Medicines and Patient Safety 2024 PDF

24 t h September 2024 Interprofessional Learning – Medicines and Patient Safety Dr. Muneera AlBuainain Healthcare Management Consultant RCSI Dublin Prof David Williams Department of Geriatric and Stroke Medicine Prof. Judith Strawbridge School of Pharmacy and Biomolecular Scienc...

24 t h September 2024 Interprofessional Learning – Medicines and Patient Safety Dr. Muneera AlBuainain Healthcare Management Consultant RCSI Dublin Prof David Williams Department of Geriatric and Stroke Medicine Prof. Judith Strawbridge School of Pharmacy and Biomolecular Sciences  LEARNING OUTCOMES At the end of this session you should be able to: – Describe the medicines use process – Classify medication errors – Identify error reduction strategies – Appreciate that using medicines safely is a complex skill that involves everyone on the team Healthcare professionals Patients THE MEDICATION-USE PROCESS Transcribin Administeri Prescribing Dispensing Monitoring g ng Who is involved? IN THE HOSPITAL SETTING…. Doctors Pharmacists (preadmission medications and amending Prescribing prescriptions) Nurses Dieticians Doctors (new drug prescriptions, kardex rewrites) Pharmacists Transcribing Nurses (drug orders to pharmacy) Dieticians Pharmacists Dispensing Pharmacy technicians Nurses Doctors Administering Pharmacists (endorsing prescriptions with administration directions) Patients (inhalers, insulin) Doctors Monitoring Nurses Pharmacists (TDM, ADRs) The Prescribing competency framework  The Cambridgeshire Enquiry A woman was commenced on methotrexate for rheumatoid arthritis by her consultant Her GP was to incrementally increase the dose to 17.5 mg once a week Three years later the patient and her daughter ask the GP to prescribe methotrexate in a way that involves taking fewer tablets – The GP inadvertently writes a prescription for 10 mg tablets to be taken once daily The locum community pharmacist then dispensed methotrexate 10 mg once daily A few days later a 2nd GP identifies the error on a repeat Rx request and crosses it off – The error remains on the computer held record The patient begins to feel unwell The Cambridgeshire Enquiry cont’d After 5/7 the pt is admitted to hospital with her own drugs and blood tests ordered. – Successive samples are inadequate for blood counts and are not followed through. – Drug chart indicates 100 mg daily of methotrexate Next day a staff nurse identifies the incorrect dosage of 100 mg and confirms with the patient that this should be 10 mg which was administered – The drug chart is not changed Next day the hospital pharmacy queries the methotrexate dose on the patient’s drug chart and asks the nurse to tell the doctor to check the dose – The doctor phones the GP’s surgery and gets confirmation from a non-medical member of staff that the 10 mg daily dose is correct. – This is accepted and methotrexate is administered at 10 mg The Cambridgeshire Enquiry cont’d The next day the patient’s condition is deteriorating. – Methotrexate is administered at 10 mg The next day a nurse suggests that methotrexate could be the cause of the problem The doctor chases the blood count results to finally reveal the serious problem. Eight days later the patient dies. The death certificate records the cause of death as gastrointestinal haemorrhage, pancytopenia and  MEDICATION ERROR Any preventable event that can cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer* *National Co-ordinating Centre for Medication error reporting and preve  MEDICATION ERROR Studies1,2 have shown that medication errors occur most commonly during the prescribing (39%–49%) and administration stages (26%– 38%) but also when transcribing (11%–12%) and dispensing (11%– 14%) medication. 1. Bates D, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29–34. STUDY OF MEDICATION ERROR IN EIGHT IRISH HOSPITALS TOTAL = 6,179 REPORTS Kirke,C IMJ 2009(102)(10) 339-41 PRESCRIBING ERRORS PRESCRIBING MEDICINES The most common intervention (for good or bad) made to improve the health of patients EQUIP An in-depth investigation into causes of prescribing errors 124,260 medication orders across 19 hospitals – 11,077 contained errors – error rate of 8.9% 50,016 were written by Year 1 doctors – 4190 errors detected – Error rate of 8.4% Almost all errors were intercepted by pharmacists before they could affect patient care Potentially lethal errors were found in less than 2% of prescriptions Dornan T et al, http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf PRESCRIBING ERROR EXAMPLES Incorrect dosing (e.g., dose adjustment for kidney function is neglected) Drug interactions with another prescription taken by the patient Illegible handwriting (for handwritten prescriptions) Electronic prescribing errors (e.g., wrong medication, wrong strength) Risk management - the right medicine Take a full drug history – Current prescription medicines Ask about different forms of medicines – inhalers, patches and oral contraceptives (if appropriate) – Non-prescription medicines, herbal and illicit drugs – Record ADRs including allergies – Ideas, concerns about medicines Choose the most appropriate medicine – Use resources (BNF, guidelines) and take advice 17  RCSI Essential medicines resource Pick any Institution listed to get the PharmaQuest App information – we have permissions to use, and this page will be deleted in the future This gives good summary information of the RCSI  Risk management : legibility What does this say? Prendergast vs Sam & Dee Ltd., Kosary, and Miller. CASE STUDY: MRS MOIRA PULLAR Died after poor handwriting on her hospital records led to her being administered ten times too much insulin. Factors involved in error: Poor hand writing by the prescriber was misread by a nurse A failure to: – check the dosage by a nurse or doctor – monitor the patient – check for blood glucose levels A prescription chart deliberately altered after the overdose, but no-one found responsible. Risk management: units Never abbreviate units What doses have been prescribed? Risk management: numerals What dose has been prescribed?  Risk management: numerals Avoid unnecessary decimal points – i.e. “trailing zeros” – E.g. 2mg not 2.0mg Where decimal points are essential always use the preceding zero – E.g. 0.5mg and not.5mg Quantities of 1 gram or more should be written as 1g Quantities of less than 1 gram should be written in milligrams IN SUMMARY: ABBREVIATIONS – A SHORTCUT TO MEDICATION ERRORS Error-Prone Abbreviations, Intended Misinterpretation Best Practice Symbols, and Meaning Dose Designations Abbreviations for Doses/Measurement Units Use unit(s) International Mistaken as IV (intravenous) or the number (International units IU** unit(s) 10 can be expressed as units alone) Use L (UPPERCASE) for liter l Liter Lowercase letter l mistaken as the number 1 Use mL (lowercase ml Milliliter m, UPPERCASE L) for milliliter Mistaken as mg Use nanogram or Ng or ng Nanogram Mistaken as nasogastric nanog Mistaken as zero or the number 4, causing a 10-fold overdose or greater (e.g., 4U seen as 40 or 4u seen as 44) U or u** Unit(s) Use unit(s) Mistaken as cc, leading to administering volume instead of units (e.g., 4u seen as 4cc) µg Microgram Mistaken as mg Use mcg ** On The Joint Commission’s “Do Not Use” list DISPENSING & ADMINISTRATION ERRORS SOUND ALIKE LOOK ALIKE DRUGS(SALADS) ‘it deosn’t mttaer in what oredr the ltteers in a word are the olny iprmoatnt tihng is that the frist and lsat ltteer are in the rghit pcale’ SOUND-ALIKE DRUG PAIR MIX-UPS Aminophylline Amitriptyline Anexate Anectine Carbamazepine Carbimazole Losec Lasix Novomix Novorapid Naloxone Lanoxin Ritonavir Retrovir Thyroxine Thymoxamine SALAD ERROR EXAMPLES FROM AN IRISH HOSPITAL Aminophylline/Amitriptylline Aminophylline MR 225mg prescribed on rewritten drug chart as Amitriptyline 225mg. Signed as administered x 9 days. Prescribed on discharge prescription - community pharmacy then spotted error. Amantadine/Amiodarone Amantadine 100mg BD prescribed for Parkinson's. Amiodarone 100mg BD ordered, dispensed and administered in error for up to 12 days in hospital. Dykinesia dramatically disimproved. Naloxone/Lanoxin® A patient, in the course of treatment in an acute hospital, was given parenteral morphine. The patient was sensitive to the drug and developed respiratory depression. The patient’s doctor called in an order for an ampoule of the antidote to morphine - naloxone to be administered. A dose was prepared from ward stock and given but there was no response. A repeat order for a second ampoule of naloxone was also given and again the patient showed no improvement. The nurse then questioned the doctor; “How much of this Lanoxin do you want me to give?” Instead of NaLoxone, the nurse heard LaNoxin. The patient subsequently died. STRATEGIES TO REDUCE SALAD ERRORS Write the full drug name when prescribing – never abbreviate Include indication for a medication to add clarity to a prescription Specify the exact dose on the prescription – never use ‘as directed’ Consider ‘tall man’ lettering eg, OxyCONTIN®, OxyNORM® when writing prescriptions or labelling medications etc. to identify key differences in high-alert SALAD pair names Avoid giving/accepting verbal medication orders/prescriptions Risk management: abbreviations Never abbreviate Names of medicines What dose has been prescribed? What is this medicine? 30 STRATEGIES TO REDUCE SALAD ERRORS Pharmacies should avoid stocking medication with packaging prone to SALAD errors “purchase for safety policy”  THE SEVEN MYTHS OF HUMAN ERROR & ITS MANAGEMENT Errors are intrinsically bad Bad errors are made by bad people Errors are random and highly variable Practice makes perfect Errors of highly trained professionals are very rare Errors of highly trained professionals are usually sufficient to cause bad outcomes It is easier to change people than situations James Reason 2004  REASON’S MODEL OF ACCIDENT CAUSATION Latent conditions Organisational Processes and Management Decisions Error Producing Conditions Environmental, Team, Individual or Task Factors that affect performance Active Failures Error (Slips, lapses, Mistakes) Violation (Ignoring rules of correct behaviour) Accident CASE REPORT - VINCRISTINE MEDICATION ERROR Patient treated for leukaemia Administered vincristine intrathecally instead of intravenously Died a month later – “We can put a man on the moon but why can't we find a safe method to prevent these deaths”(Coroner) Patient late Pharmacy sent leading to two syringes Syringes Doctor changes in with drugs in unfamiliar Doctor did not similar in procedures one bag with protocol read out route appearance and of and design procedures administration Adverse Event The latent failure model of complex system failure modified from James Reason, 1991 “HUMANS MAKE MISTAKES BECAUSE THE SYSTEMS THEY WORK IN ARE POORLY DESIGNED” James Reason 1997 Aviation: expect things to go wrong and design to compensate. High rates of reporting and shared learning Health: expect things to go right and seldom design in safety. Low rates of reporting and shared learning ERROR REDUCTION STRATEGIES PRESCRIBING SAFETY ASSESSMENT (PSA) Section 1 Section 8 Prescribing Section 2 Data Prescription Interpretation Review 8 sections – 60 Section 7 items Section 3 Drug TOTAL = 120 Planning Monitoring mins Management (200 marks) Section 6 Section 4 Adverse Drug Providing Section 5 Reactions Information Calculation Skills Empoweri ng patients PATIENT EMPOWERMENT FOR MEDICATION SAFETY CONCLUSIONS Medication errors are one of the most preventable causes of patient injury although the incidence of such errors varies widely as a result of differing definitions and methodologies The majority of medication errors occur as a result of poor prescribing, emphasising the need to improve prescribing skills The problems, sources, and methods of avoiding medication errors are multifactorial and multidisciplinary A supportive safety culture should be adopted to improve the rate of reporting of medication errors, allowing further investigation of these important causes of preventable harm PATIENT SAFETY AND MEDICINES “To err is human, to cover up is unforgivable but to fail to learn is inexcusable” Sir Liam Donaldson World Health Organisation (2004)