Transcript Reducing Medication Error Experience of the National Clinical

Reducing Medication Errors
findings of the
National Clinical Governance Protected Time Project
Paul Moore Clinical Governance Manager
Introduction
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The protected time project
Why medication errors?
What did we learn?
Main developments
Are we safer?
Protected Time Project
• Developed by NHS Clinical Governance Support
Team
• SMUHT one of 20 NHS Trust involved
• accelerated service improvement
• enables frontline staff to develop effective systems
and processes
• our approach involved representatives of all
stakeholders
• our approach identified and acknowledged problems
up front
Protected Time Programme
methodology
• define the problem and significance
• stakeholder analysis and recruitment
• process map
– identifying problems
– identifying / analysing controls and gaps
• identify opportunities
– redesigning the process
– action planning for change
• monitor performance
Why medication errors?
Problem
• our web-enabled incident reporting system,
launched in June 2001, immediately highlighted that
one of the largest areas of adverse events was the
prescription and administration of drugs
Significance
• Patient’s at risk of harm - potentially very high
• writing prescription most common therapeutic
intervention
• high associated mortality and litigation costs
• reduce by 40% the number of serious errors in the
use of prescribed drugs by 2005
Aims
Develop a whole systems approach to reducing medication errors
• Reporting medication errors
• Drug administration process
• Capturing, validating & disseminating lessons for learning
• Implementing change
• Monitoring performance
What did we learn from participants?
• Staff are motivated to keep patients safe
• Staff do not routinely share their experience of adverse
events with each other
• Systems for actively managing and learning from
adverse events were inadequate
• Disciplinary action following medication errors varies
amongst professionals and
• makes doctors less likely to report formally
• introduces reporting bias within HIRS
What did we learn from participants?
System is flawed
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training in isolation
patients - passive recipient’s not active participant’s
use of multidisciplinary team - ward rounds
pharmaceutical packaging
inadequate trust policy
varying use of disciplinary action against individuals
no formal process for reviewing and learning from error
no mechanism for disseminating learning
Main developments
• Development of HIRS
– improved web-enabled electronic data capture
– error reporting throughout the process of drug administration
Supply / Prescription / Delivery (to clinical areas) / Administration
• Development of ‘integrated’ training informed by medication errors
• Revised mandatory clinical training programme driven by incident
reporting system output
• Set up learning group to capture, validate and disseminate lessons for
learning
• Targeted clinical audit
• Empowerment initiatives to encourage greater patient participation
– Reading prescriptions
– Identification name bands
Are we safer?
Examples of incidents reported
• Heparin injection given in theatres - adrenaline
intended
• High dose Gentamicin prescribed once daily
(Patient in Renal Failure)
• Morphine diluted in lignocaine not water
• Enoxaparin overdoses (several)
• Flumazenil given pre-endoscopy instead of
Midazolam
Examples of incidents reported
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Suxamethonium given instead of Midazolam
Beta blocker given to asthmatic
24 hour Diamorphine infusion given over 9 hours
Potassium Chloride not available during cardiac
arrest
Quick wins
• 61% increase in reported adverse events
• Profile the need to weigh patient’s on admission
• Targeted staff training to areas of identified high risk
• low molecular weight heparin prescribing
• insulin sliding scale administration
• documentation of allergies and medication intolerance
• Established multidisciplinary error review group
• Updated and revised mandatory clinical training
driven by incident reporting system output
Quick wins
• Removal of manufacturers’ packs known to have
contributed to administration error
• Morphine Sulphate 30mgs/ml
• Lignocaine ampoules
Quick wins
• New medicines policy with safer procedures and
much wider target audience
• Relationship between incident reporting and
disciplinary action defined for all staff
Examples of safer practice
Would you administer Augmentin® to a
patient with a penicillin allergy?
Answer: No - as it contains Amoxycillin
• reports of poor records of medication
intolerance led to an audit. 39% of nurses and
13% of doctors did not recognize this error
potential. Now included in training.
Examples of safer practice
Combination products
• Patient received 5 x overdose of Co-beneldopa.
Was prescribed 62.5 mg dose.
• Bottle labelled as12.5/50 and interpreted as
12.5 dose and 50 tablets in bottle, so 5 tablets
given.
• Labels changed and now read:
• Co-beneldopa 12.5/50 (62.5mg) dispersible tablets
Summary
• The protected time project has accelerated the
development of a web-enabled incident
reporting and learning system for medication
errors.
• More medication errors are reported than ever
before.
• Data is used to influence training and shared
with staff for learning
• The project has improved patient safety within
the Trust