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Medication errors & how to minimise them

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1 Medication errors & how to minimise them
Medication errors & how to minimise them! Kevin Gibbs Clinical Pharmacy Manager Bristol Royal Infirmary

2 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

3 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…………

4 What is an error?

5 What is an error ? Doses omitted Wrong dose Unprescribed drug given
Wrong dosage form given Wrong route of administration Wrong rate of administration Yes

6 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

7 Error in …. Prescribing Dispensing Administration

8 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%

9 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

10 Prescribing errors Process Error Rate Serious Errors
(Primary Care) Computer generated 7.9% Hand written 10.2% (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 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% 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 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)

13 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.

14 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

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 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


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 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)

19 Improving medication safety January 2004

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 allergies Seriously ill patients Children

21 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

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

24 Providing a prescription that is:
Legible Legal Signed Giving 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 events 50,000 permanent disability 10,000 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 interaction Wrong drug / ingredient Wrong dose / frequency Wrong formulation Wrong route of administration Wrong quantity

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

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

30 Examples Rx: Insulin 7  stat Erythromycin 500mg IV in 50ml ISMN 10mg
Vancomycin IV 1g read as 70 units, given Highly irritant – should be ml ISTIN 10mg given Isosorbide mononitrate given instead of amlodipine given as bolus rather than infusion cardiac arrest

31 Methotrexate 20mg daily (Dx: RA) Digoxin 125mg IV
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

32 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

33 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

34 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.

35 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

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 dose GP 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 ward Both drugs delivered to theatre from ward Given food pre-op – op postponed

38 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

39 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

40 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

41 Myths Perfection myth Punishment 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

42 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

43 Change work conditions to make humans less error-provoking
In an active learning environment – lessons are embedded into an organisation’s culture and practices Evidence thst: “Safety cultures” – where open reporting and balanced analysis are encouraged in principle and by example – can have a positive impact on the performance or organisations “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 systems 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

44 How can we help you? Clinical pharmacists

45 How can we help you? Medicines Information Department

46 How can we help you? Formularies and Prescribing guidelines


48 How can we help you? Resources BNF Medicines for Children

49 Safe prescribing: A summary
Clear and unambiguous Approved name No abbreviations Care with IVs Care with units Legal Is it weight/BSA- related dosing. Is weight accurate?

50 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

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

52 The “5 Rights” the right patient the right drug the right time
the right dose the right route

53 If in doubt …….. Please ask

54 Further reading/references
Naylor, R. Medication Errors. Radcliffe Press. ISBN Department of Health. (2004). Building a safer NHS. Improving patient safety. National Patient Safety Agency (NPSA) (UK) Website: Institute for Safe Medication Practices (ISMP) (American) Website:

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