Towards zero harm from prescribing errors. Gillian Cavell, Consultant Pharmacist in Medication Safety Kings College Hospital

Transcription

1 Towards zero harm from prescribing errors Gillian Cavell, Consultant Pharmacist in Medication Safety Kings College Hospital

2 Outline How ambitious should patient safety goals be in relation to Medication Errors? Prescribing errors human factors vs electronic systems Designing out prescription and administration errors with electronic prescriptions The role of the Medication Safety Officer in delivering zero harm

3 How ambitious should patient safety goals be in relation to Medication Errors? What is a goal? An observable and measurable end result having one or more objectives to be achieved within a more or less fixed timeframe. Ref.

4 How ambitious should patient safety goals be in relation to Medication Errors? How should the goals be set

5 7 steps to patient safety Reducing errors The best way of reducing error rates is to target the underlying systems failures, rather than take action against individual members of staff. Dr Lucian Leape Harvard School of Public Health: the perfection myth: if people try hard enough, they will not make any errors the punishment myth: if we punish people when they make errors they will make fewer of them.

6 7 Steps to patient safety There is no single way to measure patient safety No errors? No harm? Increasing reporting rates? Air safety model

7 Proposed safety goals Increase reporting rates (measurable) Ensure learning from incidents (end-result) Know your risks (target for audit) Identify and resolve systems failures

8 Prescribing errors human factors vs electronic systems

9 Accessed 23 Oct 2015

10 Hyperkalaemia! Human Factors Knowledge Tasks Environment

11 Risk Hypoglycaemia following treatment of hyperkalaemia with insulin

12 Risk Hypoglycaemia following treatment of hyperkalaemia with insulin Adverse incident: Reported by a consultant, in which a diabetic patient was administered insulin 10units and glucose 20% for hyperk The patient s CBG was checked on 2 occasions over the next 2 hours but the patient was subsequently found unconscious with a CBG of 0.8mmol/L

13 Designing out prescription and administration errors with electronic prescriptions Human error safety assurance process Understand the incident and how changes could be made to prevent future events Identify the risks to ensure changes reduce the risk Mitigate design changes to achieve the outcome Demonstrate that changes made are acceptable and do reduce risk Monitor by gathering evidence of the outcomes

14 Problem: Hypoglycaemia after hyperkalaemia treatment Process Risks Patient Harm Hyperkalaemia Treatment: IV Insulin + Dextrose Asynchronous administration Multiple doses Hypoglycaemia Escalation of care Monitor blood glucose and potassium Lack of / inconsistent blood glucose monitoring

15 Designing out prescription and administration errors with electronic prescriptions Understand Blood glucose monitoring not carried out Glucose not administered at the same time as insulin Identify risks Severe hypoglycaemia requiring rescue therapy Mitigate Use electronic prescribing to ensure prescription and monitoring reduces the risk Demonstrate Ensure that changes are an improvement on previous systems Monitor Is the risk reduced in real life

16 Monitor using electronic prescribing

17 Mitigate using electronic prescribing

18 Mitigate using electronic prescribing

19 Ensure changes are an improvement

20 Reducing patient harm Pre-intervention 17 (30%) N=57 Significant reduction in incidence of hypoglycaemia post hyperkalaemia treatment

21 Monitor using electronic prescribing

22 Reducing patient harm Pre-intervention 17 (30%) Post-intervention 7 (12%) N=57 N=59 Significant reduction in incidence of hypoglycaemia post hyperkalaemia treatment p <0.05

23 Iterate Monitor the way the order set is being used Identify new problems Prescribing time vs administration Non-compliance Unchecking orders Is the protocol correct? New work to identify factors predisposing certain patients to post HyperK/hypoglycaemia

24 Opportunities to reduce harm Electronic prescribing systems! One example of designing an error out of the system Be proactive Use the information generated by EPMA Trigger reports Think outside the box

25 The role of the Medication Safety Officer in delivering zero harm Review all your organisations medication safety incidents Ensure you have access to categorise/amend Liaise with your Risk Managers and colleagues understand each other s roles Ask difficult questions Ensure you are involved in serious incident investigations Be objective Be a multidisciplinary team player

26 The role of the Medication Safety Officer in delivering zero harm Share your work Learn from others horizon scan Apply knowledge of risks to your own organisation Make error difficult to make

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