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Drug error in healthcare

Drug error in healthcare. Dr Craig Webster, Senior Lecturer Centre for Medical and Health Sciences Education and Department of Anaesthesiology School of Medicine, University of Auckland. January 2018. CMHSE. Centre for Medical and Health Sciences Education University of Auckland.

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Drug error in healthcare

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  1. Drug error in healthcare Dr Craig Webster, Senior Lecturer Centre for Medical and Health Sciences Education and Department of Anaesthesiology School of Medicine, University of Auckland January 2018 CMHSE Centre for Medical and Health Sciences Education University of Auckland

  2. Landmark report on cost of Preventable Adverse Events • To Err is Human, Institute of Medicine (USA), 2000

  3. Landmark report on cost of Preventable Adverse Events • A leading cause of death • - 44 000 - 98 000 Americans die in hospital pa... compare: • Breast cancer 42 297 • AIDS 16 516 • Workplace injuries 6 000 • Drug error a leading cause of patient harm • To Err is Human, Institute of Medicine (USA), 2000

  4. Older patients at greater risk of adverse drug events • In 5077 cases of emergency hospital admissions for adverse drug events in patients over 65 yrs: • two-thirds were due to unintended overdose • In 67% four medications were implicated (alone or in combo): • warfarin (33%) • insulin (13.9%) • oral antiplatelet agents (13.3%) • oral hypoglycaemic agents (10.7%) N Engl J Med 2011; 365: 2002-12

  5. Older patients at greater risk of adverse drug events Patients over 85 years of age were 3.5 times more likely to have such adverse events Extrapolating to US population: approx. 33,000 hospitalizations per year due to adverse drug events Warfarin-related events alone probably cost hundreds of millions of $US a year N Engl J Med 2011; 365: 2002-12

  6. Similar problem in New Zealand 3 Nov 2015 2013 - Six errors by 2 pharmacists saw one patient given wrong drugs, double doses and incorrectly labelled meds, 5 times in 6 months “we were very busy” – a poor explanation, Health and Disability Commission

  7. Anaesthesia “Cluster” of drug swap errors - cisatricurium instead of midazolam Similar colouring on ampoule label Anaesth Intensive Care 2015; 42: 120-1

  8. Medication-related patient harm in New Zealand Hospitals 2017 • 28% of pts experienced one or more harm • Six groups of medicines caused the greatest harm: • Opioids • Anticoagulants/antiplatelet agents • Antibiotics • Antianginals • Diuretics • Other cardiovascular medicines Robb et al NZMJ 2017 Vol 130 No 1460

  9. Mindfulness Systems People Socio-technological systems (healthcare) Training Re-design Trying harder is not enough!

  10. Error definition A generic term for all those occasions when a planned sequence of mental or physical activities fails to achieve its goal in the absence of chance interference

  11. Nature of error • They are not random events • They are unavoidable by everyone • We must develop better ways of coping with them (sheer effort won’t make them go away)

  12. Facts about how systems fail

  13. Systems aspect… • Design • Equipment • Procedures • Operators • Supplies • Environment Perrow C Normal Accidents 1984

  14. Our target for re-redesign:anaesthesia

  15. In a prospective incident study of 10,806 anaesthetics: A drug error of some kind occurred for every 133 anaesthetics (five time higher than any previously reported rate) Dosage and substitution errors made up 40% overall Webster, Merry et al Anaesth Intensive Care 2001; 29: 494-500

  16. In a prospective incident study of 10,806 anaesthetics: 69% of substitution errors occurred between pharmacologically different drugs Potentially very dangerous Webster, Merry et al Anaesth Intensive Care 2001; 29: 494-500

  17. Near-miss at our hospital

  18. Systems redesign

  19. Redesign principles • More systematic organisation • Improved cueing and checking • Facilitation of anaesthetist’s actions WITHOUT hindrance • Like a built-in checklist

  20. To create the physical record - define three areas using one or more trays “Used” “Active” or “In Use” “Prompt” or “To Use”

  21. Operational rules: • Drug must be scanned • Drug’s identity checked by listening to voice announcement • BEFORE drug is administered

  22. Large-scale multi-centre incident analysis of redesigned system Anaesthestics Response rate New 10816 80% system Conv. Hospital A 22050 88% Hospital B 41612 75% 63662 Incident data collected over 6 years Webster, Larsson et al Anaesthesia 2010; 65: 490-9

  23. Large-scale multi-centre incident analysis of redesigned system Admins. Errors Rates (95% CI) New 183,852 58 0.032% (0.024-0.041%) system Conv. 550,105 268 0.049% (0.043-0.055%) P= 0.002, Poisson 35% reduction in drug error per administration Webster, Larsson et al Anaesthesia 2010; 65: 490-9

  24. Large-scale multi-centre incident analysis of new system (subgroups) Admins. Dose Err. Rates p New 183,852 14 0.008% 0.006 Conv. 550,105 91 0.017% Admins. Omission Rates p New 183,852 4 0.002% 0.001 Conv. 550,105 57 0.010% Webster, Larsson et al Anaesthesia 2010; 65: 490-9

  25. Large-scale multi-centre incident analysis of new system (subgroups) Admins. Subt. Err. Rates p New 183,852 22 0.012% 0.590 Conv. 550,105 75 0.014% Admins. Inter-class Rates p New 183,852 5 0.003% 0.009 Conv. 550,105 48 0.009% Webster, Larsson et al Anaesthesia 2010; 65: 490-9

  26. Large-scale multi-centre incident analysis of new system (subgroups) Inter-class errors • Flumazenil for midazolam (2) • Rocuronium for neostigmine (2) • Fentanyl for etomidate • Nitroglycerine for ephedrine • Rocuronium for midazolam • Water for tramadol … Webster, Larsson et al Anaesthesia 2010; 65: 490-9

  27. Large-scale multi-centre incident analysis of new system (subgroups) Outcomes of errors No difference between Conv. and New in terms of: • Major physiological change • Prolonged physiological change • Minor morbidities But… Fewer cases of major adverse outcomes Conv. New System 11 0 p=0.028, 1-tailed Webster, Larsson et al Anaesthesia 2010; 65: 490-9

  28. Large-scale multi-centre incident analysis of new system (subgroups) Webster, Larsson et al Anaesthesia 2010; 65: 490-9

  29. Redesigned drug delivery system • Cogent evidence that the system re-design approach is working to - • Reduce error rates • Facilitate performance

  30. New safety threats… Anaesthesia 2013; 68: 308-9

  31. Wifi enabled, “smart” pumps FDA alert 2015

  32. 25 Nov 2016 Hackers stealing patient data from EHRs Could potentially use hospital devices as “attack vectors” Banks have tightened security, hospitals have not

  33. Bad work culture 17 hours awake = legally drunk Dawson et al Nature 388 17 July 1997

  34. Studies based on good quality incident data can be the “polio vaccine” for patient safety worldwide Dr Peter Pronovost

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