Intervention Study 2016 Trust-wide. Gillian Ritchie Clinical Pharmacist

Transcription

1 Intervention Study 2016 Trust-wide 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 Mental Health & Learning Disabilities Division Hawthorns One & Two Antelope House Elmleigh Kingsley Ravenswood & Southfield Leigh House & Bluebird Mother and Baby Unit East ISD Beechwood & Elmwood Berrywood & Beaulieu Dryad & Daedalus Stefano Olivieri Unit Sultan & Ark Royal Rowan & Cedar West ISD Romsey & Alton Lymington

4 Number of interventions (Trust-wide) During the 2 week study Projected number per annum 8,606 9,750 11,492 11,154

5 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

6 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

7 Intervention that was potentially life-saving PMH - two heart transplants (first one was rejected) Multiple immunosuppressants : Tacrolimus ( Adoport ) Azathioprine Cotrimoxazole Prednisolone Code 2 (no stock) being documented on chart for tacrolimus hence doses omitted Pharmacist: Re-emphasised importance of not omitting doses Ensured nurses faxed the prescription chart to pharmacy Ensured pharmacy obtained the branded product (tacrolimus - brand specific) Endorsed prescription chart : With brand name, Adoport Critical medicine do not omit doses. If no stock on ward, order from pharmacy; if out of hours, contact -call pharmacist on

8 Intervention that was potentially life-saving Medicines reconciliation for AMHT Patient had not taken medication for the past 18 months GP record lamotrigine 50mg daily (last issued Feb 2014) Reviewed by AMHT FP10 written for lamotrigine 150mg twice daily Pharmacist contacted the doctor Doctor agreed to re-titrate lamotrigine Lamotrigine can cause serious skin reactions, including Stevens Johnson syndrome, which can be fatal. Highest risk with rapid titrations If miss more than five days lamotrigine, need to retitrate Pharmacist ensured safe prescribing

9 Intervention that was potentially life-saving Pharmacy Technician was organising medicines for TTO Patient prescribed enoxaparin 120mg once daily for 6 months on prescription chart, for treatment of pulmonary embolism 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

10 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Novorapid S/C PRN 6 units prescribed Poor handwriting of prescriber Looked like 60 Pharmacist: Endorsed prescription chart: 6 units Potentially fatal insulin overdose averted

11 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Medicines not prescribed on admission : Phenytoin 100mg TDS Bisoprolol 10mg OM Candesartan 8mg OM Furosemide 40mg OM Spironolactone 25mg OM PMH: Epilepsy, heart failure Above medicines critical for this patient Pharmacy team: Discussed with SHO Outcome: Medicines prescribed No deterioration in patient s physical health

12 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Clozapine levels raised : April 1.91mg/l (dose 400mg) May 2.12mg/l (dose 300mg). Sodium valproate added June 1.39mg/l (dose 300mg) Patient mentally well, but has side-effects : Hypersalivation, sedation, tachycardia Pharmacist: Suggested GASS clozapine Slowly decrease dose by 25mg/week Repeat level in 2 weeks Optimised safe prescribing and clinical effectiveness

13 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance High dose antipsychotic therapy (HDAT) prescribed: Haloperidol 20mg daily Quetiapine 800mg daily 200% BNF maximum Tachycardic Pharmacist: Contacted doctor Advised decrease haloperidol dose to 10mg Ensured HDAT monitoring

14 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Clozapine patient on medical ward at local acute Trust Casual remark overheard in dispensary that the patient has just stopped smoking Pharmacist: Contacted the CMHT Advised needs urgent clozapine review : Dose change Clozapine level Close monitoring Potentially dangerously high clozapine level (secondary to smoking cessation) averted

15 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Erythromycin prescribed Patient also prescribed atorvastatin & clozapine Pharmacist advised: Withhold atorvastatin for duration of erythromycin Increased risk clozapine toxicity monitor for side effects Increased risk QTc interval prolongation with clozapine Monitor ECG Outcome: Pharmacist ensured safe prescribing

16 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Two month old baby Paracetamol QDS prescribed Maximum licensed dose for baby of this age is TDS Pharmacist contacted the prescriber Outcome: Dose decreased to TDS Paracetamol overdose averted

17 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient Severe osteoporosis secondary to hyperparathyroidism with hypercalcaemia No bisphosphonate / denosumab prescribed Recent endocrinology letter recommended a bisphosphonate and cinacalcet Not on GP records Not prescribed Pharmacist: Discussed with ward doctors Advised liaise with endocrinology Outcome: Patient referred back to endocrinology If left untreated, the patient could sustain fractures more easily following a fall

18 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient egfr 45mls/min Prescribed ibuprofen Pharmacist: Discussed with ward doctor Advised stopping ibuprofen Outcome: Ibuprofen stopped Further deterioration in renal function averted

19 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient egfr 46mls/min Prescribed ramipril 10mg daily Maximum licensed dose 5mg daily if egfr 30 60mls/min Pharmacist: Checked blood pressure recordings Discussed with doctor Outcome: Doctor to repeat egfr Monitor blood pressure Consider dose reduction

20 Very significant intervention that prevented a major organ failure or prevented a drug reaction of similar importance Elderly patient transferred from local acute Trust on bumetanide 2mg bd and ramipril 2.5mg bd Ward doctor prescribed bumetanide 1mg bd and ramipril 2.5mg od (hence doses halved compared with acute Trust) Pharmacist discussed with ward doctor (GP) Concerns not acted on for many days Left ventricular failure ultimately diagnosed Outcome: Diuretic doses increased Fluid balance ultimately improved Patient weight ultimately decreased Heart failure stabilised

21 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 Decreased risk of recurrent PE

22 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

23 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

24 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

25 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

26 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

27 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

28 Common interventions 2016 Allergy box blank or incorrect Inhalers not prescribed Antimicrobials length of course not stated Paracetamol prescribed regularly and PRN Transcribing errors when chart rewritten / TTOs prescribed Prescriptions not signed / dated by doctor Maximum dose in 24 hours not specified for PRN medicines Physical health medicines not prescribed / prescribed incorrectly on admission Management of side effects Switching antipsychotics Multiple benzodiazepines prescribed HDAT monitoring Lamotrigine titrations Interactions Incorrect T2 / T3 forms Incorrect / inappropriate doses prescribed Dose adjustments in renal impairment

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 makes a significant number of interventions: 429 interventions in two weeks = approximately 11,150 in a year This saves the Trust almost 3million per year 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: Include in Medicines Matters bulletin 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

33 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 - Compatibility 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 level tests 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 counselling 10 Formulation change 20 Therapeutic substitution 30 Pt identity

34 1- Interactions 2- Adverse effects 3- Drug choice 4- Dose 5- Frequency 6- Route 7- Formulation 8- Treatment duration 9- Omissions blank box 10- Omissions not available 11- Omissions - refused 12- Omissions - asleep 13- Omission on chart rewrite 14- Omission on admission 15 Duplication 16- Subsitution 17 - Administration 18- Compatibility 19- Dispensing error 20- Incorrect drug given 21- Drug level test 22- Physical health tests 23- Moniotiring 24- Counselling 25- Patient indentity 26- Omission on TTO 27- Swapping

35 Common interventions 2015 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

36 Common interventions 2014 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