Safe prescribing: How to avoid prescribing errors

1. Safe prescribing:How to avoid prescribing errors Maggie Allen UHCW/CWFS

2. 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 posts

3. 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

4. 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

5. What is an error?

6. 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 What is an error ?

7. Where do errors occur in the process of giving a drug? • Prescribing • Dispensing • Administration • Counselling/communication

8. Adverse events in hospitalsWhat is the size of the problem? An organisation with a memory. Dept of Health 2001

9. 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

10. 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 Outcomes Phillips, J etal. Am J Health Syst Pharm 2001;58: 1835-41

11. Prescribing errors Dean B, Schachter M, Vincent C, Barber N. Quality and Safety in Healthcare 2002; 11:340-344 Shah SNH, Aslam M and Avery AJ. Pharm J. 2002; 267: 860-862

13. Handwriting

14. 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

15. Dispensing and adminn errors UK references 1 – 12 from Building a safer NHS, Medication Safety

16. Similar packaging • Same drug – different manufacturers

17. Similar packaging • Same drug – several strengths • May be colour-coded but DO NOT rely on colour

18. Similar packaging • Similar sounding names / similar spelling / same strength • Ceftazidime – Cefotxime

19. 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

20. 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

21. Poor handwriting on Rx • Incorrect IV administration calculations or pump rates • Poor record keeping/checking • double doses • wrong patient • Paediatric doses • Poor administration technique

22. Complicated prescriptions • Calculations • Verbal orders • Lack of knowledge about drugs • Mistakes in identifying drugs • names • packaging • misreading

23. National & local examples

28. 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

29. 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

30. 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

31. Orignal SpR off-duty now • Cover SpR unable to leave ward, anaesthetist to admin intrathecal drug • Anaesthetist had given I/Thecal drugs before but had never given chemotherapy • Methotrexate given intravenously • Vincristine given intrathecally • Patient died

32. Improving medication safety Department of Health. Jan 2004

33. Improving medication safety:Main areas of medication error • Anaesthetic practice • Anticoagulants • Cytotoxic drugs • Intravenous infusions • Methotrexate • Opiate analgesics • Potassium chloride

34. 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 Causes → Solutions Leape et al. JAMA 1995;274:35-43

35. 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

36. 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

37. 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 recommendation Basic Clinical Pharmacokinetics. 4th edn. ME Winter.Covers Drug-specific kinetics eg Digoxin, gentamicin

38. Drug dosing in renal impairment • Based on estimation of renal function using creatinine clearance • Cockcroft-Gault equation Crcl = F x (140-age)x wt in kg S.Cr in micromol/L Where F = 1.23 for males, 1.04 for females Or use an on-line calculator such as • http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

39. Drug-drug interactionsdrug-food interactions • Resources • BNF Appendix 1 • Pharmacy Medicines Information Departments • Have specialists texts and other resources to help

40. 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

41. 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

42. ElectronicMedicinesCompendium(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.

48. In summary

49. Prescribingresponsibilities • Drug • Dose • Route • Rate of administration • Duration of treatment • Checking patient allergies & sensitivities

50. Providing a prescription that is: • Legible • Legal • Signed • Giving all information to allow safe administration