Identifying and reducing medication errors in mental health

Transcription

1 Identifying and reducing medication errors in mental health Hilary Scott Chief Pharmacist South Essex Partnership University NHS Trust with valuable input from Ian Maidment, Senior Lecturer in Clinical Pharmacy, Aston University

2 Overview What is the scale of medication errors in mental health How do we identify them Possible risk factors for medication error Medication errors reduction and picking up near misses: our experience

3 Research literature Lots of research about medication errors But very few studies looking at medication errors in mental health 3 literature reviews Grasso et al, 2003 Maidment et al, 2006 Maidment et al, primary studies 2 USA; 1 Japan; 8 UK (4 single tertiary non-nhs unit)

4 Location Mental health services are predominantly community based Studies Most focus on in-patients 7 exclusive, 4 mainly Review found 0.4% errors community NRLS 9.8% incidents from the community 63.8% incidents from in-patient units

5 Analysis of NRLS data Thematic analysis of mental health & learning disabilities data 7,734 reports in 2007 from MH & LD 400 analysed in detail Severe harm (n=23) & random sample of others (n=377) Difficult to analyse data lacking Potential cause 3.25% (13/400) Medication name (55.2%) Difficult confirm error, or potential error

6 Type of Error (Reporting & Learning System) n Other 2,792 Wrong / unclear dose or strength 1,069 Wrong frequency 895 Omitted medication 864 Wrong medicine 675 Other events (36% of total) include - Non compliance - recording errors; CD register incorrect; dropping tablets, drug keys missing, drug sent to wrong unit etc. Very few knowledge-related errors 28% related to medicines for physical health care

7 Medication Risk factors Polypharmacy: physical meds & psychotropics common Physical meds: admin errors OR 1.53 Cl (Stubbs et al; Maidment, 2013) Service Issues Numerous care interfaces Med Rec only 1ary to 2ary care ward (Kothari, MPharm student project) Medication management delivered by non-experts increasing risk (Maidment et al, 2006) Self administration systems Patient Issues

8 in-house pharmacy service in South Essex since 2010 based across 3 sites 9 pharmacists 3 medicines management technicians Who are SEPT?

9 Pharmacy-led medicines reconciliation

10 Our research 3 month prospective evaluation 20 bedded assessment unit

11 Our findings unintentional discrepancies occurred in more than half of admissions more than half involved drugs for physical conditions the vast majority involved omission of drugs if undetected the majority had the potential to cause moderate harm

12 Identifying errors medicines reconciliation by medicines management technicians triage system operated by nursing staff clinical pharmacist ward visits participation in consultant ward rounds and MDT case conferences self-reporting of incidents

13 Pharmacy interventions

14 Incident reporting

15 Common errors

16 High risk errors 18 moderate harm errors over last 2 years 5 x wrong dose/strength/frequency administered 3 x administered to wrong patient 3 x wrong dose/strength/frequency dispensed 2 x prescribed when contraindicated 1 x omitted dose 1 x prescribed wrong medicine

17 Error reduction and near misses quarterly discussion at MMC medicines management audit programme doctors induction training qualified nurses training doctors educational programme Quality Strategy

18 Reviews Grasso BC, Bates DW, Shore MF Medication Errors in Psychiatric Care: Incidence and Reduction Strategies. Available on - (Accessed 27 November 2008). Maidment ID, Paton C, Lelliott P A Review of Medication Errors in Mental Health Care. Quality & Safety Health Care, 15, Maidment ID, Haw C, Stubbs J, Fox C, Katona C, Dean Franklin B Medication Errors in Older People with mental health problems: a review. International Journal of Geriatric Psychiatry, 23, Primary studies Grasso BC et al Use of chart and record reviews to detect medication errors in a sate psychiatric hospital. Psychiatric Services, 54, Haw CM et al Prescribing errors at a psychiatric hospital. Pharmacy in Practice, 13, Haw CM et al A review of medication administration errors reported in a large psychiatric hospital in the UK. Psychiatric Services, 56, Haw CM et al Medication administration in older psychiatric inpatients. International Journal of Quality in Health Care, 19, Ito H et al Common types of medication errors on long-term psychiatric care units. International Journal of Quality in Health Care, 15, Maidment ID et al A medication error reporting scheme an analysis of the first 12-months. Psychiatric Bulletin, 25, Nirodi P et al The quality of psychotropic drug prescribing in patients in psychiatric units for the elderly. Aging & Mental Health, 6, Paton C et al Prescribing errors in psychiatry. Psychiatric Bulletin, 27,

19 Primary studies (cont.) Rothschild JM et al Medication safety in a psychiatric hospital. General Hospital Psychiatry, 29, Stubbs J et al Auditing prescribing errors in a psychiatric hospital. Are pharmacists interventions effective. Hospital Pharmacist, 11, Stubbs J et al Prescription Errors in Psychiatry a multi-centre study. Journal of Psychopharmacology, 20, Others Dean B, Barber N, Schachter M. 2000a. What is a prescribing error? Quality in Health Care, 9, Dean B, Barber N. 2000b. The validity and reliability of observational methods for studying medication administration errors. American Journal of Health-System Pharmacy, 57, Grasso BC, Rothschild JM, Genest R et al What Do We Know About Medication Errors in in-patient psychiatry. Joint Commission Journal on Quality and Safety, 29, NICE Draft Scope on the clinical and cost-effectiveness of systems based and IT based interventions in medicines reconciliation accessed 16th May NICE Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. Alert reference: NICE/NPSA/2007/PSG001. Seale C, Chaplin R, Lelliott P, Quirk A. (2006). Sharing decisions in consultations involving anti-psychotic medication: a qualitative study of psychiatrists experiences. Social Science and Medicine, 62, Warner B, Gerrett D. (2005).Identification of medication errors through community pharmacies. International Journal of Pharmacy Practice.