Intravenous Drug Administration
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Transcript Intravenous Drug Administration
Medication errors
& how to minimise
them!
Kevin Gibbs
Clinical Pharmacy Manager
Bristol Royal Infirmary
Aims
To provide an awareness of:
Common medication errors
How to minimise these
The National Patient Safety Agency
Resources available to you to aid in safer
prescribing
Objectives
By the end of the session you should be able to:
Define a medication error
List the ‘Five Rights’
Understand the NHS role in safer prescribing
Prescribe safely…………
What is an error?
What is an error ?
Doses omitted
Wrong dose
Unprescribed drug
given
Wrong dosage form
given
Wrong route of
administration
Wrong rate of
administration
Yes
Yes
Yes
Yes
Yes
Yes
Wrong time of
Yes
administration
time of day
in relation to food etc....
Using unstable/expired
drug
Wrong administration
technique
Incorrect reconstitution
Extra dose given
Yes
Yes
Yes
Error in ….
Prescribing
Dispensing
Administration
Counselling/communication
Adverse events – What is the
problem
Adverse-events per
admission (%)
AE number / year in
UK
Cost in additional
hospital stay (£)
Cost of clinical
negligence schemes/yr
Medication errors = %
of incidents
10%
850,000
£2 billion
£400 million
25%
Incidence
Difficult to estimate due to varying definitions -
US/UK
Prescribing errors
3-20 per 1000 prescriptions
Medication errors
1 per patient per day
Been estimated that drug errors account for 1/5 of
all deaths due to adverse drug events
Prescribing errors
Process
Error Rate
Prescribing errors
(Primary Care)
Computer generated
7.9%
Prescribing errors
(Primary Care)
Hand written
10.2%
Prescribing errors
(Hospital)
1.5%
Serious Errors
0.4%
Dean B, Schachter M, Vincent C, Barber N. Quality and Safety in Healthcare 2002; 11:340-344
Shah SNH, Aslam M and Avery AJ. Pharm J. 2002; 267: 860-862
Dispensing and Admin Errors
Stage of process
Error Rate
Serious Errors
Dispensing errors (P)
1%
0.18%
Dispensing errors
Undetected (H)
0.0002
Administration
Oral Medicines (H)
3 – 8%
Preparation and admin of
parenteral medicines
13%- 49%
UK references 1 – 12 from Building a safer NHS, Medication Safety
1%
The NHS position on error
Avoidable failures occur;
Untoward events which could be prevented recur, often
with devastating results
Incidents which result from lapses in standards of care in
one hospital do not reliably lead to correction throughout
the NHS
Circumstances which predispose to failure are not well
recognised
An Organisation with a Memory
Department of Health (2000)
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidan
ceArticle/fs/en?CONTENT_ID=4006525&chk=wlMQiJ
Patient safety
The process by which an organisation
makes patient care safer. This should
involve:
risk assessment; the identification and
management of patient-related risks;
the reporting and analysis of incidents;
and the capacity to learn from and follow-up
on incidents and implement solutions to
minimise the risk of them recurring.
National Patient Safety Agency
Collect and analyse information on adverse
events
Assimilate other safety-related information
Learn lessons and ensure that they are fed back
into practice
Where risks are identified, produce solutions to
prevent harm, specify national goals and
establish mechanisms to track progress
NPSA: Patient safety incident
any unintended or unexpected incident
which could have or did lead to harm for one
or more patients receiving NHS funded
healthcare.
this is also referred to as an adverse event / incident
or clinical error, and includes near misses.
NPSA: Seven steps to patient
safety
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Build a safety culture
Lead and support your staff
Integrate your risk management activity
Promote reporting
Involve and communicate with patients
and the public
Learn and share safety lessons
Implement solutions to prevent harm
NHS action on medication errors
Reduce to zero the number of patients dying or
being paralysed by maladministered spinal
injections by the end of 2001
Reduce by 40% the number of serious errors in
the use of prescribed medicines by 2005
Building a safer NHS for patients
Department of Health (2001)
www.doh.gov.uk/buildsafenhs
Improving medication safety
January 2004
www. doh.gov.uk/buildsafenhs/medicationsafety
Improving medication safety
1.
2.
3.
4.
Medication safety – a worldwide health priority.
Medication errors: definition, incidence, causes.
The medication process, prescribing,
dispensing, administration.
Reducing risks for specific patients groups.
Patients with allergies
Seriously ill patients
Children
Improving medication safety
5.
Reducing the risks for specific medicines
6.
Anaesthetic practice
Anticoagulants
Cytotoxic drugs
Intravenous infusions
Methotrexate
Opiate analgesics
Potassium chloride
Organisational and environmental strategies
Information management and technology
Improved labelling and packaging
Interfaces between healthcare settings
Education and training for medication safety
Managing medication safety in
secondary care
NHS Trusts should have dedicated machinery for
organisation wide management of patient safety.
The CNST has developed new standards for
medicines. This requires trusts to have medicines
management policies, together with annual reports,
improvement programmes with defined objectives
and progress.
Prescribing responsibilities
Drug
Dose
Route
Rate of administration
Duration of treatment
Checking patient allergies & sensitivities
Providing a prescription that is:
Legible
Legal
Signed
Giving all information to allow safe
administration
Internationally
Research says:
USA
44-98,000 deaths
“To Err is Human”
Australia 250,000 adverse events
50,000 permanent disability
10,000 deaths
“Iatrogenic Injury in Australia”
Denmark confirmed 9% of admissions
Commonest causes of medication
errors
Lack of knowledge of the drug – 36%
Lack of knowledge about the patient
“rule” violations – 10%
“Slip” or memory loss – 9%
JAMA 1995;274:35-43
Common error types
Wrong patient
Contra-indicated medicine
Allergy, medical condition, drug-drug
interaction
Wrong drug / ingredient
Wrong dose / frequency
Wrong formulation
Wrong route of administration
Wrong quantity
Poor handwriting on Rx
Incorrect IV administration calculations or
pump rates
Poor record keeping/checking
double doses
wrong patient
Paediatric doses
Poor administration technique
Complicated prescriptions
Calculations
Verbal orders
Lack of knowledge about drugs
Mistakes in identifying drugs
names
packaging
misreading
Examples
Rx: Insulin 7 stat
read as 70 units, given
Erythromycin 500mg IV
Highly irritant – should
in 50ml
ISMN 10mg
be 250-500 ml
ISTIN 10mg given
Vancomycin IV 1g
Isosorbide mononitrate
given instead of
amlodipine
given as bolus rather
than infusion
cardiac arrest
Ceftazidime 2g tds IV
written badly
Methotrexate 20mg
daily (Dx: RA)
Digoxin 125mg IV
Should be weekly
loading dose 10mg od
Neutropenia
Should be micrograms
Discharged on warfarin
Cefotaxime given
given - cardiac arrest
Not referred for dose
adjustment to clinic
14days of 10mg od
INR 12.3
Weight-related dose for
tinzaparin – 80kg body
weight estimated
CABG patient,
standard therapy
Galantamine re-started
after a gap 8ml qds
Patient was 51kg
Thyroxine missed on
admission, discovered
day 10
Should have been
12mg (2ml) bd
PRHO confused over
liquid strength
Anaesthetist adjusted
rate of fentanyl syringe
pump in Theatre
Rx: Co-amoxiclav
Penicillin-alllergic
Rx: morphine 0.4ml
30% sodium chloride
used instead of 0.9% to
dilute an epidural
New pump. Increased
rate x 1000
Respiratory arrest
Did not realise this is a
penicillin – anaphylaxis
4ml given
Severe pain
Rx: Ranitidine 50mg
In Theatre: Sodium
chloride flush for a
central line switched
with fentanyl
IV line flushed with
sodium chloride 0.9%
Given via epidural line
rather than central line
Respiratory arrest.
Syringes made up in
advance and not
labelled
Was in fact Potassium
15% - death.
Ampoules look similar
in design.
Case study 1 – "Cambridge"
Rx Methotrexate 17.5mg once a week
New Rx 10mg once a day
10mg daily dispensed by locum pharmacist
Rx error noticed by 2nd GP, but the computer
record was not altered
+5/7 patient admitted to ENT ward
Drug chart written for 100mg daily
+1/7 Nurse d/w patient – back to 10mg od
+1/7 Pharmacist queries and asks nurse to ask Dr
to check dose
GP records confirm 10mg od
+2/7 blood tests re-checked } Haem
+5/7 patient dies
Case study 2 – “Nottingham”
Rx Intrathecal methotrexate under GA in
theatre by Oncology Reg & intravenous
vincristine on ward by specialist nurse
"Outlied" on non-specialist ward
Both drugs delivered to theatre from ward
Given food pre-op – op postponed
Orignal SpR off-duty now
Cover SpR unable to leave ward, anaesthetist to
admin intrathecal drug
Aneasthetist had given I/Thecal drugs before but
had never given chemotherapy
Methotrexate given intravenously
Vincristine given intrathecally
Patient died
How to handle errors
Is there an acceptable rate ?
Should errors be graded or scored for
severity ?
Blame vs. No blame
Analyse why the errors have occurred and
try to prevent reoccurrence
When things go wrong
The "patient-centered“ approach
Identify an individual to blame
Focus on events surrounding the adverse
event
Focus on the human acts or omissions
immediately preceding the event
Blame, name & shame
Myths
Perfection myth
If people try hard enough they will not make
any errors
Punishment myth
If we punish people when they make a errors,
ther will make fewer of them
Or/ “Active learning”
= Understanding causes of failure
Human error may precipitate
a serious error
but
Deeper, systematic, factors are usually present
Addressing these would have prevented the error
Humans are fallible
Errors are inevitable
Change work conditions to make humans
less error-provoking
Why did the defences fail?
What factors contributed to the failure?
CPD
How can we help you?
Clinical
pharmacists
How can we help you?
Medicines
Information
Department
How can we help you?
Formularies
and
Prescribing
guidelines
M E D IC A L D IR E C T O R A T E A N T IB IO T IC G U ID E L IN E S
1)
3)
4)
5)
D o n ’t u s e IV a ntib io tics w ith o u t g o o d c a u s e
2 ) D o n ’t u s e m u ltip le a n tib io tic s w ith o u t g o o d in d ica tio n s
D o n ’t g ive IV th e ra p y fo r m o re th an 2 d a y s w ith o u t re vie w (n u rs es /p h a rm ac ists w ill re q u e st n e w p re sc rip tio n ) (IV to O ra l p o lic y)
D o n ’t p re sc rib e a n tib io tics fo r a c u te a s th m a w ith o u t s tro n g e v id e n c e o f b ac te ria l in fec tio n (u s u a lly vira l)
R e vie w a n tib io tic s w h e n re s u lts e .g ., u rin e, b lo o d , s p u tum c u ltu re s e tc a re a va ila b le.
U s e o ra l an tib io tic s fo r 5 -7 d a ys u n le s s o th e rw is e s ta te d .
D o s e s a s s u m e a d u lt w ith n o rm al re n al fu n c tio n
IN F E C T IO N
COM M ENTS
DRUG
DOSE
D U R A T IO N O F T X
In tra v e n o u s B e n z ylp e n ic illin s h o u ld b e s w itc h e d to o ra l A m o x ic illin w h e r e a p p r o p ria te .
In fe c tive E x ac e rb a tio n o f
COPD
C o m m u n ity A c q u ire d
P n e u m o n ia
R is k F a c to rs in C AP
(C U R B -6 5 )
C = co n fu sio n M T S 8 o r le ss
U = U re a > /= 7 m m o l/l
R = R e s p . R a te > /= 3 0 /m in
B = B P S ysto lic < 9 0 m m H g
+ /- D ia sto lic < /= 6 0 m m H g
6 5 = a g e > /= 6 5 yrs
A m o x ic illin
M o x iflo x a cin
A m o x ic illin
5 0 0 m g p o 8 ho u rly
4 0 0 m g p o o nc e da ily
5 0 0 m g p o 8 ho u rly
M ild – if a typ ic a l
s u s p ec te d o r p e n ic illin
a lle rg ic
S e v e re
M o x iflo x a cin
4 0 0 m g p o o nc e da ily
B e n z ylp e n ic illin
P L U S C ip ro flo x a c in
S e v e re – p e n ic illin
a lle rg ic
L e vo flo x a c in
2 .4 g ram s (4 m u ) iv 6 h o u rly
7 5 0 m g p o 1 2 h o u rly
5 0 0 m g iv 1 2 h o u rly
If p e n ic illin a lle rg ic
M ild
5 d a ys
7 -1 0 d a ys
7 -1 0 d a ys
S w itc h in g to o ra l
M o x iflo x a cin
4 0 0 m g p o o nc e da ily
L e g io n ella P n e u m o n ia
C ip ro flo x a cin
P L U S R ifa m p ic in
7 5 0 m g p o 1 2 h o u rly
3 0 0 m g -6 00 m g iv/p o 1 2 ho u rly
2 -3 w e e ks
S u s p e c te d
S ta p h ylo c o c c a l
P n e u m o n ia
F lu c lo xa c illin
P L U S G e n ta m ic in
2 w ee k s
5 d a ys th e n re view
A m o x ic illin
2 g ra m s iv 6 h o u rly
4 m g /k g /da y
iv s in gle da ily do s e (c he ck
tro u g h le ve l)
2 .4 g ram s iv 6 ho u rly
5 0 0 m g iv 8 h o u rly o r 1 g ram
p r 8 -1 2 h o u rly
5 0 0 m g p o 8 ho u rly
M o x iflo x a cin
4 0 0 m g p o o nc e da ily
B e n z ylp e n ic illin
P L U S C ip ro flo x a c in
2 .4 g ram s (4 M U ) iv 6 h o u rly
7 5 0 m g p o 1 2 h o u rly
(1 g ra m iv 1 2 h o u rly
a n d c h ec k le ve ls )
B e n z ylp e n ic illin
P L U S M e tro n id a zo le
A s p ira tio n P n e u m o n ia
M ild N o so c o m ia l
C h e s t In fec tio n
If p e n ic illin a lle rg ic
S e ve re N o s o c o m ia l C h es t
In fe c tio n
(C o n s id e r V a n c o m yc in
in s te a d o f B e n p e n . – if M R S A
c o lo n is e d )
M e n in g itis
A ll C a s e s
In itia l tre a tm e n t T H E N
d iscu s s fu rth e r
m a n a g e m e n t w ith
m icro b io lo g is ts
C e llu litis
If p e n ic illin a lle rg ic
C e llu litis in D iab e tics
C e ftria x o n e
4 g ra m s iv on c e d a ily
If O v e r 5 5 yr s A D D
A m p ic illin
2 g ra m s iv 4 h o u rly
B e n z ylp e n ic illin
P L U S F lu c lo x a c illin
2 .4 g ram s (4 M U ) iv 6 h o u rly
1 g ra m iv 6 ho u rly
C lin d a m yc in
6 0 0 m g iv 6 h o u rly o r 4 5 0m g
p o 6 ho u rly
6 2 5 m g p o 8 ho u rly
C o -a m o x ic la v
Depends on
in d ivid u a l ca s e .
OR
C ip ro flo x a cin
P L U S C lin d a m yc in
U rin a r y T ra c t In fe c tio n
U rin a r y C a th e te r
In fe c tio n s
a n d P ye lo n e p h ritis
T rim e th o p rim
A m p ic illin
P L U S C ip ro flo x a c in
PLUS
S ta t d o s e G e n ta m ic in
S e p s is o f u n kn o w n
s o u rc e
7 5 0 m g p o 1 2 h o u rly
4 5 0 m g p o 6 ho u rly
2 0 0 m g p o 1 2 h o u rly
1 g ra m iv 6 ho u rly
7 5 0 m g p o 1 2 h o u rly
M ild
S e ve re
(L ife T h re a te n in g )
B e n z ylp e n ic illin
P L U S C ip ro flo x a c in
C e ftria x o n e
P L U S G e n ta m ic in
4 m g /k g iv s ing le d os e
2 .4 g ram s (4 M U ) iv 6 h o u rly
7 5 0 m g p o 1 2 h o u rly
4 g ra m s iv on c e d a ily
4 m g /k g /da y iv s in g le d aily
d o s e (c he ck trou g h )
3 d a ys
How can we help you?
Resources
BNF
Medicines
for Children
Safe prescribing: A summary
Clear and
unambiguous
Care with units
Legal
Is it weight/BSArelated dosing. Is
weight accurate?
Approved name
No abbreviations
Care with IVs
Clear decimal
points
0.5ml not .5ml
Rewrite charts
***** In English
If abbreviate use
‘standard’ ones
od / bd / tds / qds
regularly
NOT 250mg3
Take time, eg to
read labels
Care if:
Impaired renal function (NB: GFR)
Hepatic dysfunction
Children
The elderly
Drug unknown to you
Very new drug
The “5 Rights”
• the right patient
• the right drug
• the right time
• the right dose
• the right route
If in doubt ……..
Please ask
Further reading/references
Naylor, R. Medication Errors. Radcliffe
Press. ISBN 1857759567
Department of Health. (2004). Building a
safer NHS. Improving patient safety.
National Patient Safety Agency (NPSA) (UK)
Website:
http://www.npsa.nhs.uk/
Institute for Safe Medication Practices
(ISMP) (American)
Website:
http://www.ismp.org/