Reducing Medication Errors findings of the National Clinical Governance Protected Time Project

1. Reducing Medication Errorsfindings of the National Clinical Governance Protected Time Project Paul Moore Clinical Governance Manager

2. Introduction • The protected time project • Why medication errors? • What did we learn? • Main developments • Are we safer?

3. Protected Time Project • Developed by NHS Clinical Governance Support Team • SMUHT one of 20 NHS Trust involved • accelerated service improvement • enables frontline staff to develop effective systems and processes • our approach involved representatives of all stakeholders • our approach identified and acknowledged problems up front

4. Protected Time Programmemethodology • define the problem and significance • stakeholder analysis and recruitment • process map • identifying problems • identifying / analysing controls and gaps • identify opportunities • redesigning the process • action planning for change • monitor performance

5. Why medication errors? Problem • our web-enabled incident reporting system, launched in June 2001, immediately highlighted that one of the largest areas of adverse events was the prescription and administration of drugs Significance • Patient’s at risk of harm - potentially very high • writing prescription most common therapeutic intervention • high associated mortality and litigation costs • reduce by 40% the number of serious errors in the use of prescribed drugs by 2005

6. Aims • Develop a whole systems approach to reducing medication errors • Reporting medication errors • Drug administration process • Capturing, validating & disseminating lessons for learning • Implementing change • Monitoring performance

7. What did we learn from participants? • Staff are motivated to keep patients safe • Staff do not routinely share their experience of adverse events with each other • Systems for actively managing and learning from adverse events were inadequate • Disciplinary action following medication errors varies amongst professionals and • makes doctors less likely to report formally • introduces reporting bias within HIRS

8. What did we learn from participants? System is flawed • training in isolation • patients - passive recipient’s not active participant’s • use of multidisciplinary team - ward rounds • pharmaceutical packaging • inadequate trust policy • varying use of disciplinary action against individuals • no formal process for reviewing and learning from error • no mechanism for disseminating learning

9. Main developments • Development of HIRS • improved web-enabled electronic data capture • error reporting throughout the process of drug administration Supply / Prescription / Delivery (to clinical areas) / Administration • Development of ‘integrated’ training informed by medication errors • Revised mandatory clinical training programme driven by incident reporting system output • Set up learning group to capture, validate and disseminate lessons for learning • Targeted clinical audit • Empowerment initiatives to encourage greater patient participation • Reading prescriptions • Identification name bands

10. Are we safer?

11. Examples of incidents reported • Heparin injection given in theatres - adrenaline intended • High dose Gentamicin prescribed once daily (Patient in Renal Failure) • Morphine diluted in lignocaine not water • Enoxaparin overdoses (several) • Flumazenil given pre-endoscopy instead of Midazolam

12. Examples of incidents reported • Suxamethonium given instead of Midazolam • Beta blocker given to asthmatic • 24 hour Diamorphine infusion given over 9 hours • Potassium Chloride not available during cardiac arrest

13. Quick wins • 61% increase in reported adverse events • Profile the need to weigh patient’s on admission • Targeted staff training to areas of identified high risk • low molecular weight heparin prescribing • insulin sliding scale administration • documentation of allergies and medication intolerance • Established multidisciplinary error review group • Updated and revised mandatory clinical training driven by incident reporting system output

14. Quick wins • Removal of manufacturers’ packs known to have contributed to administration error • Morphine Sulphate 30mgs/ml • Lignocaine ampoules

17. Quick wins • New medicines policy with safer procedures and much wider target audience • Relationship between incident reporting and disciplinary action defined for all staff

18. Examples of safer practice Would you administer Augmentin® to a patient with a penicillin allergy? Answer: No - as it contains Amoxycillin • reports of poor records of medication intolerance led to an audit. 39% of nurses and 13% of doctors did not recognize this error potential. Now included in training.

19. Examples of safer practice Combination products • Patient received 5 x overdose of Co-beneldopa. Was prescribed 62.5 mg dose. • Bottle labelled as12.5/50 and interpreted as 12.5 dose and 50 tablets in bottle, so 5 tablets given. • Labels changed and now read: • Co-beneldopa 12.5/50 (62.5mg) dispersible tablets

20. Summary • The protected time project has accelerated the development of a web-enabled incident reporting and learning system for medication errors. • More medication errors are reported than ever before. • Data is used to influence training and shared with staff for learning • The project has improved patient safety within the Trust