Transcript wk 1. error+safe prescribingv0_2

SAFE AND EFFECTIVE
PRESCRIBING
Why errors occur, incident analysis
and Safe prescribing
Dr Ian Coombes,
Senior Clinical Lecturer University of Queensland
Schools of Medicine and Pharmacy
Safe Medication Practice Unit, Queensland Health
The University of Queensland
Session Objectives (part 1)
 Why medication errors occur
 Develop understanding of how “error chains” and
human factors lead to errors, mistakes and harm
 Introduce concept of incident analysis
 Enable students to apply key principles of safe
prescribing
 Facilitate students writing regular in hospital
prescriprion
Prescribing error: definition
“A prescribing decision or prescription
writing process that results in an
unintentional, significant reduction in
the probability of treatment being
timely and effective or increases the
risk of harm, when compared with
generally accepted practice”
 Dean et al, Quality in Healthcare 2000
3
1st day of job as junior Dr
% agreement (n=101)
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Able to prescribe for most simple complaints…… 84%
Complete discharge prescriptions ……….……….81%.
Confident to prescribe warfarin ……………………54%
Able to order intravenous fluids …………..…….…66%.
Nurses make more than a “few” errors …….……..57%
Their prescriptions safely administered …….…….99%
Felt errors would not be dealt with constructively...40%
A blame culture existed at their hospitals ……….. 79%
Coombes, Stowasser, Mitchell. Medical Education 2008
Queensland Sunday Mail, 22nd February 2004
• Patient admitted with retinal abscess
• PMH = CCF, AF, Prostate CA
• Day 6 developed Incr. SOB, pulmonary
oedema sent to CCU
• What are the three drugs – what happened?
• 14 nurses administered
• 10 days of medical review by multiple staff
• 8 days of clinical pharmacy review
A case of safe and effective
prescribing?
 34 year old lady with fever and green sputum and
cough – no known previous medical history –
Diagnosed with upper resp. tract infection
Prescribing questions?
 Prescribed:
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Common organisms for URTI?
Co-Amoxiclav 1 tds
Likelihood atypical organism ?
Doxycycline 100mg D
History of asthma – risk vs benefit?
Prednisolone 40mg D
History asthma – risk vs benefit
Theophylline 200mg bd
Need for acid suppression?
Omeprazole 20mg D
Metoclopramide 10mg tds Why is she nauseous ?
Salbutamol 2 puff inhale prn Benefit of brochodilation?
Does she know what to take?
Will she take it?
Lessons from Aviation
The Medicines Management Team
DOCTORS
Transfer
information
Monitor
response
Decision to
prescribe
Order entry
Review order
Individual
Supply medicine
Administer
Distribute
Nurses
Supply
information
Pharmacist
From Bates et al 1995
The Prescribing process
Information
Retrieval –
Presenting
complaint,
History, Lab
Monitoring
and review
Patient
Decision re,
Drug, route,
dose vs
Patient,
disease,
drugs
Instruction to:
prescribers,
pharmacists,
nurses
1
Coombes I, PhD
Where Medication Errors Occur
Errors
Drug Related Admissions
Frequency
(600 bed hospital)
4-5 patients/day
Prescribing Errors
40-160 orders/day
Dispensing Errors (pharmacy)
1-5/week (low!)
Administration Errors
Discharge Prescribing Errors
40-100 doses/day
20-70 items/day
Ref: 2nd Aus National Report on Patient Safety – Improving Medication Safety
So drugs are safe ………………..
Photosensitivity from
Amiodarone
Severe extravasation of
amiodarone infusion
NSAID or COX-2 induced peptic ulcer
Goitre – Hypothyroidism
Secondary to Amiodarone
Bleeding due to excessive
anticoagulation with warfarin
Erythemal rash from penicillin – in patient with a previous
Known allergy/ adverse drug reaction
Necrotising fascititis – secondary to infection at site of IV injection
Acute Liver failure from Black Cohosh - herbal medicine
Drugs most frequently
associated with ADE (ADRs)
1.
2.
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6.
anticoagulants
antibiotics (aminoglycosides)
analgesics (Opiates/ NSAID/ COX-2)
electrolytes
diabetic
cardiac
Junior Doctor Prescribing Errors
Clinically significant intern prescribing errors
• Dosing errors most common type by far (> 40%)
• Where errors occur:
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admission?
during stay?
discharge?
transcribing?
Most junior Dr errors – transcribing (writing the order)
(perceived as menial/‘just another job’)
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Least errors - during stay (many on admission/ discharge)
(interns rarely initiate new Rx unsupervised)
Coombes et al. Med J Aus 2008
What This Means For YOU
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~ 40 patients to manage concurrently
average length of stay = 5 days
≈ 3000 patients per year
~ 10 (1-42) medicines prescribed per patient stay
YOU will prescribe ~ 15,000 meds in your 1st year!
error rate 2.5–10% (350–1500 errors per year)
If 1% clinically significant and likely to cause harm:
4–15 critical errors per year!
THIS IS IMPROTANT STUFF!
Why Do Errors Occur?
Will YOU Be Involved?
Human Error
Error is inevitable due to “our” limitations:
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limited memory capacity
limited mental processing capacity
negative effects of fatigue other stressors
 We all make errors all the time
 Generalised lack of awareness that errors occur
 Patients suffer adverse events much more often than
previously realised
 Errors often NOT immediately observed
The Accident Causation Model
(Adopted from Reason & Dean)
Latent
Conditions
Error
producing
conditions
Active
Failures
- Slips&lapses
- Mistakes
Accident
Defences
Active Failures
 Slips in concentration
- intending to prescribe one drug, but prescribing
another (look alike/ sound alike)
 Lapses in memory
- forgetting to discontinue one drug (heparin) when
another prescribed (enoxaparin)
 Mistakes
- lack of knowledge i.e. not checking previous drug
allergies or renal function or weight
Latent factorsof incident
Findings
analysisError-producing factors
Organisational/ Management– work load, hand written prescriptions, staffing
Culture of lack of support for interns
(adapted from Reason with permission)
Environmental – busy ward, interruptions
Team – lack of supervision
Individual – limited knowledge, information
Task - repetitious, poor medication chart design
Patient – complex, communication difficulties
Active failures
Error – slip, lapse or Violation
Defenses
Inadequate –
Guideline confusing
No pharmacist
Harm
Latent or Lurking Factors
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Lack of undergraduate training in prescribing
Lack of awareness of medication errors
Perception of ‘just another job/task’
Juniors assume if ‘told to .. it must be right’
Seniors overestimate knowledge/ability
don’t want to be‘patronising’
 Expect senior ‘review’ of prescribing
 Power gradients and hierarchies
Adverse Event Analysis…
… is a systematic process to identify
the factors which contributed:
what, when, where, how and…
why versus who!
The System:
Only as safe as it’s designed to be!
“I assumed the brown glass
ampoule was adrenaline”
(ICU RN after injecting 10mg
frusemide, patient suffering
caridogenic shock did not
recover)
KCl instead of NaCl
How a patient with documented ADR to
cephalosporin received two more doses
{From Reason’s Swiss Cheese Model}
Verbal order by Surgeon for antibiotic in OT
Transcribed by Registrar to medical notes/record
Phone call – Nurse to ward call dr (outlier)
Prescribed by Dr (1st term junior)
Severe anaphylaxis, dialysis,
steroids, antihistamines Prepared by Nurse 1 (busy)
Check Nurse 2 (agency)
Patient (asleep)
Given
by RN
Re-exposure to Cephalosporin
 Patient Factors
 Sedated, post op
 Task Factors
 Writing a prescription some one else ordered
 Practitioner Factors
 Hungry, tired, late, inexperienced, ill-informed
 Team Factors
 What team? – Outlied patient, ward call doctor
 Workplace Factors
 Medicine charts – ADRs/Allergies on front of chart – order on inside
 Organisation Factors
 Did not invest in safety systems or training for safe prescribing
So What is a Prescribing?
The Prescribing process
Information
Presenting
complaint,
History, Lab
guidelines
Monitoring
and review
Patient
Decision re,
Drug, route,
dose vs
Patient,
disease,
drugs
Instruction to:
prescribers,
pharmacists,
nurses
3
Coombes I, PhD
Key stage of prescribing for
junior doctors is…
Communicating information about:
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drug
form
route
dose
frequency
administration time/s
administration of IV meds
duration of therapy
in a CLEAR, UNDERSTANDABLE form to:
Other doctors
Nurses
Pharmacy staff
Case Study – Mr AD
 68 y.o. 60 kg ♂ presents to ED
 PC: SOB pyrexial and sputum
 HoPC: 2/52 increased, cough, sputum, fever 7 days of
amoxycillin from local (private Dr) no response
 Exam: BP 110/70; HR 90; RR 19, bi-basal chest crackles
 Creatinine, urea other E, LFTs Normal
 PMH: RA (10 yrs); HT (20 yrs),
 Dx: URTI
 Social Hx: lives alone
 ADR: Erythromycin – severe Hives, rash – 2005
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68 y.o. 60 kg ♂ presents to ED
PC: SOB pyrexial and sputum
HoPC: 2/52 increased, cough,
sputum, fever 7 days of
amoxycillin from local (private Dr)
no response
Exam: BP 110/70; HR 90; RR 19,
bi-basal chest crackles
Creatinine, urea other E, LFTs
Normal
PMH: RA (10 yrs); HT (20 yrs),
Dx: URTI
Social Hx: lives alone
ADR: Erythromycin – severe
Hives, rash – 2005
Your Registrar asks you to
write up Mr AD’s chart
(DOB: 01/4/40; UR:155566;
date: today; ward:
medical)
 Co-amoxiclav oral1 TDS
 Clarithromycin oral
500mg BD
 Captopril oral 25mg BD
 Diltiazem SR oral 240mg
mane
 Methotrexate oral 10 mg
weekly on Sundays
Write up the medicines the
person should have
Pass to the Person Next to You
Is Everything OK?
Imagine you are a junior nurse at 8 a.m. on Friday
 Name - care with “sound alikes”
- Lasix®/Losec®, Oxycontin®/ MS Contin®
 Drug Form – immediate vs sustained release
- e.g. Diltiazem sustained release vs standard
 Combinations – Co-amoxiclav – contains penicillin
 Strengths - if unsure,(1 tablet) make a clinical decision
 Route - oral, IV, IM, SC, IT – can they take it?
 Dose - multiple/partial tablets & decimal points
- e.g. digoxin 62.5 micrograms, 5.0 units insulin
 Frequency - explicit standard terms – NB: weekly
medication (cross out unnecessary days)
 Times to be entered by doctor when prescribing?
ADR – Erythromycin = Hives
ADRs
 Class effects (macrolide antibiotics) :common trap
 BEWARE trade names and combination drugs
 Document all relevant ADR details on chart
BEFORE prescribing!
 ADR details in medical chart/notes as well
 Ask patient , carer, previous notes
 Check with patient and chart and front of medical
record file BEFORE prescribing
What if the patient gets 4 x 60 mg tablets ?
Weekly medicines
 Medicines to be taken once a week:
 Ie Methotrexate for arthiritis
 Alendronate for osteoporosis
 Significant risk that your order may be
misinterpreted by nursing staff and
patient may receive daily = pancytopenia
Ceasing Medications
Physically block further
administration
Prevent transcription errors
but still legible for records
Sign and Date,
reason for ceasing
State
Reducing the risk of adverse events
 Always
 include a detailed drug history in the consultation
 Only
 use drug treatment when there is a clear indication
 Stop
 drugs that are no longer necessary
 Check
 dose and response, especially in the young, elderly
and those with renal, hepatic or cardiac disease
Patient Assessment Questions
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Does the patient need this drug ?
Is this drug the most effective and safe ?
Is this dosage the most effective and safe ?
If side effects are unavoidable does the patient
need additional drug therapy for these side effects?
• Will drug administration impair safety or efficacy ?
• Are there any drug interactions ?
• Will the patient comply with prescribed regimen ?
Summary
 Accidents happen everywhere
 The best people make mistakes
 Same “simple” mistake - different
consequences
 Everyone is responsible for patient safety
 Writing an order is as important as making
the decision what to prescribe