UoD Pharmacy Technician Conference

1. UoD Pharmacy Technician Conference Professional Pharmacy Technician – Impact on Practice May 14th 2010 ‘Decimal point errors’ and their impact on the technicians role Clive Newman Deputy Chief Pharmacist

2. Decimal point errors 1) Decimal point errors What types occur & how are they relevant to technicians? 2) Root Cause Analysis What is it & how does it help us discover the real problem 3) Case study Ten fold manufacturing error involving two technicians

3. Decimal point errors How common are errors? • 9% of medicines prescribed by a Junior Doctor include an error1 • In one study 200 tenfold prescribing errors were detected over 18months in a small hospital (80% adults, 20% paediatric)2 Overdoses were commoner than underdoses (61% v 39%) & 45% of errors were rated as potentially severe • At Derby Hospitals in a typical week Pharmacists will spot tenfold prescribing errors involving chemotherapy & aciclovir Refs 1) GMC. An investigation into causes of prescribing errors by junior doctors (EQUIP study); December 2009 2) TS Lesar. Tenfold medication dose prescribing errors. Annals of Pharmacotherapy 2002; 36(12):1833-39

4. Decimal point errors • Decimal point errors occur at different stages of the Medicines management process -Prescribing errors -Administration errors -Dispensing errors • Common themes: -Use of a calculation, misreading of decimal points, multiple zeros in the dose, doses less than 1

5. Decimal point errors Common drugs involved • Levothyroxine • Morphine • Insulin • Heparin • Acetylcysteine • Antimicrobials • Epoetin

6. Decimal point errors Prescribing errors • Abbreviations or illegible handwriting • ‘U’ or ‘IU’ (insulin or heparin) • Misplaced decimal (45.5) • Trailing zeros (1.0) • Omitted zeros (.1)

8. Decimal point errors Administration errors • Misreading of prescription (trailing, omitted zeros) • Setting pump rates • Calculation of volumes to administer Insulin: What is the standard concentration in a vial?

9. Decimal point errors Dispensing errors • Conversion of units (e.g. mg to ml) • Labelling errors (syrups & injections) • Annotation errors • Manufacturing (calculation) errors • Manufacturing (syringe volume) errors e.g. neonatal TPN

10. Decimal point errors Root Cause Analysis (RCA) • A problem solving methodology for discovering the real or root cause(s) of a problem • Encourages a systems based (rather than person centred) approach to analysis

11. Decimal point errors RCA tools include • Timeline • The 5 Whys • Cause & effect charts (e.g. Fishbone) • Control analysis

12. Decimal point errors The incident • Phenobarbital liquid made (x10) too concentrated in Pharmacy • Baby receives one dose & deteriorates rapidly • Admitted to intensive care unit for treatment of overdose • Baby makes full recovery System based or people centred approach???

13. Decimal point errors We will • Work through the incident using RCA tools to identify the real causes • Vote to identify the most significant cause of error identified by the RCA • Vote for the most significant of these causes that could/does occur in your own work environment.

14. Decimal point errors Investigation findings (i) • Two members of pharmacy staff prepared the product (A student technician was supervised by a qualified pharmacy technician) • The normal departmental manufacturing process was followed • A worksheet & the designated extemporaneous preparation room were used • The student had limited experience of extemporaneous manufacture and this was the first product she had made for several months. • The balance being used to weigh the powder was affected by the window being open & the door being repeatedly opened. • The extemporaneous preparation room was being used far more than usual (as the department had just merged sites). • There were large numbers of interruptions with both supervisors being disturbed several times by other staff.

15. Decimal point errors Investigation findings (ii) • Supervision of the student was transferred to a second qualified technician halfway through the process • The supervising technicians also performed the manufacturing check. • A written training package on making extemporaneous products did not exist • The training of staff to make extemporaneous products is not formally planned in advance and depends on workload, availability of staff etc. • There is no written procedure available on using the equipment (balance) involved • The worksheet uses a different unit of measure (milligram) to the balance (which measures in grams). • The worksheet included ‘trailing zeros’.

16. Decimal point errors Fishbone diagram

17. Decimal point errors

18. Decimal point errors

19. Decimal point errors Voting: In this incident which factor had the biggest impact: • Equipment • Team & social factors • Patient • Working conditions • Education & training • Communication • Individual

20. Decimal point errors Voting: In your place of work which factor is the commonest cause of incident • Equipment • Team & social factors • Patient • Working conditions • Education & training • Communication • Individual

21. Decimal point errors Take Home Messages • Decimal point errors are relatively common & associated with misreading of decimal points and calculations • They can occur at the prescribing, administration or dispensing stage • Root Cause Analysis will help you determine the underlying problems • In your workplace the commonest factor that causes incidents is……………….

22. Decimal point errors Thank you for taking part Questions?