Prescribing Audit on Hope Hospital Intensive Care Unit

1
Prescribing Audit on Hope Hospital Intensive Care
Unit

• February April 2006
• Dr A.Day, Dr S. Laha, Dr T.Thomas

2
Introduction

• In the UK, awareness of adverse incidents in
  health care is growing.
• May be gt10 in UK hospitals.
• The actual scale of the problem is unknown1.
• Drug prescription errors are a common cause.

1. Vincent C, Neale G, Woloshynowych M. Adverse
events in British hospitals preliminary
retrospective record review. BMJ 2001 322517-9
3
Introduction

• In the UK, potentially serious errors occur
  between 1 in 1 000 and 1 in 10 000
  prescriptions2.
• Complex and urgent treatment and prolonged
  hospital stay are associated with more errors3.

• Anonymous. Report maps road to medication
  safety. CMO Update 2004381-3
• Bates DW, CullenDJ, Laird N, et al. Incidence of
  adverse drug events and potential adverse events
  implications for prevention. Journal of the
  American Medical Associaton 1995274 29-34

4
Introduction

• A recent paper collaborated results from 24
  critical care units in the UK4
• 15 prescriptions had one or more errors
• Most errors were minor
• But, 19.6 errors were significant, serious or
  life threatening.

• Ridley SA, Booth SA, Thompson CM and the
  Intensive Care Societys Working Group on Adverse
  Incidents. Prescription errors in UK Critical
  Care units

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Aim

• To collect data about prescription errors in Hope
  Intensive Care Unit
• To evaluate the error rate and make changes to
  improve prescribing practice.
• To provide feedback to individual doctors.

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Method
Five Day Audit
Two Hour Teaching Session
1 week later
Five day Audit
4 weeks later
Five day Audit
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Method
Collect signatures and assign each doctor a number
Daily review of all prescriptions
No
ERROR?
Record
Yes
Classify nature of error5
Classify clinical impact of error
Minor No obvious harm
Serious Significant reduction in probability of
Tx being timely or effective
Significant Slight adverse affect E.g G.I upset,
rash
Potentially Life Threatening Increased risk of
harm to patient
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Method

• All data was entered onto a database.
• Prescriptions for intravenous and haemofiltration
  fluids, enteral and parenteral feeds and blood
  products were excluded.

5. Greater Manchester Critical Care Network.
Categories of Error. Clinical Audit of
prescription errors. Feb 2004
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Results

• Total 56 patients.
• Over the three week period, 1 403 new
  prescriptions (approx. 25 new prescriptions per
  patient) were written.

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Comparison of Error Free and Erroneous
Prescriptions
78
22
Error Free
Erroneous
11
Errors Per Prescription
11.3
4.7
0.7
Single Error
Two Errors
Three Errors
12
Distribution of Errors
Illegible
Ambigous
Abbrevitations
Transcription
13
Results

• The five most common incorrect prescriptions were
  for propofol (6.0), alfentanil (5.5),
  salbultamol (4.6), vancomycin (4.2), potassium
  chloride (4.2)
• Four categories with the highest error rate (non
  standard nomenclature, illegible, ambiguous,
  transcription) accounted for 65 of all errors!

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Comparison of Correct and Incorrect Prescriptions
Per Doctor
Correct
Incorrect
U
Doctor Identification
15
Percentage Error for Each Doctor
1
U
Doctor Identification Number
16

• 63 of unidentifiable prescriptions were
  incorrect prescriptions.

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Distribution of Potential Consequences
Minor
Significant
Serious
Life Threatening
18
Results

• 18 prescriptions (1.2 of new prescriptions
  written) were considered significant, serious or
  potentially life threatening.
• This gives a rate of potentially clinically
  important prescription errors as 5 per 400 new
  prescriptions.
• Majority of non-minor errors were prescriptions
  inappropriate for the patient
• E.g wrong drug, wrong dose or omission of drug.

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Doctors Responsible for Significant, Serious and
Life Threatening Errors
2
3
4
5
6
7
10
11
12
16
U
Doctor Identification Number
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Discussion

• What is it about unidentifiable prescriptions
  that leads to higher error rates?
• Rushed decisions?
• Prescribing at night?
• Information not readily available?
• Reluctance to be identified?

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Discussion

• The groups of drugs associated with the largest
  number of prescription errors may simply reflect
  a larger number of prescriptions for those drugs.

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DISCUSSION

• Hand-written prescriptions are frequently
  illegible, incomplete or subject to transcription
  errors.
• Improvements could therefore be achieved by
  reinforcing the importance of proper prescription
  writing.
• However adverse events are commonly caused by
  prescribing errors and include wrong choice of
  drug, dose, route, formulation or time of
  administration, unfamiliar drugs/preparations
• Improvements could be made by more immediate
  access to relevant information relating to the
  drug (i.e indications, contraindications,
  interactions, therapeutic dose or side effects)
  or the patient (allergies, co-morbidities, recent
  laboratory results).

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DISCUSSION

• Improvements
• Education and Information
• Access to electronic data bases BNF, Uptodate,
  Toxbase
• Three monthly audit.
• Electronic Prescribing

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CONCLUSION

• THANK YOU
• QUESTIONS?
• Thanks to E. Boxall and D. Grundy