Prescribing Audit on Hope Hospital Intensive Care Unit

1. Prescribing Audit on Hope Hospital Intensive Care Unit February – April 2006 Dr A.Day, Dr S. Laha, Dr T.Thomas

2. Introduction • In the UK, awareness of adverse incidents in health care is growing. • May be >10% in UK hospitals. • The actual scale of the problem is unknown1. • Drug prescription errors are a common cause. 1. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001; 322:517-9

3. Introduction • In the UK, potentially serious errors occur between 1 in 1 000 and 1 in 10 000 prescriptions2. • Complex and urgent treatment and prolonged hospital stay are associated with more errors3. • Anonymous. Report maps road to medication safety. CMO Update 2004;38:1-3 • Bates DW, CullenDJ, Laird N, et al. Incidence of adverse drug events and potential adverse events: implications for prevention. Journal of the American Medical Associaton 1995;274: 29-34

4. Introduction • A recent paper collaborated results from 24 critical care units in the UK4 • 15% prescriptions had one or more errors • Most errors were minor • But, 19.6% errors were significant, serious or life threatening. • Ridley SA, Booth SA, Thompson CM and the Intensive Care Society’s Working Group on Adverse Incidents. Prescription errors in UK Critical Care units

5. Aim • To collect data about prescription errors in Hope Intensive Care Unit • To evaluate the error rate and make changes to improve prescribing practice. • To provide feedback to individual doctors.

6. Method Five Day Audit Two Hour Teaching Session 1 week later Five day Audit 4 weeks later Five day Audit

7. Method Collect signatures and assign each doctor a number Daily review of all prescriptions No ERROR? Record Yes Classify nature of error5 Classify clinical impact of error Minor No obvious harm Serious Significant reduction in probability of Tx being timely or effective Significant Slight adverse affect E.g G.I upset, rash Potentially Life Threatening Increased risk of harm to patient

8. Method • All data was entered onto a database. • Prescriptions for intravenous and haemofiltration fluids, enteral and parenteral feeds and blood products were excluded. 5. Greater Manchester Critical Care Network. Categories of Error. Clinical Audit of prescription errors. Feb 2004

9. Results • Total 56 patients. • Over the three week period, 1 403 new prescriptions (approx. 25 new prescriptions per patient) were written.

10. Comparison of Error Free and Erroneous Prescriptions 78% 22% Error Free Erroneous

11. Errors Per Prescription 11.3% 4.7% 0.7% Single Error Two Errors Three Errors

12. Distribution of Errors Illegible Ambigous Abbrevitations Transcription

13. Results • The five most common incorrect prescriptions were for propofol (6.0%), alfentanil (5.5%), salbultamol (4.6%), vancomycin (4.2%), potassium chloride (4.2%) • Four categories with the highest error rate (non standard nomenclature, illegible, ambiguous, transcription) accounted for 65% of all errors!

14. Comparison of Correct and Incorrect Prescriptions Per Doctor Correct Incorrect U Doctor Identification

15. Percentage Error for Each Doctor 1 U Doctor Identification Number

16. 63% of unidentifiable prescriptions were incorrect prescriptions.

17. Distribution of Potential Consequences Minor Significant Serious Life Threatening

18. Results • 18 prescriptions (1.2% of new prescriptions written) were considered significant, serious or potentially life threatening. • This gives a rate of potentially clinically important prescription errors as 5 per 400 new prescriptions. • Majority of non-minor errors were prescriptions inappropriate for the patient • E.g wrong drug, wrong dose or omission of drug.

21. Doctors Responsible for Significant, Serious and Life Threatening Errors 2 3 4 5 6 7 10 11 12 16 U Doctor Identification Number

22. Discussion • What is it about unidentifiable prescriptions that leads to higher error rates? • Rushed decisions? • Prescribing at night? • Information not readily available? • Reluctance to be identified?

23. Discussion • The groups of drugs associated with the largest number of prescription errors may simply reflect a larger number of prescriptions for those drugs.

24. DISCUSSION • Hand-written prescriptions are frequently illegible, incomplete or subject to transcription errors. • Improvements could therefore be achieved by reinforcing the importance of proper prescription writing. • However adverse events are commonly caused by prescribing errors and include wrong choice of drug, dose, route, formulation or time of administration, unfamiliar drugs/preparations • Improvements could be made by more immediate access to relevant information relating to the drug (i.e indications, contraindications, interactions, therapeutic dose or side effects) or the patient (allergies, co-morbidities, recent laboratory results).

25. DISCUSSION • Improvements: • Education and Information • Access to electronic data bases – BNF, Uptodate, Toxbase • Three monthly audit. • Electronic Prescribing

26. CONCLUSION • THANK YOU • QUESTIONS? • Thanks to E. Boxall and D. Grundy