I’ve got a bad feeling about this

1. I’ve got a bad feeling about this Everyone feels bad when they discover medication incidents. Don’t give in to the dark side, look for the ‘human factors’ & share the significant event audit. Dec 2015 Human Factors know how: http://bit.ly/1TpdLSx

2. NSAIDs ‘nuff said NSAID adverse reactions found in 1 in 5 patients presenting at A&E. Errors in prescribing are plentiful. I took an NSAID and I was elderly, had CVD, CKD, CCF, asthma, raised BP, aspirin 75 & didn’t take my PPI. I wish I’d had some paracetamol instead. Oct 2015 Prescribing advice: http://bit.ly/1Qkki1D and http://bit.ly/1XNKoKU

3. Take a lead in LD Evidence shows over-medication of patients with learning difficulties (LD). Advocate the discontinuation of, or reduction to lowest effective dose of, psychoactive drugs LD or autism patients. Oct 2015 Psychotropic medicine use in learning difficulty and autism http://bit.ly/1HDzmAf

4. TrimethoGRIMM The Brothers Grimm could not write a tale as scary as the story told by the prescribing errors with Trimethoprim. “take this poison tablet fair patient, worry not about your allergies, for this will make you better. Ah ha ha ha ha!” Cackled the wicked Witchdoctor Oct 2015 NICE Allergy Guidance baseline assessment: http://bit.ly/1LrjyER

5. Could you be pregnant? Probably should ask. Probably OK not to ask Sept 2015 Treating for Two http://1.usa.gov/1zZpFqV

6. Pika of a bad lot Pika is Eastern European slang for Methamphetamine which is used on vulnerable people in the sex trade. Prescription security and tight control on controlled drugs are essential public health measures. Sept 2015 'My Parrot Ate My Pain Pills‘ (log in, its worth it) www.medscape.com/viewarticle/768768

7. NOAC or D‘oh’AC New Oral Anticoagulants NOAC are also called Direct Oral Anticoagulants (DOAC). Renal Function is critical in managing these drugs, whatever you call them. Calculate the CrCl and check the dose. Aug 2015 MHRA guidance on preventing bleeds with NOACs http://bit.ly/1Ncl7cK

8. A sharp intake of breath The number of different inhalers for use in Asthma and COPD has increased rapidly in the last few years. Clinical review, medication review and medicines reconciliation in general practice are the means by which inhaler errors can be identified and rectified. 50th Snippet! July 2015 http://www.asthma.org.uk/patient-safety Asthma UK patient safety campaign.

9. Incomprehensible Inhalers Knowledge based errors were as common as picking errors and omissions. The use of protocols and formularies for prescribing in Asthma and COPD are helpful. July 2015 First choice inhaler guide in COPD http://bit.ly/1NvK6VA on the Leeds Formulary

10. It worked for Captain America Captain America, the iconic comic book hero, got his powers from a high dose vitamin serum. In real life, errors when prescribing and monitoring Vitamin D / Colecalciferol have overdosed patients, sometimes over long periods. Most cases required dose adjustment and monitoring. ADRs from Vitamin D overdose can be severe. No-one has got superpowers yet. Follow the updated Guidelines on Leeds Health Pathway June 2015 Evidence that Vitamin D in overdose does not make superheroes http://bit.ly/1Lft8wi

11. Bi-Bisphosphonate A near miss in the hospital had highlighted the potential for co-prescribing oral and IV bisphosphonates as care of bone health is shared across organisations. When the practice receives a letter stating that Zolendronic acid has been administered, this should be treated the same as any other red drug and recorded on the patient’s record as ‘issued elsewhere’ with a duration of at least 1 year. June 2015 NICE Quality Standard for osteoarthritis http://bit.ly/1GsXEi2

12. Two weeks too long An epileptic patient has been left with severely compromised speech and mobility when they were left without medication for 2 weeks. The post-discharge review appointment was not scheduled to take place before the patient ran out of medication. May 2015 NICE NG5 Medicines Optimisation Guidance on transitions.

13. Concentration is Critical Prescribing Insulin is complex, error prone and high risk. D – Drug Name. Prescribe by Brand. Check for errors with similar named products. D – Device. Check changes are intended and agreed with the patient. D – Dose. If the dose is included on the prescription make sure it is reviewed and updated. D – Duration. Check for short and longer acting insulin mix-ups D – Deadly. Ensure high-strength insulins are intended before prescribing May 2015 MHRA guide to prescribing insulins: www.gov.uk/drug-safety-update/high-strength-fixed-combination-and-biosimilar-insulin-products-minimising-the-risk-of-medication-error

14. Prednisolone Perils Prescribing oral steroids is error prone. Our Datix system has 34 incidents relating to prednisolone or hydrocortisone. Errors include; Dose errors in short courses. Course duration errors. Failure to discontinue and Failure to prescribe protective polypharmacy April 2015 MHRA e-learning tool to manage risks of prescribing steroids www.gov.uk/drug-safety-update/corticosteroids-e-learning-module-launched

15. Former Formulary Foul When trying to prescribe atorvastatin the practice formulary offered simvastatin as an alternative. This was a throwback to before the most recent guideline. Check you practice formulary and remove simvastatin as a synonym of atorvastatin. March 2015 Check how safe your prescribing is with the PINCER audit tool http://www.nottingham.ac.uk/primis/tools/audits/pincer.aspx

16. Five Alive Remove warfarin 5mg tablets from the repeat list of any patient who does not take a dose of ≥5mg. Don’t add 5mg tablets to repeat unless the dose is ≥5mg. At least annually, advise patients who take white 0.5mg tablets to “watch out” for the red/pink 5mg tablets to avoid errors. Feb 2015 Page 7 Patient Information Book for warfarin

17. Kidney Conundrum 12 reports on Datix highlight the difficulty of prescribing drugs for CKD Patients. Clinicians should set up CKD warnings to appear for patients with CKD stage 3,4 & 5. When prescribing for patients with CKD stage 3,4 & 5 read the on-screen prescribing information for suitability of the selected drug. Feb 2015 MHRA Safety update on Nitrofurantoin www.gov.uk/drug-safety-update

18. All they want is Radio GABA 11 incident reports this year involve Pregabalin or Gabapentin. 6 were dose errors at transitions of care. • Reconcile dose 48 hrs after hosp’ appt . 1 incident included death involving abuse of gabapentin Jan 2015 PHE-NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf

19. I said ‘4T’ not ‘40’! The words used to tell people about dose changes of methotrexate can mislead. • Never assume 2.5mg tablets are in use. • Check if the patient has 10mg tablets. • Always give written instructions stating dose in mg and number of tablets. Jan 2015 Improving the safety of telephone of verbal orders

20. Mortality METHOd • TriMETHOprim increases METHOtrexate toxicity. • The interaction has been fatal. • Degree of harm is not dose dependent. There have been 2 reported incidents of co-prescribing this combination this year in Leeds. Never prescribe trimethoprim to patients on methotrexate (not even a short course or low dose) Educate patients to watch out for this interaction. Dec 2014 • Methotrexate info for patients & Arthritis Research UK

21. Thrush Rush Reaction • Oral Miconazole gel interacts with Warfarin, increasing INR. • 1 patient with INR of 22 required blood transfusion as result. • Computer alerts are easily overridden. Nystatin & warfarin are safer. Miconazole and Dabigatran is safe. Dec 2014 • Pharmaceutical Journal Article on this interaction .

22. In Datix We Trust Less than 7% of medicines related incidents on Datix are reported to have occurred in Acute Trusts. Use Datix to report hospital incidents relating to DANs, TANs and medicines at admission & discharge . Hospitals Nov 2014 #SaferNHS

23. Beware the Blaggers Patient’s who attempt to manipulate health systems and prescribers to obtain psychoactive drugs need a whole team approach to their management. Vulnerabilities in the system can include: • Targeting time pressured urgent appointments. • Targeting GP registrar’s or “push over” GPs • Requesting drugs less known for abuse (pregabalin, gabapentin, promethazine etc) Sept 2014 • SMAH Addiction to medicines factsheets www.rcgp.org.uk/smah

24. The Other Trouble Putting ‘Red’ drugs and drugs prescribed elsewhere on the repeat list presents the risk that these drugs will be inadvertently prescribed by the GP. There is a “How to” guide to avoiding this risk. Sept 2014 SystmOne & EmisWeb Guide to managing “other drugs” in Medicines Management sections of: http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

25. Always Ask About Allergy 13 drug allergy incidents reported since April’14 Prescribing when not in the GP surgery is a common contributing factor. NICE says: Check a person's drug allergy status and confirm it with them (or their family or carers) before prescribing any drug. Make a @signuptosafety pledge: “I will Always Ask About Allergy” Sept 2014 • www.england.nhs.uk/signuptosafety@SignUpToSafety

26. “One” to be watched The SystmOne pre-set dose for warfarin is “One to be taken as directed”. This might be misleading. Change the warfarin dose to “Dose dependent on INR test results” On new prescriptions and repeat templates. June 2014 Health And Social Care Information Centre - Patient Safety Incident Reporting: National Service Desk Telephone – 0845 366 0066 ssd.nationalservicedesk@hscic.gov.uk

27. Allergy Alert 2 out of every 5 care home patients have inaccurate allergy status. Inform Care Homes and their supplying pharmacies of your patients allergy status. June 2014 SystmOne & EmisWeb Guide to managing allergy status in Medicines Management sections of: http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

28. Motivation for Monitoring • Medication monitoring shows when drug changes are needed before Adverse Drug Reactions lead to hospitalisation • In 384 care home patients 676 monitoring tests were needed to carry out annual medication reviews, inc. • U&Es for those prescribed ACEi, ARBs, diuretics • TFTs, FBCs, HbA1c • Shared care monitoring for amber drugs inc. antipsychotics June 2014 Guide to monitoring for safer use of medicines: http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Drug%20monitoring%20document%20Feb%202014.pdf

29. Transitions of care such as hospital discharge are error prone All medicines changes need accurate reconciliation on GP systems (and MAR charts). The changes should be authorised by a prescriber and made by a clinician. Transition Trouble June 2014 http://www.nice.org.uk/nicemedia/pdf/PSG001Guidance.pdf

30. Dorment Drugs pose Danger There have been a number of cases of high risk drugs remaining on the repeat list after they were discontinued. eg • Methotrexates tabs on repeat when changed to S/C • Warfarin left on repeat after end of 6/12 course. • Dabigatran left on repeat when changed to warfarin • Aspirin continued when clopidogrel started instead May 2014 Community Pharmacy New Medicines Service: Improves adherence and highlights errors. http://www.cpwy.org/pharmacy-contracts-services/advanced-services.shtml

31. Don’t Forget Dementia Two cases reported on Datix of patients on Alzheimer's drugs not receiving a memory clinic review every 6 months. Dementia friends could help support your patients with dementia. May 2014 www.dementiafriends.org.uk

32. Picking-List Pitfalls Three errors picking the wrong drug have occurred because of the way the GP system presents the drug list: Buprenorphine presented 2mg but not 0.2mg tabs “B12” presented cyanocobalamin not hydroxycobalamin. ‘Polyvinyl alcohol’ presents FML drops as well as liquifilm MAY 2014 Incident report all such incidents: http://nww.incidentreportform.nhsleeds.nhs.uk/index.php

33. I don’t need rescuing! A parent with an epileptic child ordered buccal midazolam every month. But the child was never admitted with a seizure. Over-ordering of repeats with PRN doses are not highlighted by GP systems. May 2014 Thinking of making a change? Experiment first using Plan, Do, Study, Act cycles. www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html

34. Clozapine Communication 77% of GPs had been correctly informed of their patient(s) being prescribed clozapine ,but only 41% reported the that the information on clozapine would be available at consultation. Recording of Clozapine and other “red drugs” can be improved using the new guides for SystmOne and Emis Web. (See link below) Dec 2013 http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

35. Sensitive issue Sensitivities to medication have been missed if not entered on the GP system correctly. • Use the guidance documents below to Record ADRs and Allergies. Dec 2013 http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

36. Stop at home Set a short review date when discontinuing drugs that affect heart rhythm. Provide written advice to staff in care homes on monitoring the patient when stopping drugs Sept 2013 “Deprescribing” in www.australianprescriber.com/magazine/34/6/182/5

37. Missed the red spot • All DANs and Hospital Letters must be screened by a clinician before changes are made to a patient’s medication. • The Leeds Formulary should be checked if hospital letters include drugs that the GP is not familiar with. Oct 2013 The Leeds Formulary www.leedsformulary.nhs.uk/

38. Yellow Card Reporting • MHRA must now monitor ADRs from medication errors and drug abuse. • Consider ADRs from errors and drug abuse to be  reportable. • Use Datix or MHRA Yellow Card to report ADRs August 2013 Yellow card reporting on MHRA website https://yellowcard.mhra.gov.uk/

39. Noxious NSAIDS • Make repeat prescribing of NSAIDs the exception rather than the rule. • Always ask the patient about OTC use of NSAIDs at review. • Review NSAIDs regularly with an intention of discontinuing if possible. August 2013 Reminder: MHRA alert on Diclofenac on www.mhra.gov.uk

40. Lithium levels • Lithium levels are affected by fluid intake. • Risk of dehydration may require additional monitoring for lithium toxicity • Remind care homes to monitor the hydration of patients on Lithium. July 2013 NPSA alert on Lithium www.nrls.npsa.nhs.uk/alerts/?entryid45=65426

41. Action Allergy • Capture allergy status from letters/DANs. • Record allergy “cause and consequence” • Present allergy status prominently. • Habitually ask about allergies. • Test your systems for barriers. July 2013 www.worldallergy.org/professional/allergic_diseases_center/drugallergy/

42. Warfarin Wary In May 2013, 617 patients had been prescribed warfarin when they did not have an INR result recorded on the GP system in the preceding 13 weeks. One had not had an INR in the last 14 months. One had not had an INR in years! July 2013 New Warfarin Amber Drug guidelines on Leeds Health Pathways

43. Cutting corners A GP squeezed in one more job before surgery started. They didn’t look at all the information presented to them which led to them missing the changes on the DAN. • Give yourself time to concentrate on medication changes. June 2013 Easy time- Management tips on www.nhs.uk

44. NOACs & Renal Function There is a clear link between renal function and the safe use of the New Oral Anticoagulants (NOACs), Rivaroxaban, Apixaban and Dabigatran. • Follow the new shared care guidelines when monitoring NOACs June 2013 NOAC Amber Drug guidelines on Leeds Health Pathways

45. Symptom or Side Effect 3 patient stories on Datix show how easy it is to miss Adverse Drug Reactions caused by drug errors. • Suspect a Side-effect when new symptoms cannot be explained by the existing morbidities. June 2013 Drug Analysis Prints on www.mhra.gov.uk

46. Equine Colic Pethidine has an established place in therapy for treating horses with colic. However, Pethidine is no longer advocated for pain relief for home births. Any requests for pethidine for home births should be reported on Datix and referred back to the midwife. Jan 2013 Home Births – Appendix A of “Care of Women in Labour” nww.lhp.leedsth.nhs.uk

47. Abuse potential Pregabalin and Gabapentin abuse is on the increase. They enhance the effects of opiates and have euphoric effects. They can be injected, snorted or taken orally. • Caution in substance using patients. • Tighten control on repeat requests. Jan 2013 Useful look into abuse potential of drugs from RCGP based on prescribing prisons: www.rcgp.org.uk/news/2011/november/~/media/Files/News/Safer_Prescribing_in_Prison.ashx

48. Drug using patients and SSRIs Methadone & (es)citalopram – QT interval Crack & SSRIs – Serotonin syndrome • Review need to antidepressant • Change to Mirtazipine/sertraline if necessary • Seek advice from CDT clinical lead Jan 2013 Substance Misuse Management in General Practice www.smmgp.org.uk

49. Red letter days • GPs still receive requests to prescribe red (and black-light) list drugs • Requests from patients can be difficult to refuse. • The reasons for red and black-light classifications are available to patients Dec 2012 Traffic Light lists on www.leeds.nhs.uk/medicines

50. Weighty decisions Even simple calculations are worth a second look. Errors in calculating the dose based on a child’s weight may not be necessary – Check the children’s BNF for age related doses Include the patient’s weight and the calculations in the script notes Nov 2012 Children’s BNF available for smart phones: http://www.nice.org.uk/aboutnice/nicewebsitedevelopment/NICEApps.jsp