Intervention Study 2016 West ISD. Gillian Ritchie Clinical Pharmacist

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1 Intervention Study 2016 West ISD Gillian Ritchie Clinical Pharmacist

2 Introduction Annual data collection Two weeks All Medicines Management Team interventions Details recorded Classified by type Outcomes graded by significance by audit lead pharmacist

3 Wards and units included Romsey & Alton Lymington New Forest Hospital

4 Number of interventions West ISD Trust-wide West ISD Total Romsey and Alton Lymington During the 2 week study Projected number per annum 11,154 1, ,092

5 Number of interventions by type Trust-wide West ISD Total Romsey and Alton Lymington Documentation Clinical Financial NOTE: some interventions were of more than one type

6 1 Illegible 5 - Incomplete 2 Ambiguous 6 - Illegal 3 Allergy missing 7 MHA issue 4 Allergy incorrect

7

8 1 Drug omission on chart rewrite 11 Treatment duration 21 Stopping medication 2 Prescribing error on chart rewrite 12 Omissions blank box(es) 22 - Administration 3 Interactions 13 Omissions drug unavailable 23 - Compatability 4 Adverse effects 14 Omissions doses refused 24 Dispensing error 5 Drug choice 15 Omissions patient asleep 25 Incorrect drug administered 6 Swapping medication 16 Drug omission on admission 26 Drug blood levels 7 Dose 17 Drug omission on TTO 27 Physical health tests 8 Frequency 18 Fridge issues 28 - Monitoring 9 Route 19 Therapeutic duplication 29 Pt / carer counselling 10 Formulation 20 Therapeutic substitution 30 Patient identity 31 - Other

9 1 Drug omission on chart rewrite 11 Treatment duration 21 Stopping medication 2 Prescribing error on chart rewrite 12 Omissions blank box(es) 22 - Administration 3 Interactions 13 Omissions drug unavailable 23 - Compatability 4 Adverse effects 14 Omissions doses refused 24 Dispensing error 5 Drug choice 15 Omissions patient asleep 25 Incorrect drug administered 6 Swapping medication 16 Drug omission on admission 26 Drug blood levels 7 Dose 17 Drug omission on TTO 27 Physical health tests 8 Frequency 18 Fridge issues 28 - Monitoring 9 Route 19 Therapeutic duplication 29 Pt / carer counselling 10 Formulation 20 Therapeutic substitution 30 Patient identity

10 1 Cost information / analysis 2 Cost effectiveness 3 Formulary compliance

11

12 1 Intervention accepted and treatment altered 2 Intervention accepted but treatment not altered 3 Intervention accepted and recommendation actioned 4 Intervention rejected 5 Information only

13

14 1 Detrimental to patient 2 No significance to patient care 3 Significant but did not lead to improvement in standard of care 4 Significant and resulted in improvement in standard of care 5 Prevented a major organ failure or drug reaction of similar importance 6 Potentially life-saving

15

16 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Pharmacy Technician was organising medicines for TTO Patient prescribed enoxaparin 120mg once daily for 6 months for treatment of pulmonary embolism on prescription chart To continue until December 2016 Not prescribed on TTO Pharmacy Technician discussed with ward doctor Doctor added enoxaparin to TTO Potentially fatal omission of enoxaparin and communication failure with GP averted

17 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Patient prescribed rivaroxaban 20mg once daily for pulmonary embolism (PE) PE diagnosed three weeks previously Patient refusing doses Critical medicine to decrease risk of further PE Pharmacist: Discussed with nurses (patient asleep at time of pharmacist visit) Emphasised importance of patient taking rivaroxaban consistently Outcome: Patient started to take rivaroxaban again

18 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Warfarin not prescribed on admission Atrial fibrillation (AF) Pharmacist: Checked prescription charts from acute Trust for most recent warfarin doses Checked blood results for recent INR Advised dose Advised repeat INR Outcome: Critical medicine doses were not omitted Decreased risk of stroke secondary to AF

19 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Co-careldopa 12.5/50mg omitted from discharge summary Critical medicine for Parkinson s disease Continuation of Parkinson s medication vital Pharmacist: Checked medical notes Discussed with doctor Outcome: Co-careldopa added to TTO Parkinson s medication continued

20 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient Enoxaparin 40mg daily prescribed Severe renal impairment Decreased clearance Increased risk bleeding Pharmacist: Advised doctor to switch to unfractionated heparin (UFH) Outcome: Enoxaparin switched to UFH Venous thromboembolism prophylaxis prescribed safely

21 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient Bed bound since admission three days previously No venous thromboembolism (VTE) risk assessment completed No VTE prophylaxis prescribed Pharmacist discussed with doctor Outcome: Enoxaparin 40mg daily prescribed Decreased risk of VTE

22 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient Prescribed multiple medications for Parkinson s Disease: Madopar hard capsules Madopar controlled release Tolcapone Naso-gastric (NG) tube and nil by mouth Patient likely to miss doses of these critical medicines / NG tube will block unless formulation changes Pharmacist: Advised doctor to switch all madopar preparations to dispersible tablets Advised doctor to switch tolcapone to equivalent entacapone dose Outcome: More evidence that crushing and dispersing entacapone in water will not alter drug effect Patient received revised treatment No loss of mobility or increase in Parkinson s symptoms

23 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient egfr 13mls/min Prescribed morphine Pharmacist: Advised Dr that risk of opiate accumulation is much higher in renal failure Switching morphine to oxycodone would significantly decrease this risk Advised re dose conversion Outcome: Morphine switched to equivalent oxycodone dose Safe and effective analgesic use in renal failure

24 Common interventions 2016 (West ISD Romsey & Alton) Transcribing errors when chart rewritten / TTOs prescribed Allergy box blank or incorrect Medicines prescribed incorrectly on admission Dose adjustments in renal impairment

25 Common interventions 2016 (West ISD Lymington) Allergy box blank or incorrect on prescription chart Paracetamol prescribed regularly and PRN Transcribing errors when chart rewritten / TTOs prescribed Enoxaparin dose incorrect due to renal impairment Dose adjustments in renal impairment Medicines prescribed incorrectly on admission

26 Common interventions 2015 (Trust-wide) Allergy box blank or incorrect Inhalers not on prescription chart Enoxaparin dose incorrect due to renal impairment Antibiotics length of course not stated Paracetamol prescribed regularly and PRN Dose adjustments in renal impairment Medicines prescribed incorrectly on admission Transcribing errors when chart rewritten / TTOs prescribed Prescriptions not signed / dated by doctor Lithium levels, clozapine levels Choice of antipsychotic & how to switch Management of side effects

27 Common interventions 2014 (Trust-wide) Allergy box blank. Enoxaparin dose incorrect due to renal failure. Inhalers not on drug chart especially salbutamol prn More than one paracetamol-containing products prescribed Psychotropic medication and QTc prolongation risk/monitoring Old doses not crossed when new ones prescribed Antibiotics length of course not stated SSRIs and NSAIDs increased risk of GI bleed Procyclidine prescribed at night

28 Common interventions 2013 (Trust-wide) Insulin not given as penfill cartridges but no pen on ward and nurses were not happy to use insulin syringes with cartridges. Allergy box blank. Enoxaparin dose incorrect due to renal failure. Calcichew formulary formulations. Clozapine side-effects especially tachycardia Type/brand of insulin not stated e.g. M3 for Humulin Brand/strength inhaler not stated. Inhalers not on drug chart especially salbutamol prn Regular benzodiazepine review requests.

29 Cost to the organisation Based on NICE economic analysis (PSG001) Costs of a medicine error - largely through increasing bed stay and increasing monitoring testing Does NOT include the cost to the individual Significant error Serious error Life threatening error ,484 1,085-2,120

30 Economic analysis Significance EQUIP SHFT 2015 SHFT 2016 Potential lethal 2% 7% 7% 930,930-1,818,960 per year 789,880-1,543,360 per year Significant 53% 79% 86% 593,190-1,368,900 per year 626,990-1,446,900 per year Total costs of SHFT interventions 1,524,120-3,187,860 per year 1,416,870-2,990,260 per year

31 Conclusions Medicines Management Team make a significant number of interventions: 429 interventions in two weeks = approximately 11,150 in a year This saves the Trust almost 3million per year All interventions were either accepted or for information only 86% were significant and improved patient care 7% either prevented an organ failure or drug reaction of similar importance, or were potentially life-saving

32 Recommendations Repeat study for two weeks in 2017 Present Divisional findings to each Division Communicate common issues identified to relevant staff: Junior doctors induction Medical and nursing staff on wards Nurses Medicines Management training days Further develop, and invest in, the Medicines Management Team: Seek to enhance level of Medicines Management service provided throughout the Trust Thereby further enhance patient safety and optimise prescribing that is both clinically- and cost-effective Thereby generate further cost savings

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