5 What is an error ? Doses omitted Wrong dose Unprescribed drug given Wrong dosage form givenWrong route of administrationWrong rate of administrationYes
6 Wrong time of administration time of dayin relation to food etc....Using unstable/expired drugWrong administration techniqueIncorrect reconstitutionExtra dose givenYes
7 Error in …. Prescribing Dispensing Administration Counselling/communication
8 Adverse events – What is the problem Adverse-events per admission (%)AE number / year in UKCost in additional hospital stay (£)Cost of clinical negligence schemes/yrMedication errors = % of incidents10%850,000£2 billion£400 million25%
9 Incidence Difficult to estimate due to varying definitions - US/UK Prescribing errors3-20 per 1000 prescriptionsMedication errors1 per patient per dayBeen estimated that drug errors account for 1/5 of all deaths due to adverse drug events
10 Prescribing errors Process Error Rate Serious Errors (Primary Care)Computer generated7.9%Hand written10.2%(Hospital)1.5%0.4%Dean B, Schachter M, Vincent C, Barber N. Quality and Safety in Healthcare 2002; 11:Shah SNH, Aslam M and Avery AJ. Pharm J. 2002; 267:
11 Dispensing and Admin Errors Stage of processError RateSerious ErrorsDispensing errors (P)1%0.18%Dispensing errorsUndetected (H)0.0002AdministrationOral Medicines (H)3 – 8%Preparation and admin of parenteral medicines13%- 49%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 resultsIncidents which result from lapses in standards of care in one hospital do not reliably lead to correction throughout the NHSCircumstances which predispose to failure are not well recognisedAn Organisation with a MemoryDepartment of Health (2000)
13 Patient safetyThe 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 eventsAssimilate other safety-related informationLearn lessons and ensure that they are fed back into practiceWhere 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 cultureStep 2 Lead and support your staffStep 3 Integrate your risk management activityStep 4 Promote reportingStep 5 Involve and communicate with patients and the publicStep 6 Learn and share safety lessonsStep 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 2001Reduce by 40% the number of serious errors in the use of prescribed medicines by 2005Building a safer NHS for patientsDepartment of Health (2001)
19 Improving medication safety January 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 allergiesSeriously ill patientsChildren
21 Improving medication safety Reducing the risks for specific medicinesAnaesthetic practiceAnticoagulantsCytotoxic drugsIntravenous infusionsMethotrexateOpiate analgesicsPotassium chlorideOrganisational and environmental strategiesInformation management and technologyImproved labelling and packagingInterfaces between healthcare settingsEducation 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 Prescribing responsibilities DrugDoseRouteRate of administrationDuration of treatmentChecking patient allergies & sensitivities
24 Providing a prescription that is: LegibleLegalSignedGiving all information to allow safe administration
25 Internationally “To Err is Human” “Iatrogenic Injury in Australia” Research says:USA ,000 deaths“To Err is Human”Australia 250,000 adverse events50,000 permanent disability10,000 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 interactionWrong drug / ingredientWrong dose / frequencyWrong formulationWrong route of administrationWrong quantity
28 Incorrect IV administration calculations or pump rates Poor handwriting on RxIncorrect IV administration calculations or pump ratesPoor record keeping/checkingdouble doseswrong patientPaediatric dosesPoor administration technique
29 Complicated prescriptions Calculations Verbal orders Lack of knowledge about drugsMistakes in identifying drugsnamespackagingmisreading
30 Examples Rx: Insulin 7 stat Erythromycin 500mg IV in 50ml ISMN 10mg Vancomycin IV 1gread as 70 units, givenHighly irritant – should be mlISTIN 10mg givenIsosorbide mononitrate given instead of amlodipinegiven as bolus rather than infusioncardiac arrest
31 Methotrexate 20mg daily (Dx: RA) Digoxin 125mg IV Ceftazidime 2g tds IVMethotrexate 20mg daily (Dx: RA)Digoxin 125mg IVDischarged on warfarin loading dose 10mg odwritten badlyCefotaxime givenShould be weeklyNeutropeniaShould be microgramsgiven - cardiac arrestNot referred for dose adjustment to clinic14days of 10mg odINR 12.3
32 Weight-related dose for tinzaparin – 80kg body weight estimated CABG patient, standard therapyGalantamine re-started after a gap 8ml qdsPatient was 51kgThyroxine missed on admission, discovered day 10Should have been 12mg (2ml) bdPRHO confused over liquid strength
33 Anaesthetist adjusted rate of fentanyl syringe pump in Theatre Rx: Co-amoxiclavPenicillin-alllergicRx: morphine 0.4ml30% sodium chloride used instead of 0.9% to dilute an epiduralNew pump. Increased rate x 1000Respiratory arrestDid not realise this is a penicillin – anaphylaxis4ml givenSevere pain
34 Rx: Ranitidine 50mgIn Theatre: Sodium chloride flush for a central line switched with fentanylIV line flushed with sodium chloride 0.9%Given via epidural line rather than central lineRespiratory arrest. Syringes made up in advance and not labelledWas 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 day10mg daily dispensed by locum pharmacistRx 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 doseGP 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 wardBoth drugs delivered to theatre from wardGiven food pre-op – op postponed
38 Orignal SpR off-duty now Cover SpR unable to leave ward, anaesthetist to admin intrathecal drugAneasthetist had given I/Thecal drugs before but had never given chemotherapyMethotrexate given intravenouslyVincristine given intrathecallyPatient died
39 How to handle errors Is there an acceptable rate ? Should errors be graded or scored for severity ?Blame vs. No blameAnalyse why the errors have occurred and try to prevent reoccurrence
40 When things go wrong The "patient-centered“ approach Identify an individual to blameFocus on events surrounding the adverse eventFocus on the human acts or omissions immediately preceding the eventBlame, name & shame
41 Myths Perfection myth Punishment myth If people try hard enough they will not make any errorsPunishment mythIf 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 precipitatea serious errorbutDeeper, systematic, factors are usually presentAddressing these would have prevented the error
43 Change work conditions to make humans less error-provoking In an active learning environment – lessons are embedded into an organisation’s culture and practicesEvidence thst:“Safety cultures” – where open reporting and balanced analysis are encouraged inprinciple and by example – can have a positive impact on the performance ororganisations“Blame clutures” – encourage people to cover up errors for fear of retribution and act against the identification of the true causes of failure – they ficus heavily on individual actions and largely ignore the role of underlying systemsHumans are fallibleErrors are inevitableChange work conditions to make humans less error-provokingWhy did the defences fail?What factors contributed to the failure?CPD
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