Using drugs safely

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Using drugs safely
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Audit commission report

• The commission estimated that just under 11 of
  patients on hospital medical wards experience an
  adverse event, such as being given the wrong drug
  or having an adverse reaction to a drug.
• Such an event, although not fatal, can lead on
  average to an additional stay in hospital of
  8.5 days, costing the NHS as much as 1.1bn
  (1.5bn 1.8bn).

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Medication errors

• Errors included
• giving patients with cancer temazepam when they
  should have received tamoxifen
• giving a contraceptive steroid instead of an
  antipsychotic injection
• and prescribing an anticancer medicine at
  1000 times the correct dose.
• The commission estimated that nearly half these
  events were preventable.

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What is the size of the problem?

• Every year in the NHS
• 400 die/seriously injured by medical devices.
• 10,000 have serious adverse reaction to a drug
• Adverse events that lead to harm occur in 10 of
  hospital admissions.
• 28,000 written complaints about clinical
  treatment in hospital.
• 400m to settle clinical negligence claims.
• (potential liability of 2.4 billion)
• (ref An Organisation with Memory)

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When it goes wrong
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Health news The TimesJuly 19, 2006 Doctors'
drug ignorance putting lives at risk By Mark
Henderson, Science Editor PATIENTS are being
put at risk from adverse reactions to drugs
because doctors are not properly trained in
prescribing, leading pharmacologists said
yesterday. Too many junior doctors are leaving
medical school with a sketchy knowledge of drug
safety that is leading to dangerous mistakes,
according to critics, including the heads of the
NHS treatment watchdogs for England and Scotland.
Adverse drug reactions contribute to at least
250,000 hospital admissions and 5,000 deaths each
year, according to British Medical Association
figures released in May. Another study indicated
that 6.5 per cent of admissions followed an
adverse drug reaction, and that the drug was the
direct cause of admission in 80 per cent of these
cases.
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The Sunday TimesAugust 20, 2006 Doctors'
scrawl is a health risk TWO THIRDS of doctors
signatures on medical charts are illegible, a
survey has found. And the more senior the doctor,
the worse the scrawl, writes Siobhan Maguire.
The research, carried out at Wexford general
hospital over a one-month period, examined the
handwriting of three teams of doctors, including
interns, senior house officers, and registrars.
More than 1,136 signatures on 110 medical charts
were analysed. In one group, just 37 of 315
signatures could be read. Overall, two thirds of
house officers signatures were illegible and 91
of registrars. Those of interns were easier to
read, with 95 having a legible signature. Poor
penmanship was more prevalent with increasing
seniority of grade, said the authors of the
study. Doctors have a reputation for illegible
handwriting, although it has been demonstrated
that other professions have equally poor
penmanship.
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09/12/03 - Health news section Wrong one in
10 prescriptions by JENNY HOPE, Daily Mail
                                                
                                          18/12/0
1 - News section More patients dying after
medical blunders
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Deadly Toll of Medication Errors

• Pilot study in 2 London hospitals

Adverse events in gt1 in 10 pts
1/3 of these are serious
In 8 of these cases, it lead to the patients
death
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• Why do you think medication errors happen?

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Some factors that could increase the rate of
medication errors

• More rapid throughput of patients
• New drug developments, extending medicines into
  new areas
• Increasing complexity of medical care
• Increased specialisation
• Increased use of medicines generally
• Sicker and older patients, more vulnerable to
  adverse effects

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Causes of medication incidents

• Fatigue Sleep deprivation
• Hunger Long lapses between food/drink
• Concentration Lapses
• Stress Loss of control/cutting corners
• Distraction
• Lack of training
• Lack of access to information (not timely)
• Other factors Alcohol, drugs illness

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• Have you made a medication error?
• Have you seen a medication error?
• What did you do?

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Some I can remember

• Wrong heparin dose
• Teenage patient with congenital heart disease
  admitted for investigation. On verapamil on
  admission. Seen by different consultant
  cardiologist in the afternoon, given atenolol
  50mg and discharged.
• Patient in opposite bed given ACE inhibitor by
  bank staff nurse
• Monday evening patient on warfarin and aspirin
  dies of huge intracerebral haemorrhage

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Common Prescribing Errors

• Wrong drug (e.g. drugs that sound alike)
• Wrong dose
• Inappropriate Units
• Poor/illegible prescriptions
• Failure to take account of drug interactions
• Omission
• Wrong route/multiple routes (IV/SC?PO)
• Calculation errors (important in Paediatrics)
• Poor cross referencing
• Infusions with not enough details of diluent,
  rate etc. Poor cross-referencing between charts
• Once weekly drugs
• Multiple dose changes

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Patient with angina..
.cost the cardiologist and the pharmacist
450,000!
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Buspar or prozac??
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Fiorinel (analgesic) or florinef
(fludrocortisone)?
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Always check the patient information

• Age
• Weight
• Renal and hepatic function
• Concurrent diseases
• Laboratory test results
• Concurrent medications
• Allergies
• Medical/Surgical/Family History
• Pregnancy

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Dont use abbreviations

• Dont use abbreviations
• Drug names (CBZ for example)
• QD or OD for the word daily
• Letter U for unit
• mg for microgram (probably not mcg either)
• Sc for subcutaneous

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Hydrochlorothiazide misread as hydrocortisone! AZ
T Zidovudine or azathioprine?
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• Avoid decimal points if possible
• Use 500 mg for 0.5 g
• Use 125 microgrammes for 0.125 mg
• Never leave a decimal point naked
• Haolperidol .5 mg Haloperidol 0.5 mg
• Never use a terminal zero
• Colchicine 1 mg not 1.0 mg
• Leave a space between name and dose
• Atenolol50mg - Atenolol 50mg
• Dont use trade names unless you have to

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Spot the difference?
Look alike drugs contribute to medication errors
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Spot the difference?
Look alike drugs contribute to medication errors
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Spot the difference?
Look alike drugs contribute to medication errors
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Lidocaine

• Administering the wrong drug could be fatal
• NHS standard
• Water
• Sodium chloride
• Lidocaine (lignocaine)

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Examples
Drugs that sound alike Clotrimazole/Co-trimoxazole
Carbamazapine/carbimazole Risedronate/Methotrexat
e Drugs that look similar in writing ISMN /
ISTIN
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Once weekly drugs
Oral methotrexate Methotrexate prescribed as
10mg once daily, when correct dose frequency is
once weekly.
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Prevention of Medication Errors

• The Five Rs
• Right Patient
• Right Drug
• Right Dose
• Right Route
• Right Time

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Formularies Essential Drugs

• National formularies (e.g. the BNF) provide an
  independent source of advice
• Grampian joint formulary reflects
  hospital/primary care choices
• WHO provide a model list of essential drugs
  (300 items) some controversial!

Most prescribing limited to 100 formulations
(vs. gt 60,000 total)
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Scenarios to work on

• Patient scenario what drugs to continue on
  admission
• Scenario on communicating medication error
• How do you report error?