Transcript ESA Medication Error - European Society of Anaesthesiology

MEDICATION ERROR
IN ANAESTHESIA
Andrew Smith, Lancaster, UK
on behalf of the ESA/EBA
Task Force Patient Safety
DEFINITIONS
Adverse drug event ADE
“An adverse drug event, injuries resulting from medical intervention related to
a drug, includes both appropriate and inappropriate use of drugs."
[Carlton G et al. Medication-related errors: a literature review of incidence and antecendents.
Annu Rev Nurs Res 2006]
Synonyms in the literature
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Drug misadventures
Drug related problems
Drug related incident
The term comprises both
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Adverse drug reactions
Medication errors
DEFINITIONS
Adverse drug reaction ADR
“An adverse drug reaction is a response to a drug which is noxious and unintended
and which occurs in man at doses normally used for prophylaxis, diagnosis or
therapy of disease, or for modification of physiological function.”
[World Health Organization WHO, 2003]
Medication error
"A medication error is any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control
of the health care professional, patient, or consumer. Such events may be related
to professional practice, health care products, procedures, and systems, including
prescribing; order communication; product labeling, packaging, and nomenclature;
compounding; dispensing; distribution; administration; education; monitoring; And
use."
[National Coordinating Counsel for Medication Error Reporting and Preventing NCC MERP, June 2008]
DEFINITIONS
Side-effect:
a known effect, other than that primarily intended, relating to the pharmacological
properties of a medication
• e.g. opiate analgesia often causes nausea
Adverse reaction:
unexpected harm arising from a justified action where the correct process was
followed for the context in which the event occurred
• e.g. an unexpected allergic reaction in a patient taking amedication for the
first time
WHAT SORT OF ERRORS CAN OCCUR?
• Wrong drug
• Wrong patient
• Wrong route
• Wrong dose
ERROR PRONE PRESCRIPTIONS
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Illegible handwriting
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Using misleading decimal places
1.0 mg instead of 1 mg
.1 mg instead of 0.1 mg
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Use of abbreviations
2x (means 2 tablets or 2x daily ???)
Recommendations:
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Avoid trailing zeros
e.g. write 1 not 1.0
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Use leading zeros
e.g. write 0.1 not .1
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Know accepted local terminology
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Write neatly, print if necessary
HOW CAN PRESCRIBING GO WRONG?
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Inadequate knowledge about drug indications and contraindications
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Not considering individual patient factors, such as allergies, pregnancy,
co-morbidities, other medications
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Wrong patient, wrong dose, wrong time, wrong drug, wrong route
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Inadequate communication (written, verbal)
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Documentation - illegible, incomplete, ambiguous
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Mathematical error when calculating dosage
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Incorrect data entry when using computerized prescribing e.g. duplication,
omission, wrong number
World Health Organization WHO, Patient Safety Curriculum Guide
HOW CAN ADMINISTRATION
GO WRONG?
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Wrong patient
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Wrong route
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Wrong time
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Wrong dose
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Wrong drug
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Omission, failure to administer
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Inadequate documentation
World Health Organization WHO, Patient Safety Curriculum Guide
WHICH PATIENTS ARE MOST AT RISK
OF MEDICATION ERROR?
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Patients on multiple medications
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Patients with another condition, e.g. renal impairment, pregnancy
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Patients who cannot communicate well
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Patients who have more than one doctor
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Patients who do not take an active role in their own medication use
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Children and babies (dose calculations required)
World Health Organization WHO, Patient Safety Curriculum Guide
IN WHAT SITUATIONS ARE STAFF MOST LIKELY
TO CONTRIBUTE TO A MEDICATION ERROR?
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Inexperience
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Rushing, doing two things at once
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Interruptions
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Fatigue, boredom, being on “automatic pilot” leading to failure to check
and double-check
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Lack of checking and double checking (including two-person checking)
habits
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Poor teamwork and/or communication between colleagues
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Reluctance to use memory aids
World Health Organization WHO, Patient Safety Curriculum Guide
THE 5-R’S
• Right Drug
• Right Route
• Right Time
• Right Dose
• Right Patient
World Health Organization WHO, Patient Safety Curriculum Guide
PHASES OF DRUG DEVELOPMENT AND
PRECLINICAL AND CLINICAL TRIALS
THE MEDICATION USE PROCESS
AT WHICH STEP IN THE MEDICATION
PROCESS DO ERRORS OCCUR?
Prescription
Administration
(hand written)
38%
39%
Documentation
12%
Dispensation
11%
Bates et al., JAMA 1995, 274
“SOUND ALIKE – LOOK ALIKE”
– Examples from Switzerland
Sound alike and look alike drug names
Generic name
Clonidin
Clomipramin
Codein
Trade name
Catapresan
Anafranil
Codein Knoll
Etodolac
Cotrimazol
Clotrimazol
Lodin
Bactrim, Cotrim, Nopil
Canesten, Corisol
http://www.patientensicherheit.ch/de/publikationen/Quick-Alerts.html
HOW FREQUENT IS MEDICATION
ERROR IN ANAESTHESIA?
Difficult to tell as many are not reported BUT
Estimated frequencies are:
1 in 572 anaesthetics
1 in 274 anaesthetics
1 in 133 anaesthetics
(Yamamoto J Anesth 2008; 248-52)
(Llewellyn Anaes Intens Care 2009; 37: 93)
(Webster Anaes Intens Care 2001; 29: 494)
How many anaesthetics do you
give every year?
WHAT ARE THE CONSEQUENCES
OF DRUG ERROR?
Death is uncommon but what happens if....
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Atracurium is given instead of midazolam?
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Cefuroxime is given instead of thiopentone?
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Metoclopramide is given instead of succinylcholine?
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Bupivacaine is given intravenously instead of epidurally?
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Fentanyl is given intrathecally instead of intravenously?
Loss of expected effect and possible physical or psychological harm to the patient
PREVENTING MEDICATION ERROR:
KEY STRATEGIES
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Standardised preparations and concentrations of drugs and infusions
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Avoid boxes and ampoules of different drugs which look alike
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Label syringes
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Take care with predisposing factors
- Organisation and tidiness of work spaces
- Human factors such as fatigue and haste
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Check drug during preparation and before administration with two people
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‘High-tech’ solutions: bar code systems and computerised prescribing
STANDARDISED SYRINGE LABELS
TWO-PERSON CHECKING
Ask the right question:
‘What drug is this?’
not
‘This is X, isn’t it?’
- So both people have to actively read and check the label
RECOMMENDATIONS
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Use generic names where appropriate
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Tailor your prescribing for each patient
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Learn and practise thorough medication history taking
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Know which medications are high-risk and take precautions
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Be very familiar with the medication you prescribe and/or dispense
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Use memory aids
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Remember the 5 R’s when prescribing and administering
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Communicate clearly
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Develop checking habits
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Encourage patients to be actively involved in the process
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Report and learn from medication errors
World Health Organization WHO, Patient Safety Curriculum Guide
MORE INFORMATION
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Anaesthesia Patient Safety Foundation video on medication safety in the OR:
http://www.apsf.org/resources_video2.php
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WHO safety curriculum
(pdf included in this Starter Pack)
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Vincent C. Essentials of Patien Safety, pages 30-34
(pdf included in this Starter Pack)