Transcript SNAPP Medication Errors - Neonatal and Paediatric Pharmacists

How to Harm Children with
Medicines – a guide for
pharmacists*
James Wallace – Yorkhill Hospital Glasgow
Peter Mulholland – Southern General Hospital Glasgow
*With apologies to Professor Imti Choonara
Learning outcomes
• Definitions & identification of medication
errors
• Extent & nature of medication errors in
children
• Strategies to avoid errors
Definition
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
In the UK
• The UK Department of Health in 2000
recognised that a weakness of the NHS is in
preventing serious incidents in which patients
are harmed or experience poor outcomes of
care.
NPSA 2007. Safety in doses: improving the
use of medicines in the NHS.
• National Reporting and Learning
System - 60,000 incidents reported in
18 months
• Children ≤ 4years involved in 10%
incidents where age stated
NPSA 2007. Safety in doses: improving the
use if medicines in the NHS
Recurring themes
– Problems with injectable medicines
– Gentamicin – NPSA alert issued Feb 2010
– Children being treated in non-paediatric
areas
– Errors in dose calculation
– 10 fold errors
– Vaccines
Most common error type
• Dosing errors
28%
• Route of administration 18%
• MAR transcription & documentation
14%
• Wrong date
9.9%
• Frequency
9.4%
Classification of errors
•Wrong dose administered
•Dose omitted
•Additional dose given
•Wrong drug given
•Wrong infusion rate
•Dispensing / labelling error
•Wrong I/V concentration
•Wrong patient
•Wrong route
•Other
How do errors occur?
• Medication errors are almost never
caused by the failure of a single
element or the fault of a single
practitioner
• Usually the result of the combined
effects of ‘latent’ errors in the system
combined with ‘active failures by
individuals
Why do individuals make errors ?
Psychological state
Interruptions
Lack of information
Calculation errors -Electronic calculators
Corporate livery
Confirmation bias
Tiredness/stress
Noise
Temperature
Workload/staffing levels / Rotas
• Unreasonable to expect absolute perfection or
error free performance from any person
• Systems need to be in place to minimise the risk of
medication errors by providing opportunities for
checks, good communication, and a stress free
environment
• In any post error evaluation process - any system
deficiencies should be identified and corrected
before placing all responsibility on human error
Why are children at greater risk of
medication errors?
& What can WE do about it?
• Drug doses calculated individually
–
–
–
–
Based on age, weight, surface area
More calculations
Weights change rapidly (esp neonates)
10-fold errors
• Inadequate information
• Incorrect use of dose information resources
Why are children at greater risk of
medication errors?
& What can WE do about it?
• Lack of suitable dosage forms and concentrations
• Need for complex calculations & dilutions by
medics/nurses/pharmacy
Medication errors with the potential to
cause harm are eight times more likely
to occur in neonatal intensive care units
(NICUs) compared with hospital patient
care areas for adults.
Kaushal R, Bates DW, Landrigan C et al. Medication errors and adverse drug events in pediatric inpatients. JAMA.
2001; 285:2114–20.
Medication errors in children more
likely with unlicensed medicines
Percent of
prescriptions
Percent of errors
Off-label
23%
10%
Unlicensed
7%
17%
13% of errors caused moderate harm and 60% of these involved
unlicensed and off label drugs. Medication errors causing moderate
harm were significantly more likely to be associated with unlicensed and
off label drugs than licensed drugs
Reference: Arch Dis Child, published early online 4 December 2010
• Children can’t always tell us
– if we’re about to make a mistake
– if they suffer adverse effects
• Children have less internal reserves
with which to ‘buffer’ the effects of
errors
Strategy for error reduction
Reporting system
Review of errors
Identification of system
weaknesses
Change of policies / procedures /
training / availability of
information
Feedback to staff
Non disciplinary
Confidential
telephone line
What has been done?
• Ward-based clinical pharmacist
95%
• Computerised physician order entry with
decision support
68%
– e.g. drug-allergy; drug-dose; drug-drug
interaction checks
• Computerised medication administration
record
18%
Kaushal R et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-20
Interventions
• Increased input from clinical
pharmacists
• Prospective review of 10778 medication orders in two
children’s hospitals
• Analysed 10 error prevention strategies
• 3 interventions had the greatest potential impact
• clinical pharmacists might have prevented 81.3%
• computerised prescribing might have prevented 72.7%
• improved communication between staff might have
prevented 47.7%
• In combination 98.5% could potentially have been
prevented.
Fortescue et al, Pediatrics. 2003;111:722-9
• Simpson et al (Arch Dis Child
2004) Glasgow
– Pharmacist led education programme
– Errors fell from 24/1000 to 5/1000
– Change in staff increased rate to
12/1000
– Still lower than before intervention
Ways to avoid?
•
•
•
•
Education for prescribers (& testing?)
Rules regarding zeroes/decimal points
Ready access to paediatric drug dosing texts
Avoid calculations by use of standard
doses/dose charts etc
• Provide drug monographs of high risk drugs
• Individualised emergency drug dose chart
Other ways to avoid?
• Check weight is appropriate for age
• Ensure dose is not > adult dose
• Do not accept poor/ambiguous
prescriptions
• Accurate patient history taking
– involve families
– maintain patient profiles for regular patients
Other ways to avoid?
• Avoiding interruptions
– tabards
– quiet room
– medication nurse/technician
• Double checking
• Root-cause analysis of all major errors
Purchasing for safety
Assess all new products before introducing:
• Handwritten drug
name
• Verbal drug name
• Dose overlap
• Presentation
• Directions &
frequency
• Indication
• Alphabetical
location
• Packaging &
labelling
• Information
Storage for safety
Numerous commercially available parenteral medications
indicated for neonates were being stored on shelves in
the central pharmacy adjacent to similar-sounding and
similar-appearing medications for adults.
• Resolution
Neonatal medications were segregated into a “neonates
only” portion of clearly marked shelving. Purchasing
personnel created this new segregated shelving space
and allocated purchased medications to this space
when deliveries arrived from the distributor
Summary
• Acknowledge the problem
• Quantify it’s extent and causes
• Cease finger pointing
• Analyse all errors via quality assurance
• Evaluate proposed solutions
Summary of learning points
• Establishment of a medication error review scheme
is essential
• A ‘no blame’ system of reporting should be
established
• Suitable paediatric reference sources should be
readily available
• Users should be aware of problems relating to
unlicensed or off label drug use
• Patients / carers should have suitable information
• Any system that helps prevent medical
mistakes, by helping doctors come
forward without the fear of being blamed,
would hold real benefits for the NHS
Michael Wilks, chairman of the British Medical Association's MedicoLegal Committee