Lite Bites of learning for improving medicines safety

1. Medicine Safety Group Lite Bites of learning for improving medicines safety April 2014 Headline 1: Patient sent home with wrong medication Headline 2: Patient on insulin & dextrose for hyperkalaemia doesn’t get correct monitoring Headline 3: Too many warfarin doses are being prescribed ‘out of hours’ Incident: A patient was discharged from a ward by nursing staff. The patient was sent home with prednisolone (which had been stopped during admission) but they had not been sent home with a supply of required warfarin. At home the patient had a low INR, and was told to increase the number of tablets they took. When the patient was seen by the GP it transpired that they had been taking 50mg prednisolone as 'blood thinning' tablets as they didn’t have warfarin. Incident: A patient admitted with high potassium was prescribed insulin and dextrose. No blood sugars were recorded for over 3 hours, and the patient then became very unwell. On checking, the blood sugar was 2.6mmol/l and it was identified that an incorrect dose of insulin had been administered. Incident: Over 300 phone calls per month are made to Hospital at Night to dose warfarin. • Message: • Discuss the need to prioritise warfarin at the board round. • Assist the patient to get blood taken as promptly as possible. • Encourage the ward-based doctors to complete warfarin prescription before finishing work at the end of the day • Message: • All patients receiving IV administration of insulin need regular blood sugar monitoring. • For patients receiving insulin for treatment of high potassium level, follow the Guideline for the Management of Acute Hyperkalaemia in Adults • Message: Ensure nurses explain to patients: • what medication they are taking home. • that the TTO’s they have match the prescription and are correct