Medication errors & how to minimise them! Kevin Gibbs Clinical Pharmacy Manager Bristol Royal Infirmary

1. Medication errors& how to minimise them!Kevin GibbsClinical Pharmacy ManagerBristol Royal Infirmary

2. Aims • To provide an awareness of: • Common medication errors • How to minimise these • The National Patient Safety Agency • Resources available to you to aid in safer prescribing

3. Objectives • By the end of the session you should be able to: • Define a medication error • List the ‘Five Rights’ • Understand the NHS role in safer prescribing • Prescribe safely…………

4. What is an error?

5. Doses omitted Wrong dose Unprescribed drug given Wrong dosage form given Wrong route of administration Wrong rate of administration Yes Yes Yes Yes Yes Yes What is an error ?

6. Wrong time of administration time of day in relation to food etc.... Using unstable/expired drug Wrong administration technique Incorrect reconstitution Extra dose given Yes Yes Yes Yes

7. Error in …. • Prescribing • Dispensing • Administration • Counselling/communication

8. Adverse-events per admission (%) AE number / year in UK Cost in additional hospital stay (£) Cost of clinical negligence schemes/yr Medication errors = % of incidents 10% 850,000 £2 billion £400 million 25% Adverse events – What is the problem

9. Incidence • 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. 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

11. Dispensing and Admin Errors UK references 1 – 12 from Building a safer NHS, Medication Safety

12. The NHS position on error • Avoidable failures occur; • Untoward events which could be prevented recur, often with devastating results • Incidents which result from lapses in standards of care in one hospital do not reliably lead to correction throughout the NHS • Circumstances which predispose to failure are not well recognised An Organisation with a Memory Department of Health (2000) http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4006525&chk=wlMQiJ

13. Patient safety • The process by which an organisation makes patient care safer. This should involve: • risk assessment; the identification and management of patient-related risks; • the reporting and analysis of incidents; • and the capacity to learn from and follow-up on incidents and implement solutions to minimise the risk of them recurring.

14. National Patient Safety Agency • Collect and analyse information on adverse events • Assimilate other safety-related information • Learn lessons and ensure that they are fed back into practice • Where risks are identified, produce solutions to prevent harm, specify national goals and establish mechanisms to track progress

15. NPSA: Patient safety incident • any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare. • this is also referred to as an adverse event / incident or clinical error, and includes near misses.

16. NPSA: Seven steps to patient safety • Step 1 Build a safety culture • Step 2 Lead and support your staff • Step 3 Integrate your risk management activity • Step 4 Promote reporting • Step 5 Involve and communicate with patients and the public • Step 6 Learn and share safety lessons • Step 7 Implement solutions to prevent harm

18. NHS action on medication errors • Reduce to zero the number of patients dying or being paralysed by maladministered spinal injections by the end of 2001 • Reduce by 40% the number of serious errors in the use of prescribed medicines by 2005 Building a safer NHS for patients Department of Health (2001) www.doh.gov.uk/buildsafenhs

19. Improving medication safetyJanuary 2004 www. doh.gov.uk/buildsafenhs/medicationsafety

20. Improving medication safety • Medication safety – a worldwide health priority. • Medication errors: definition, incidence, causes. • The medication process, prescribing, dispensing, administration. • Reducing risks for specific patients groups. • Patients with allergies • Seriously ill patients • Children

21. Improving medication safety • Reducing the risks for specific medicines • Anaesthetic practice • Anticoagulants • Cytotoxic drugs • Intravenous infusions • Methotrexate • Opiate analgesics • Potassium chloride • Organisational and environmental strategies • Information management and technology • Improved labelling and packaging • Interfaces between healthcare settings • Education and training for medication safety

22. Managing medication safety in secondary care • NHS Trusts should have dedicated machinery for organisation wide management of patient safety. • The CNST has developed new standards for medicines. This requires trusts to have medicines management policies, together with annual reports, improvement programmes with defined objectives and progress.

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

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

25. Internationally Research says: • USA 44-98,000 deaths “To Err is Human” • Australia 250,000 adverse events • 50,000 permanent disability • 10,000 deaths “Iatrogenic Injury in Australia” • Denmark confirmed 9% of admissions

26. Commonest causes of medication errors • Lack of knowledge of the drug – 36% • Lack of knowledge about the patient • “rule” violations – 10% • “Slip” or memory loss – 9% • JAMA 1995;274:35-43

27. 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

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

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

30. Rx: Insulin 7  stat Erythromycin 500mg IV in 50ml ISMN 10mg Vancomycin IV 1g read as 70 units, given Highly irritant – should be 250-500 ml ISTIN 10mg given Isosorbide mononitrate given instead of amlodipine given as bolus rather than infusion cardiac arrest Examples

31. Ceftazidime 2g tds IV Methotrexate 20mg daily (Dx: RA) Digoxin 125mg IV Discharged on warfarin loading dose 10mg od written badly Cefotaxime given Should be weekly Neutropenia Should be micrograms given - cardiac arrest Not referred for dose adjustment to clinic 14days of 10mg od INR 12.3

32. Weight-related dose for tinzaparin – 80kg body weight estimated CABG patient, standard therapy Galantamine re-started after a gap 8ml qds Patient was 51kg Thyroxine missed on admission, discovered day 10 Should have been 12mg (2ml) bd PRHO confused over liquid strength

33. Anaesthetist adjusted rate of fentanyl syringe pump in Theatre Rx: Co-amoxiclav Penicillin-alllergic Rx: morphine 0.4ml 30% sodium chloride used instead of 0.9% to dilute an epidural New pump. Increased rate x 1000 Respiratory arrest Did not realise this is a penicillin – anaphylaxis 4ml given Severe pain

34. Rx: Ranitidine 50mg In Theatre: Sodium chloride flush for a central line switched with fentanyl IV line flushed with sodium chloride 0.9% Given via epidural line rather than central line Respiratory arrest. Syringes made up in advance and not labelled Was in fact Potassium 15% - death. Ampoules look similar in design.

35. 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

36. 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

37. 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

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

39. How to handle errors • Is there an acceptable rate ? • Should errors be graded or scored for severity ? • Blame vs. No blame • Analyse why the errors have occurred and try to prevent reoccurrence

40. When things go wrong The "patient-centered“ approach • Identify an individual to blame • Focus on events surrounding the adverse event • Focus on the human acts or omissions immediately preceding the event • Blame, name & shame

41. Myths • Perfection myth • If people try hard enough they will not make any errors • Punishment myth • If we punish people when they make a errors, ther will make fewer of them

42. Or/ “Active learning” = Understanding causes of failure Human error may precipitate a serious error but Deeper, systematic, factors are usually present ¯ Addressing these would have prevented the error

43. Humans are fallible • Errors are inevitable • Change work conditions to make humans less error-provoking • Why did the defences fail? • What factors contributed to the failure? • CPD

44. How can we help you? Clinical pharmacists

45. How can we help you? Medicines Information Department

46. How can we help you? Formularies and Prescribing guidelines

48. How can we help you? • Resources BNF Medicines for Children

49. Care with units Legal Is it weight/BSA-related dosing. Is weight accurate? Safeprescribing: A summary • Clear and unambiguous • Approved name • No abbreviations • Care with IVs

50. ***** In English If abbreviate use ‘standard’ ones od / bd / tds / qds NOT 250mg3 • Clear decimal points 0.5ml not .5ml • Rewrite charts regularly • Take time, eg to read labels