safe prescribing: how to avoid prescribing errors kevin gibbs clinical pharmacy manager united...
TRANSCRIPT
Safe prescribing:How to avoid prescribing errors
Kevin GibbsClinical Pharmacy ManagerUnited Bristol Healthcare Trust
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 To give you some prescribing
pointers to look out for in your clinical placements
By the end of the session you should be able to: Define a medication error List the ‘Five Rights’ Identify common types of medication
errors Begin 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 information
Co-morbid conditions Drug information
Pharmacology Pharmacokinetics and pharmacodynamics Therapeutics
Systems Policies, guidelines, prescribing aids etc
What is an error?
What is an error ?
Doses omitted Wrong dose Unprescribed drug
given Wrong dosage form
given Wrong route of
administration Wrong rate of
administration
Wrong time of administration time of day in relation to food
etc.... Using
unstable/expired drug Wrong administration
technique Incorrect
reconstitution Extra dose given
Where do errors occur in the process of giving a drug?
Prescribing Dispensing Administration Counselling/communication
Adverse events in hospitalsWhat is the size of the problem?
Adverse events per admission (%)
10%
AE number / year in UK 850,000
Cost in additional hospital stay (£)
£2 billion
Cost of clinical negligence schemes/yr
£400 million
Medication errors = % of incidents
25%
An organisation with a memory. Dept of Health 2001
Reported incidences
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
Outcomes
Data collated by US National Co-ordinating council for Medication Error Reporting and Prevention 1993-98 Performance deficit
29.8% Communication
problem 15.8% Knowledge deficit
14.2% Dose miscalculation
13%
5366 reports 68.2%- Serious patient
outcomes 9.8% - fatal
Improper dose Wrong drug Wrong route of
administration
Phillips, J etal. Am J Health Syst Pharm 2001;58: 1835-41
Prescribing errors
Process Error Rate Serious Errors
Prescribing errors(Primary Care)
Computer generated
7.9%
Prescribing errors(Primary Care)Hand written
10.2%
Prescribing errors(Hospital)
1.5% 0.4%
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
Handwriting
Errors in medication history taking
Literature review 22 studies, 3755 patients
Errors in medication histories In up to 67% of cases 10-61% had at least 1 omission error 54% of patients had at least 1
medication history error Clinically important errors in 11-59%
Tam et at Canadian Medical Association Journal 2005;173(5):510-15
Dispensing and adminn errors
Stage of process Error Rate Serious Errors
Dispensing errors (P) 1% 0.18%
Dispensing errorsUndetected (H)
0.0002
AdministrationOral Medicines (H)
3 – 8%
Preparation and admin of parenteral medicines
13%- 49% 1%
UK references 1 – 12 from Building a safer NHS, Medication Safety
Similar packaging
Same drug – different manufacturers
Similar packaging
Same drug – several strengths May be colour-coded but DO NOT rely on
colour
Similar packaging
Similar sounding names / similar spelling / same strength
Ceftazidime – Cefotxime
Similar packaging
If in a hurry – These look similar Water for injection, Sodium Chloride injection
So does Potassium 15% injection = Why there are NPSA/Trust policy on restricting this
Summary: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
Poor handwriting on Rx Incorrect IV administration
calculations or pump rates Poor record keeping/checking
double doses wrong patient
Paediatric doses Poor administration technique
Complicated prescriptions Calculations Verbal orders Lack of knowledge about drugs Mistakes in identifying drugs
names packaging misreading
National & local examples
Discharged on warfarin loading dose 10mg od
Not referred for dose adjustment to clinic
14days of 10mg od
INR 12.3
Admitted with frank haemorrhage
Weight-related dose for tinzaparin – 80kg estd
Patient was 51kg, risk of haemorrhage
Rx: Ranitidine 50mg Given via epidural line rather than central line
Discharged on warfarin loading dose 10mg od
Not referred for dose adjustment to clinic
14days of 10mg od
INR 12.3
Admitted with frank haemorrhage
Weight-related dose for tinzaparin – 80kg estd
Patient was 51kg, risk of haemorrhage
Rx: Ranitidine 50mg Given via epidural line rather than central line
CABG patient, standard therapy
Thyroxine missed on admission, discovered day 10
Galantamine re-started after a gap, Rx; 8ml qds
Should have been 12mg (2ml) bd
prescriber confused over liquid strength
Rx: Co-amoxiclavPenicillin-alllergic
Did not realise this is a penicillin
anaphylaxis
Anaesthetist adjusted rate of fentanyl syringe pump in Theatre
New pump. Increased rate x 1000
Respiratory arrest - death
Rx: morphine 0.4ml 4ml given
30% sodium chloride used instead of 0.9% to dilute an epidural
Severe pain
In Theatre: Sodium chloride flush for a central line switched with fentanyl
Respiratory 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 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
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
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
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
Improving medication safety
Department of Health. Jan 2004
Improving medication safety:Main areas of medication error
Anaesthetic practice Anticoagulants Cytotoxic drugs Intravenous infusions Methotrexate Opiate analgesics Potassium chloride
Causes → Solutions
Lack of knowledge of the drug – 31%
Wrong dose, choice, drug.
Interaction Allergy checking
“rule” violations – 10% Incl. communication
problems
“Slip” or memory loss – 9%
Drug information Eg: Interactions
Resources available Patient condition Renal / liver function
Guidelines, formulary
Leape et al. JAMA 1995;274:35-43
Avoiding errors
Patient knowledge Have a therapeutic goal
Is prescribing the right answer? Have you included the patient in this decision?
Knowledge about the drug Monitor for effects and adverse effects Use your resources Good communication
Taking a good medication history
How reliable is your source – does it have enough detail?
Patient, patient’s repeat prescription, own drugs, GP admission letter, on-call service
Drug details dose, frequency, formulation (eg modified
release), start date, indication Include: Prescribed drugs, ‘OTC’ drugs,
complementary medicines, vitamins, ? ‘Recreational drugs’
Allergies including severity Compliance Therapeutic failures
Factors affecting a drugs pharmacodynamics or pharmacokinetics
Children The elderly Renal impairment Hepatic impairment Prescribing in pregnancy or breast feeding Drug 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 impairment
Based on estimation of renal function using creatinine clearance Cockcroft-Gault equationCrcl = F x (140-age)x wt in kg
S.Cr in micromol/LWhere F = 1.23 for males, 1.04 for females
Or use an on-line calculator such as http://www.kidney.org/professionals/kdoqi/gfr_cal
culator.cfm
Drug-drug interactionsdrug-food interactions
Resources BNF Appendix 1 Pharmacy Medicines Information
Departments Have specialists texts and other
resources to help
mOre in a leter talk
Resources available to you
Summary of Product Characteristics for each medicine - eMC
Pharmacy Medicines Information On-line National Electronic prescribing Other medical and non-medical
prescribers
Pharmacy
Avaliable for help and advice Ward Pharmacist Local Medicines Information
department Regional medicines Information
Mainly Community sector enquiries Out-of-hours: On-call or resident
pharmacist
Electronic Medicines Compendium (eMC)
The eMC provides up-to-date information on licensed UK medicines http://emc.medicines.org.uk/ Summary 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 responsibilities
Drug Dose Route Rate of administration Duration of treatment
Checking patient allergies & sensitivities
Providing a prescription that is: Legible Legal Signed Giving all information to allow safe
administration
Hints
Clear and unambiguous
Approved name
No abbreviations
Care with IVs
Care with units
Legal
Is it weight/BSA-related dosing. Is weight accurate?
Clear decimal points0.5ml not .5ml
Rewrite charts regularly
Take time, eg to read labels
Avoid abbreviations
od / bd / tds / qds
Not 250mg3
Take particular care if: Impaired renal function Hepatic dysfunction Children The elderly Drug is unknown to you Very new drug
Remember the “Five Rights”
• the right patient• the right drug• the right time• the right dose• the right route
If in doubt ……..
Ask
Further reading & resources
Naylor, R. Medication Errors. Radcliffe Press. ISBN 1857759567
Department of Health. (2004). Building a safer NHS. Improving medication safety.
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4071443&chk=PH2sST
National Patient Safety Agency Website: http://www.npsa.nhs.uk/
National Prescribing Centre Website: http://www.npc.co.uk/
Institute for Safe Medication Practices (ISMP) (American) Website: http://www.ismp.org/
National Electronic Library for Medicines Website:
http://www.druginfozone.nhs.uk/home/default.aspx
Aronson & Richards. Oxford Handbook of Practical Drug Therapy. ISBN 0198530072