Appendix B Patient Stories

Transcription

1 Sharing patient stories is a powerful way to illustrate key messages about medication safety. Use your own stories, ask for your audience to share stories, and/or choose from those described below. Share both positive stories and those with challenges in providing safe care. Highlight the lesson learned from the story. Focus on how a better patient/family and healthcare provider partnership can positively influence medication safety and reduce potential for patient harm. You can find more patient stories about medication safety at The stories in this document illustrate key messages in the following areas: 1. Medication Incidents Can Happen 2. Be Engaged in Patient Safety! 3. Keep a Current Medication List 4. Know your Medications: Check name and purpose of medications when you get a prescription, fill a prescription, are given medications 5. Know your Medications: Understand the risks of non- prescription/over- the- counter medications 6. Store Medications Safely 7. Dispose of Medications Safely 8. Report and Learn from Medication Incidents 9. Supplemental Topic: Children and Teens 10. Supplemental Topic: High Alert Medications 11. Supplemental Topic: Seniors 12. Supplemental Topic: Travelling with Medications 13. Supplemental Topic: Cancer Medications in the Home 1

2 1. Medication Incidents Can Happen A consumer was given two medications that are known to interact with each other resulting in a reduced effectiveness of her medication to treat breast cancer. 1 A patient s anti- depressant medication was mistakenly discontinued on admission to hospital, resulting in her progressive deterioration that had a major impact on her and her family s quality time at the end of her life. 2 A client on home care was finding it difficult to cope and unable to live her life normally due to extreme dizzy spells when standing and walking. Medication reconciliation helped identify that she was on multiple blood pressure medications. She was reassessed, her blood pressure stabilized, and she no longer required home nursing care Be Engaged in Patient Safety! I recently was on holiday in BC when I fractured my collarbone. I was transported by ambulance from Sicamous to Salmon Arm. The paramedics asked me what medications I took. I showed them my current MIPS medication card. Both paramedics said this tool was a great idea and made their jobs easier. They asked where they could get the med card and I told them My tip is to carry a current medication card with you at all times and show it when receiving any health care services, as it helps any provider that requires information about your medications Keep a Current Medication List A consumer had received a prescription for the antidepressant citalopram, at a dose of 30 mg per day. When asking a family doctor for a refill, the consumer relied on memory and said that the dose was 45 mg daily. The family doctor thought the dose seemed high and wrote a prescription for 40 mg daily. After the consumer started taking the higher dose, some side effects occurred. 5 1 SafeMedicationUse.ca Newsletter. Vol. 3(4) June 14, [cited 2013 July 15]. Available at: 2 Canadian Patient Safety Week Newsletter Ask. Listen. Talk. [cited 2013 July 15]. Available at: 3 Canadian Patient Safety Institute. Medication Reconciliation in Home Care. Getting Started Kit. [cited 2013 July 15]. Available at: 0Kit.pdf. 4 Manitoba Institute for Patient Safety. S.A.F.E. Patient Blog. [cited 2013 July 15]. Available at: 5 SafeMedicationUse.ca Newsletter, Vol. 3(7) December 19, [cited 2013 July 15]. Available at: 2

3 A consumer noticed potential problems on two occasions while receiving care in an emergency department. On one occasion, information that was obtained from a computer system did not include the current dose of the consumer's blood thinning medication, warfarin. On another occasion, the computer system did not have current information on the consumer's dose of high blood pressure medication, candesartan cilexetil (brand name Atacand). A mistake with either of these medications could cause harm. The consumer spoke up and made sure that the healthcare providers got the right information Know your Medications: Check name and purpose of medications when you get a prescription, fill a prescription, are given medications A patient received a prescription for warfarin, and was to take one 5 mg tablet every day for 5 days, then have a Prothrombin Time and International Normalized Ratio (INR) test. The INR result was too low, so the dose was increased to 7 mg (one 5 mg tablet and two 1 mg tablets). The next INR was too high, so the dose was reduced to 3 mg (three 1 mg tablets). The results of the next INR were even higher. The warfarin was stopped altogether, and restarted once the INR fell to a safe level. The warfarin was restarted at 0.5 mg daily (half of a 1 mg tablet). The INR was checked again after 2 and 4 days, and was found to be in the correct range. Later, while cutting a tablet in half for another dose, the patient noticed the tablet was marked with the number 5. The patient then checked the tablets in the bottle labelled as "warfarin 5 mg" and found that they were marked with the number 1. The patient visited the pharmacy where the prescriptions had been filled and it was confirmed that the container labels had been switched. 7 A patient was treated for a disease that can occur when a person s immune system attacks normal body cells. Following hospitalization, the patient was sent home with a prescription for a medication cyclophosphamide. Once home, the patient noticed that the medication received at the pharmacy was labeled cyclosporine. She did not take the drug and contacted the pharmacy. Similarities in the appearance of names of medications can cause confusion. 8 The consumer had cancer of the esophagus and wished to remain at home. To help manage pain, the consumer was given prescriptions for slow- release and regular- release hydromorphone tablets. As the cancer got worse, the consumer became unable to swallow anything and a feeding tube was inserted into the stomach. The consumer could no longer use the slow- release hydromorphone tablets and was given a prescription for an injectable form of hydromorphone. On a day when a home care nurse was visiting, the consumer was 6 SafeMedicationUse.ca Newsletter. Vol 3(1). January 11, [cited 2013 July 15]. Available at: 7 SafeMedicationUse.ca Newsletter. Vol. 1(7) November 11, [cited 2013 July 15]. Available at: 8 SafeMedicationUse.ca Newsletter. Vol. 3(3) May 1, [cited 2013 July 15]. Available at: 3

4 experiencing severe pain. At the time, the slow- release hydromorphone tablets were still in the home. The nurse crushed one of the slow- release hydromorphone tablets, mixed it with some liquid, and tried to give the mixture through the G- tube. This mixture blocked the tube. Family members eventually cleared the tube. Later, they realized that pushing the crushed tablet through the G- tube could have made a large dose of the medicine enter the consumer's body all at once, which could have been dangerous. 9 A pregnant woman was prescribed an antibiotic. She went to the pharmacy to pick up her medication, without noticing that she was given someone else s prescription for methotrexate, a medication used to treat certain types of cancer, arthritis and psoriasis. Methotrexate can cause birth defects or possibly a miscarriage. The woman took one of the methotrexate tablets before noticing the mistake. This happened because of a mix- up with patient names. The names of the pregnant woman and the person who was supposed to receive the methotrexate were very similar Know your Medications: Understand the risks of non- prescription/over- the- counter medications. A patient with pneumonia received and filled a prescription for an antibiotic. The doctor and pharmacist did not know that the patient was taking a non- prescription drug that contained minerals. Some minerals can prevent the body from absorbing some drugs. The antibiotic did not work and the pneumonia was not cured. The patient was prescribed the same drug again. This time, the doctor told a family member that it was important that the patient stop taking minerals while they were on the antibiotic. The patient stopped taking the non- prescription minerals while on the second prescription of the antibiotic, and the pneumonia was cured. 11 In proper doses, acetaminophen is a safe drug, but overdose is a common cause of acute liver failure. The recommended maximum daily dose of acetaminophen for healthy adults is 4 grams, and is much lower for children and elderly patients. Since many cough, cold and flu products contain acetaminophen to control fever and aches, it is easy to take too much acetaminophen if you don t check the ingredients. The safe dose is easily exceeded when consumers take a little extra of one product or take a number of products that contain acetaminophen SafeMedicationUse.ca Newsletter. Vol. 4(4) July 9, [cited 2013 July 15]. Available at: 10 SafeMedicationUse.ca Newsletter. Vol. 4(2) April 29, [cited 2013 August 23]. Available at: 11 SafeMedicationUse.ca Newsletter. Vol. 1(6) September 15, [cited 2013 July 15]. Available at: 12 SafeMedicationUse.ca Safety Tools and Resources. Get Medication Safety Tips. [cited 2013 July 15]. Available at: 4

5 A patient taking oral chemotherapy had been advised to take Gravol. The patient later returned to the clinic reporting ongoing nausea. She mentioned that she was taking "non- drowsy" Gravol. The pharmacist realized that the patient had been taking the Gravol ginger product, instead of the Gravol product containing dimenhydrinate Store Medications Safely A family member had placed the pet dog's pills on a bookcase. Later, the elderly relative moved the dog's pills to a bedside table where other medications were stored. The elderly relative then took the deworming pills instead of a regularly prescribed medication for several days. 14 Do you need to worry about items in your medicine cabinet YES! In a recent survey of students in grades 7-12, over 7% reported using an over- the- counter cough or cold medication containing dextromethorphan (DM) to get high. Nearly 3% of the students reported using over- the- counter sleeping medication such as Nytol for non- medical reasons. 15 Poisoning is a common cause of injuries in Canada. Over 60% of all poisoning- related deaths are accidental. Young children are often poisoned by things found in the home, including medications. Children are drawn to colourful products. Keep medications and all harmful substances out of sight and reach of children Dispose of Medications Safely A 2- year- old boy was found unconscious 2 days after visiting a relative in a nursing home. He later died, and a patch containing fentanyl, a very strong pain killer, was found in his throat Report and Learn from Medication Incidents ISMP Canada reviewed an unexpected death at a long- term care home. A number of vulnerabilities were found during their analysis that could exist at other facilities. Their 13 SafeMedicationUse.ca Alert. Vol. 1(3) August 17, [cited 2013 July 15]. Available at: 14 SafeMedicationUse.ca Newsletter. Vol. 3(6) October 9, [cited 2013 July 15]. Available at: 15 SafeMedicationUse.ca Safety Tools and Resources. Get Medication Safety Tips. [cited 2013 July 15]. Available at: 16 SafeMedicationUse.ca Safety Tools and Resources. Get Medication Safety Tips. [cited 2013 July 15]. Available at: 17 SafeMedicationUse.ca Alert. Vol. 3(4) July 4, [cited 2013 July 15]. Available at: 5

6 analysis of potential contributing factors and recommendations offer insight into how to reduce the likelihood of the same or similar situation occurring in that and other long- term care homes. The goal of this shared learning is improved medication safety Supplemental Topic: Children and Teens Many people are aware that medicines should be safely stored out of the reach of children but, they may not be aware that even over- the- counter products that seem harmless, such as certain eye drops and nasal sprays, may be dangerous if swallowed. Examples of these products include Visine, Clear Eyes, Albalon, Otrivin, Dristan, and Claritin. If you are buying products like these, check the label to identify the ingredients they contain and ask your pharmacist for advice on their safe use and storage. Medicines and hazardous products should be stored in cabinets with safety locks. 19 A 2- year- old boy was found unconscious 2 days after visiting a relative in a nursing home. He later died, and a patch containing fentanyl, a very strong pain killer, was found in his throat Supplemental Topic: High Alert Medications A patient received a prescription for warfarin, and was to take one 5 mg tablet every day for 5 days, then have a Prothrombin Time and International Normalized Ratio (INR) test. The INR result was too low, so the dose was increased to 7 mg (one 5 mg tablet and two 1 mg tablets). The next INR was too high, so the dose was reduced to 3 mg (three 1 mg tablets). The results of the next INR were even higher. The warfarin was stopped altogether, and restarted once the INR fell to a safe level. The warfarin was restarted at 0.5 mg daily (half of a 1 mg tablet). The INR was checked again after 2 and 4 days, and was found to be in the correct range. Later, while cutting a tablet in half for another dose, the patient noticed the tablet was marked with the number 5. The patient then checked the tablets in the bottle labelled as "warfarin 5 mg" and found that they were marked with the number 1. The patient visited the pharmacy where the prescriptions had been filled and it was confirmed that the container labels had been switched. 21 A patient was discharged from the hospital and transferred to a long- term care facility. At the long- term care facility, the receiving nurse reviewed the transfer information. The 18 ISMP Canada Safety Bulletin. Vol. 12(12) December 12, [cited 2013 July 15]. Available at: canada.org/download/safetybulletins/2012/ismpcsb _opioid- Related_Incident_LTC_Home.pdf. 19 SafeMedicationUse.ca Alert. Vol. 3(6) December 6, [cited 2013 July 15]. Available at: 20 SafeMedicationUse.ca Alert. Vol. 3(4) July 4, [cited 2013 July 15]. Available at: 21 SafeMedicationUse.ca Newsletter. Vol. 1(7) November 11, [cited 2013 July 15]. Available at: 6

7 receiving nurse mistakenly listed the insulin concentration of 100 units/ml as the insulin dose. The nurse contacted the patient s physician, whose instructions were to continue the same orders that the patient received while in hospital. Despite the unusually high dose, the insulin order was filled by the pharmacy. The patient received one dose of 100 units, experienced severe hypoglycemia and was transferred back to the hospital. Unfortunately, the patient died soon- after Supplemental Topic: Seniors It's best not to rely on your memory when providing information about the medications you are taking. In one incident, a consumer called a pharmacy to request a refill but did not refer to the prescription bottle for the name of the medicine and the prescription number. The consumer relied on memory and asked for a medicine taken in the past to treat a different condition. Even though it had been over a year since the consumer had taken the requested medicine, the pharmacy contacted the consumer's doctor and got approval to dispense it. When picking up the medicine, the consumer checked the prescription and noticed the mistake Supplemental Topic: Travelling with Medications Spotlight on Acetaminophen: In proper doses, acetaminophen is a safe drug, but overdose is a common cause of acute liver failure. The recommended maximum daily dose of acetaminophen for healthy adults is 4 grams, and is much lower for children and elderly patients. The safe dose is easily exceeded when consumers take a little extra of one product or take a number of products that contain acetaminophen. This problem could be encountered when travelling to other countries where the over the counter medications may be different. For example, people can purchase acetaminophen (Tylenol) in Canada but in the UK, it is called paracetamol. Not knowing that the drug has different names in different countries could lead to serious problems such as overdose and liver failure. The best advice is to read every label carefully to be sure you know the ingredients of any product you use. If in doubt, ask your pharmacist! ISMP Medication Safety Alert Newsletter. Vol. 18(15) July 25, [cited 2013 August 23]. Available at: 23 SafeMedicationUse.ca Newsletter. Vol. 3(7) December 19, [cited 2013 July 15]. Available at: 24 SafeMedicationUse.ca Safety Tools and Resources. Get Medication Safety Tips. [cited 2013 July 15]. Available at: 7

8 13. Supplemental Topic: Cancer Medications in the Home The consumer had received a prescription for tamoxifen from a cancer specialist. Tamoxifen is a medicine that is used to treat certain types of breast cancer. Later, the consumer's family doctor prescribed duloxetine (brand name Cymbalta) to treat depression. Duloxetine can reduce the effectiveness of tamoxifen. The consumer took both of these medicines for several months before finding out about the drug interaction during visit with the cancer specialist. The cancer specialist told the consumer to stop taking the tamoxifen and prescribed a different breast cancer medicine that does not interact with duloxetine SafeMedicationUse.ca Newsletter. Vol. 3(4) June 14, [cited 2013 July 15]. Available at: 8