Medicine Errors H.Beadle, L.Baxendale, Clinical Governance Pharmacists Coventry and Warwickshire Partnership Trust Medicines Management Team 2015
Why Should Errors Be reported? Learning Prevention of future errors Optimizes patient care and safety To identify aspects of Medicines Management where changes are needed to ensure patient care: Revised or Additional Medicines Policy Guidance To highlight training needs
How Are Errors Reported? We use the Safeguard electronic reporting system on the intranet. Select: Systems Incident Reporting System Guidance in Medicine Policy MMG19 Timely reporting essential
Advantages of Electronic Reporting Separate paper medicines error form not required Immediate reporting Automatically forwarded to: Medicines Management Safety and Quality
Electronic reporting: Under Medication select yes for Was this a Medication Error Incident? Then Select: Process Type Type of Error
Process error At what stage did the error occur?: Advice Administration Medicines Reconciliation Monitoring Ordering Pharmacy Dispensing Preparation Prescribing Recording Storage/Security Supply Please select carefully!
Type of error Select Adverse drug reaction Drug given but allergy status not confirmed Drug given but drug sheet not signed Drug not given Incorrect patient Missing drug Near miss Other Patient allergic to treatment Unauthorised dosage/drug given Unknown Or.. (more to follow)
(continued) Wrong drug/medicine formulation frequency method of preparation/supply quantity route storage or unclear dose or strength Wrong or omitted patient information leaflet verbal patient directions or passed expiry date or transposed medicine label
What happens to the reports? Used as learning to help prevent future errors Reported to the National Reporting and Learning System(NRLS) if harm has resulted (see next slide)
NRLS Feedback Our Trust can access our patient safety data online We can choose our peer groups for comparisons to others: Like for Like Mental Health Trusts
Patient Safety Incidents - 2013/4 by Stage of medication process
Incidents - 2013/14 by Type of Error Also: CWPT Like for Like Unknown 7 1,206 Other 155 626 Wr = wrong Om = omitted
CWPT Data Quarterly Errors by Reporting Area, April 2013 to June 2014 50 45 40 35 30 25 20 15 10 5 0 April to June '13 July to September '13 Oct to Dec '13 Jan to Mar '14 April to June '14
Medicines Errors/Near Misses Any examples for sharing?
Group Discussions Medicines Errors Examples for Discussion Examine different types of error/dilemmas Discuss/Consider: What was the cause of the error? What type of error? What effect could this have had on the patients? How can we prevent them from occurring again? Level of action: Counselling, Suspension from medicines admin. & retraining, or Disciplinary?
Example 1 Newly admitted patient prescribed Humalog Mix50. 50U TDS The patient has type 1 diabetes & weighs 80Kg Is this dose reasonable? Is the prescription reasonable? How would you know? Is this an error? What effect could this have had on the patient? What type of error? Answers (following slides)
Example 1 answers Is this dose reasonable? Probably no more than 1unit/kg/day needed Dose prescribed = twice the maximum Is the prescription reasonable? No. Prescribe as units not U How would you know? Medicines Reconciliation More information: 1. Patient admitted due to an insulin overdose (200units of Mixtard). 2. GP had originally prescribed Humalog Mix25 not Mix50. 3. Also on the ward round it was decided that no insulin was to be prescribed under the direction of the diabetic nurse until after the weekend.
Is this an error? Yes! Evaluation of the Error Error classification? Process: Medicines Reconciliation, Prescribing Type: Wrong formulation, wrong dose What possible effects on Patient? Insulin overdose Loss of confidence/trust How can we prevent this? Use medicines reconciliation process Communication
Example 2 It was noticed that a doctor had written Chlorphenamine 25mg instead of Chlorpromazine 25mg in the PRN section of a drug card. What is the difference between the two medications? Possible effects on patient? How can this be avoided? What type of error? Answers (next slide)
Example 2 answers Possible effects on patient? Chlorphenamine an antihistamine Chlorpromazine an antipsychotic Type of error: Prescribing, Wrong Drug How to avoid this situation: Check prescription charts carefully on rewrite Pay particular attention to similar sounding names Level of action?
Example 3 Lithium monitoring A patient was prescribed Priadel 800mg each day Became physically unwell and dehydrated Subsequently admitted to local acute Trust with lithium toxicity Discharged back to our care with instructions to maintain on a dose of 400mg Priadel daily New dose written on prescription chart, but Priadel 800mg not crossed off Both doses of Priadel were administered for a few days Whose error was this? What type of error? What should be done? How can this be prevented? Answers (next slide)
Example 3 answers Whose error: Prescriber, nurses who administered lithium Type of error: Prescribing, administration, wrong dose What are the consequences? Risk of lithium toxicity Loss of trust of patient What should be done? Contact prescriber lithium level taken urgently Prescription chart amended How to prevent this? Look at the prescription chart as a whole Be aware of the patient s plan of care Level of action???
Example 4 A patient was to be administered midazolam from 10mg/2ml ampoules It was found that the pharmacy had supplied midazolam 2mg/2mls wrongly labelled as midazolam 5mg/5mls Is this an error? Whose error? What type of error? Significance? Answers (next slide)
Yes this is an error: Dispensing, Near Miss Example 4 answers Possible Effect: Possible underdose and poor symptom control. Opposite error could have lead to an overdose. - a Never Event How to Prevent Reoccurrences? Check all medications carefully Calculate all doses carefully Immediately query any possible errors
Example 5 Prescription/Administration Charts What errors can commonly occur? What are the consequences? How can we avoid these errors?
Example 5 answers No Home/Consultant Details Chart? Of? Allergy Status? Missing Propranolol dose Amoxicillin not dated and no indication Amoxicillin Prescription not cancelled on 18 th July Insulin dose should be prescribed in units not as U Very low insulin dose?! Clozapine missed doses (>48 hours) Is the Clozapine dose clear? 150 or 750? Co-codamol overdose Co-codamol not signed Methotrexate should be weekly Dutasteride not for females! mcg should not be written (write in full as micrograms) Clozapine and codeine risk of constipation/ GI obstruction (Awareness)
Summary Follow the Medicines Policy/NMC Guidance Report all errors promptly Consider Accountability
Any Questions?