Medication errors

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

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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

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What is an error?
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What is an error ?

• 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

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• 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

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Error in .

• Prescribing
• Dispensing
• Administration
• Counselling/communication

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Adverse events What is the problem

• 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

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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

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Prescribing errors
Process Error Rate Serious Errors
Prescribing errors (Primary Care) Computer generated 7.9
Prescribing errors (Primary Care) Hand written 10.2
Prescribing errors (Hospital) 1.5 0.4
Dean B, Schachter M, Vincent C, Barber N.
Quality and Safety in Healthcare 2002
11340-344 Shah SNH, Aslam M and Avery AJ. Pharm
J. 2002 267 860-862
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Dispensing and Admin Errors
Stage of process Error Rate Serious Errors
Dispensing errors (P) 1 0.18
Dispensing errors Undetected (H) 0.0002
Administration Oral Medicines (H) 3 8
Preparation and admin of parenteral medicines 13- 49 1
UK references 1 12 from Building a safer NHS,
Medication Safety
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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/Pub
  lications/PublicationsPolicyAndGuidance/Publicatio
  nsPolicyAndGuidanceArticle/fs/en?CONTENT_ID400652
  5chkwlMQiJ

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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.

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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

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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.

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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

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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

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

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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

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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.

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Prescribing responsibilities

• Drug
• Dose
• Route
• Rate of administration
• Duration of treatment
• Checking patient allergies sensitivities

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

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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

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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 199527435-43

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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

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

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

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Examples

• 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

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• 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

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• 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

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• 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

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• 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.

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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

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• 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

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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

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• 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

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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

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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

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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

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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

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• 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

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How can we help you?

• Clinical
• pharmacists

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How can we help you?

• Medicines
• Information
• Department

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How can we help you?

• Formularies
• and
• Prescribing
• guidelines

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How can we help you?

• Resources
• BNF
• Medicines
• for Children

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Safe prescribing A summary

• Care with units
• Legal
• Is it weight/BSA-related dosing. Is weight
  accurate?

• Clear and unambiguous
• Approved name
• No abbreviations
• Care with IVs

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• Clear decimal points
• 0.5ml not .5ml
• Rewrite charts regularly
• Take time, eg to read labels

• In English
• If abbreviate use standard ones
• od / bd / tds / qds
• NOT 250mg3

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• Care if
• Impaired renal function (NB GFR)
• Hepatic dysfunction
• Children
• The elderly
• Drug unknown to you
• Very new drug

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The 5 Rights

• the right patient
• the right drug
• the right time
• the right dose
• the right route

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If in doubt ..

• Please ask

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Further reading/references

• Naylor, R. Medication Errors. Radcliffe Press.
  ISBN 1857759567
• Department of Health. (2004). Building a safer
  NHS. Improving patient safety.
• National Patient Safety Agency (NPSA) (UK)
• Website http//www.npsa.nhs.uk/
• Institute for Safe Medication Practices (ISMP)
  (American)
• Website http//www.ismp.org/