intrathecally• A number of medications, such as

opioids, corticosteroids and chemotherapeutic agents (e.g. methotrexate) are routinely injected intrathecally.

• Medication administered for intrathecal administration must be specially formulated and not not contain any preservatives.contain any preservatives.

• Vinca alkaloids (i.e. vincristine) have been administered intrathecally in error resulting in devastating neurological effects (85% of cases of this type of error have resulted in death). All vincristine products must be labelled “FOR INTRAVENOUS USE ONLY – Fatal if given by other routes”

Intravenous Medicines Given Intrathecally



• Failure Mode and Effects Analysis (FMEA) and Self Assessments

• Forcing Functions and Fail Safes

• Limit Access or use

• Maximum access to information

• Constraints and Barriers

• Standardise

• Simplify

• Externalise or Centralise Error Prone Processes


medication safety -wa style delivering a healthy wa kerry fitzsimons medication safety pharmacist...

Documents

standardised medication

medication chart

medication safety wa

medication related incidents

medication subcommittee

carers kerry fitzsimons

healthcare slide

administration errors