Transcript HMO Medication Safety - Peter Mac Education Portal

Quality Use of Medicines
at Peter Mac
“tips, hints and updates”
Medication Safety Committee, Peter Mac
Janelle Penno – QUM pharmacist
Kate Witney – QUM pharmacist
Outline
1.
2.
3.
4.
5.
6.
7.
8.
9.
Access to medication information using Verdi®
Insulin prescribing
Opioids
Chemotherapy
Anticoagulants
Antibiotics
Potassium
Safe prescribing practices
Time critical medications and how to reduce delayed or
missed doses
10. Contacts and resources
Access to medication information in Verdi®
Drug
Alerts/Allergies tab
Medication Histories at
admission are
completed by the ward
pharmacist and located
behind the medication
chart
or
use the Pharmacy
section In Verdi®
3. Click on Admission
medication
1. Click on Pharmacy.
2. Click on
Medication
Reconciliation
Report
4. Sometimes “Other
dispensings” is useful to
see what we have
dispensed and when
Importing discharge medication lists from Verdi into
discharge summaries
3. Double-click on the episode
for the appropriate date.
1. Click on Pharmacy.
2. Click on Discharge
Medication Summary
Important to include all
information on the
discharge prescription
(PBS CHART), as
everything on the
discharge prescription
is automatically faxed to
the GP (electronically)
Importing discharge medication lists from Verdi into discharge
summaries
Export this list to Excel by right-clicking on the list
Copy and paste this list (via Excel) into the
discharge summary
Important to list any
medication changes made
to the medication regimen in
the discharge summary
This improves the continuity of
care across healthcare
settings
Medication Lists for
discharge summaries
Click on Medication
Reconciliation
Reports tab
3. Click on Patient discharge
chart for appropriate date.
1. Click on Pharmacy.
2. Click on Medication
Reconciliation Reports
Lists any medication changes
at the end of the chart in the
discharge summary
At Peter Mac we have a
PBS
Medication
Chart
Peter Mac’s medication chart is
used to prescribe and
administer medications.
It is also used to supply and
claim medications from
the chart for discharge.
ie. The chart becomes the
discharge prescription
PBS Chart: Benefits
-
Improve patient safety
Dramatically reduces transcription errors (from chart to prescription)
-
- Reduce workload/paperwork requirements for medical staff
- Improve time efficiencies
-
Streamline communication
Prescribing, administration and discharge script all in one place.
How to Use the Chart
1. Fill in Prescriber section on
front page of chart
Prescriber details must include
the date and a signature
- Prescriber details must be filled on each chart if you are the doctor
discharging the patient
- Pharmacist will not be able to dispense discharge medications if this is
not completed
2. If an authority is required – use this
number on the front of the chart 
‘Script Number’ to quote if an
authority approval number is
required
NOTE: the numbers are different
on each chart-watch out when you
need an approval number for
items on different charts
3. Fill in the VTE section
(or the warfarin section if applicable)
REMEMBER: to
prescribe TEDs
if appropriate
-
Complete the VTE risk assessment for all patients
Enoxaparin is first choice at PMCC
Chart TEDs if indicated
Peter Mac patients represent an inherently higher risk group for
VTE and all inpatients should receive it unless it is contraindicated.
4. Prescribing with the chart
a) Complete the
‘Start Date’ (usually
the same day the
order is written but
could be used if you
wanted a
medication to start
on a particular day
in the future)
‘Valid for Duration’ or
Stop Date are
optional but good
practice to fill in
b) Prescribe the dose
and frequency in the
same box and then
enter the
administration times
(liaise with the nurse
or pharmacist for
appropriate times if
unsure)
METOPROLOL
8:00
oral
50mg BD
20:00
c) Where appropriate,
on discharge
complete the
‘Streamline Authority
Code’ or Authority
Approval No’
d) Ignore
this!
5. Completing the chart for discharge
It is important to consider
whether the drug route, dose
and frequency is appropriate
for discharge.
Modify orders for
appropriateness at discharge.
Discharge Supply space
1.
2.
3.
4.
5.
Circle Y or N for “continue on discharge?”
Leave the “dispense? y/n” blank as the pharmacist will fill this
in
Fill in quantity – use the blank section nearby for writing
words and figures (NB: Multiple strengths may need to be
written separately due to limited space)
Sign and date each medication order
If adding something on for discharge purposes only, cross out
the administration section and write "for discharge purposes
only“
If unsure about the quantity use the PBS website (www.pbs.gov.au)
or liaise with the pharmacist
6. Some other things to consider
- Communicate with your pharmacist when you have
completed the discharge sections or there have been any
additions, as this can delay the patients discharge home (not
as obvious as a completed discharge prescription).
- Complex items:
- titrating doses: use variable dose chart if possible- a separate
prescription may be needed.
- multiple strengths (e.g. Oxycontin® 70mg– space limits may require
separate orders to allow for approval numbers and quantities to be
written in words and figures. )
- oral chemotherapy
7. Situations where separate scripts may
still be needed.
Prescription will still be needed if:
- outside of PMCC pharmacy hours (chart cannot be taken outside of Peter
Mac)
- the patient/carer/nursing home wants to get medications from a
community pharmacy
- repeats, deferrals and regulation 24 are essential for a particular item
- day leave
- complex directions may need a prescription
-
PBS chart can still be used for;
- Insulin orders – on the day of discharge write insulin prescription on the
chart  cross off the admin section and document “for discharge only”
- Pain and Palliative care emergency orders
- Post chemotherapy medications- cross off the admin section and
document “for discharge only”
8. Final Key Points
- Utilise and communicate with your ward pharmacist
- Fill out the prescriber details at the front if
discharging patient
- Fill out the discharge section for each medication
and approval numbers if necessary
- Is the drug order right for discharge? Check drug,
route, dose, frequency is appropriate.
- Discharge prescription will still be available if
necessary
High risk medications: APINCH
(strongly feature at Peter Mac)
-
Antimicrobials
Potassium
Insulin
Narcotics
Chemotherapy
Heparin (LMWH)
- Worldwide incidents associated with all
- High-risk medicines have a narrow therapeutic index
- High-risk medicines can cause significant harm when system
errors occur
- Medicines can present a high risk when administered via the
wrong route
Insulin prescribing at Peter Mac
- Insulin recognised internationally as a high risk medicine
- Insulin has a narrow therapeutic index and doses are highly
individualised
- There are a large amount of insulin preparations on the
market, increasing the risk of mix-ups (e.g. rapid acting vs
regular insulin)
Transcribing and Administration errors with Insulin
can have serious consequences
- A Peter Mac patient received 80 units instead of 8 units  ICU admission
- Another Peter Mac patient was prescribed 10 units of insulin – however
100 units was accidentally drawn up  picked up by an incidental 3rd
nursing check prior to administration
A subcutaneous insulin chart was
implemented at Peter Mac in 2013
– all prescribing, monitoring and administration is
combined into a separate chart to standardise practice
and reduce the risk of error.
Monitoring
Communication and Safety
Insulin Administration
Insulin Orders
1. Using the chart: before you start
1. Cross reference the insulin form on the NIMC
or
2. Affix bradma (with the patient’s name printed underneath)
3. Document who to notify of
out of range BGLs or other
diabetes-related concerns
2. Monitoring / Notification Instructions
-
Prescriber indicates the BGL frequency of monitoring required
- Default BGL monitoring for inpatients is Pre-meals and at
21:00hrs
- ALERTS prompting clinical review for
HIGH BGL and LOW BGL
3. Insulin Orders (Prescribing)
- A patient may be prescribed any combination of
Routine, Supplemental, and Stat / Phone Insulin
Orders
- If a patient with diabetes is not receiving
subcutaneous insulin, this form should still be used
for BGL monitoring
Valid until changed or ceased
4. Routine Insulin Orders
Valid until ceased or changed
Six (6) spaces to
prescribe routine insulin
Four (4) spaces with
Meal / time pre-printed
Breakfast
Lunch
Dinner
Pre-Bed
Orders are valid for 5 days
unless ceased or changed.
5. Supplemental Insulin Orders
-
Tick the appropriate Frequency
-
Write the Name of insulin, start date and start time
-
Standardised BGL ranges are pre printed
- if required, different BGL ranges may be used
-
Write insulin doses
- For suggested doses, see Table 1 (pg 1, MR61F)
-
Sign and initial the order
-
Review supplemental doses as required
-
Changes are validated by initialling
changes in the corresponding column
-
Also write the Name of supplemental
insulin in the Administration Record
6. Guidelines for Managing Hyperglycaemia Alerts
To assist inexperienced and non specialist
clinicians with management of hyperglycaemia
in hospital inpatients. The guidelines provide
information related to:
 assessment required when called for a
Hyperglycaemia Alert
 initiation of basal and mealtime insulin and
adjustment of insulin doses
 suggested stat and supplemental doses based
on weight or previous total daily dose.
These are not designed to decrease autonomy
or specialist input. If there are any clinical
concerns, senior medical officer advice should
be obtained.
1
2
3
7. Management of Hypoglycaemia in Diabetes - Adult
-
-
Has four treatment pathways:
- conscious and cooperative
- insulin infusion
- nil by mouth or nil by tube
- oral or tube fed
Appropriate food choices are listed
- Food choices should be centrally located
- Each ward has access to glucose 50%
intravenous 50mL and glucagon 1mg
injection to use in emergency situations
- Glucose based products are preferred as
initial treatment
- Non diet products must be used to treat
hypoglycaemia
ALL Insulin doses > 30 units must be verified
as correct prior to administration.
This is EVERYONE’S
RESPONSIBILITY
1. VERIFY with a reliable
source. E.g. carer,
patient, GP, pharmacy
records
2. DOCUMENT ON INSULIN
PRESCRIBING FORM:
“insulin “ (e.g. Lantus)
dose > 30units
validated
Only 30 unit insulin syringes are available in ward areas – this
is to improve awareness of high doses and reduce the risk of
larger doses being given in error.
Additional Insulin Resources
- Insulin guideline - iPolicy
- Medical Registrar
- Endocrinology and diabetes educator - from RMH
Narcotics/Opioids - why the high risk?
- Risk of product selection error during the administration process
often there are multiple ampoule strengths
- Complex calculations when converting opioid products from one
opioid to another and from IV to oral-not an exact science
- Multiple products – similar sounding names e.g. morphine,
hydromorphone
- High volume usage at Peter Mac with cancer pain population
Intranet Clinical CornerResourcesToolsOpioid identification and conversion chart
Physical copies in all ward areas
Opioid Resources
-
Ipolicy
- Procedure for supply or methadone and
buprenorphine pharmacotherapy
- Ketamine Infusion for analgesia
- Guidelines for the conversion, prescription and
administration of methadone for pain
- Management of post operative epidural infusion
for acute pain management
- Management of intrathecal single shot morphine
for acute postoperative analgesia
- Patient controlled analgesia
-
Outpatient Referral:
-
-
Email .painmx (Pain referral)
Email .palliative (Palliative care referral – multiple
symptoms).
Inpatient Referral  through VReferrals
Chemotherapy - why the high risk?
- Narrow therapeutic index
- Sound alike/look alike drugs e.g. doxorubicin, daunorubicin
- Wrong route administration can be fatal e.g. vinca alkaloids
- Variation in dosing between protocols and tumour stream
- Variations in dosage calculations e.g. carboplatin
Chemotherapy
“THE CHARM
CHART”
•
Watch for duplicate orders between
CHARM chart and inpatient medication
chart e.g. granisetron on Charm,
ondansetron on chart
•
All pre-meds/fluids +/- hypersensitivity
meds (in cases of allergy in drugs
known to be allergenic) are
administered using the CHARM chart
Post-chemo supportive care discharge medications on last page of
CHARM chart
Needs to be prescribed on PBS Chart (can be used for discharge and
administration if patient remains an inpatient)
LOCATING the
CHARM
CHARTS from
the wardseither:
Electronic
Copy on Verdi
in the
Chemotherapy
Section
OR
Physical Copy
In the Patients
Medication
Chart / (or the
Medication
Room)
Click on Chemo
Drug Charts
Click on appropriate chart
for date
All Supportive care and
discharge medications are
on the CHARM chart.
Antimicrobials-why the high risk?
- Inappropriate use is attributed to promoting antimicrobial
resistance
- Some have a narrow therapeutic index and extra monitoring
and thought is needed (e.g. aminoglycosides, vancomycin,
colistin, amphotericin)
- Allergies to antibiotics are prevalent - refer to Dr Jason
Trubiano – ID allergy clinic
Antimicrobial Resources
-
Guidance MS (incorporates Therapeutic Guidelines)
Antimicrobial Stewardship Team (pg 1110106)
-
-
ID registrar for referrals (pg 1110035)
Allergy Clinic – Dr Jason Trubiano
-
-
Can refer for review via email, referral form on iPolicy> Antibiotic allergy clinic referral
Guidelines available on ipolicy
-
-
Can request review using the AMT Review Request button under Drug Approvals on Verdi
Febrile Neutropenia
Sepsis Pathway
Antifungal prophylaxis
PJP prophylaxis
Surgical prophylaxis
Splenectomy Vaccination Guidelines
Antibiotic Allergy Clinic Protocol and Referral
Vancomycin, aminoglycoside dosing
Other useful guidelines
-
Therapeutic Guidelines (available on the intranet under clinical corner drug information)
Potassium - why the high risk?
- If given too concentrated via a peripheral line it can cause:
- Burning, blistering, extravasation
- If given too fast or too high a concentration it can cause:
- hyperkalaemia as insufficient time is available for intracellular
potassium uptake = may cause cardiac arrest within minutes. The
effect of hyperkalaemia on the heart is complex – virtually any
arrhythmia may be observed1
Potassium resources
- Potassium Guidelines – iPolicy
- Pre-made bags available on each ward (various
concentrations)
Potassium error at PeterMac
Patient received: 100mmol KCl in previous 24 hours10 x 10mmol potassium
ampoules mixed with approx. 100ml normal saline 0.9% in the burette
- Left peripheral cannulae
- Propofol infusion
- Right peripheral
cannulae
- Drug and Flush line:
KCl 10-20mmol IV prn
- Antecubital fossa
Endorsed by pharmacist: CVC
only
- Insulin infusion + 25%
dextrose @ 10mL/hour
Reflection
- How could this have been prevented?
- Nurse could have used pre-made bags
- Doctor could have put a central line in
- Pharmacist should have asked what lines the patient had
and given advice on pre-made bags
- Would lignocaine with the potassium help?
- No – this would just mask the pain of the injury
- Few studies have shown little benefit of adding lignocaine
to a bag of potassium for pain
Heparin/anticoagulants – why the high risk?
- Worldwide anticoagulants are the class of medicines most
commonly associated with fatal medication errors
- Narrow therapeutic index
- Selection error (6 strengths of heparin available and the
packaging looks very similar)
- Heparin infusions require constant monitoring and frequent dose
changes
Heparin/Anticoagulation Resources
- Intranetclinical cornerresourcesclinical
guidelinescancer surgeryAnaesthesia guidelines
- STEP Protocol (available as an app)
• search for: "Surgical Thromboembolism Prevention" or just
"Thromboembolism"
- New Oral Anticoagulants
- Fast Track Warfarin Reversal (includes bridging enoxaparin
advice) – this information is available in the Vnote
- Ipolicy
- Heparin infusion Guideline (located on the back of the
heparin chart, which is kept in AAA)
- Plan to hyperlink guidelines on ipolicy in the near
future so easier to find everything
Preventing Dose Omissions
Focus on Time Critical Medications
- Dose omissions occur when a dose is not administered at its
scheduled administration time
- A multi-centre Victorian Hospital Study found that for 17,000
doses in 300 patients up to 14% of intended doses where
omitted
- Time critical medications are those medications at greater risk
of causing harm if not administered within a timely manner
- Omitted doses of time critical medications may increase the
length of stay and healthcare costs
Time Critical Medications
Although there is no absolute
definition of a time critical
medication, this table should
be used as a guide
Other medications maybe
considered time critical for
an individual patient
depending on the context
and the condition being
treated
What you can do to reduce omissions of
time critical medications
- The time critical nature of a new medication needs to be
communicated when prescribing with the relevant nurse and
pharmacist
- Also communicate any changes to time critical medications
- Document the indication of any time critical medications on
the inpatient chart
- Ensure there is a documented plan for time critical medications
- Withholding any time critical medications peri-operatively
- NBM/dysphagia liaise with pharmacist for alternative formulations
- Ensure your order is legible
Medication Related Contact Numbers
Contact (email/phone/pager)
Medicines Information
ext: 95204
Email: [email protected]
Ward Pharmacists
Ward 3 pager: 1110089
Ward 5 pager: 1110084
CDU pager: Ph. 60340 / 60343 / 60344
AAA: 1110103
Ward 6: 1110087
Senior Clinical Pharmacist (Brett) pager: 1110097
Outpatient dispensary
ext. 95202
Cytosuite Level 5
ext. 64310
QUM/AMS Pharmacist
pager 1110106
Pain and Palliative Care Pharmacist
pager 1110102
ext. 98172
Pre Admission Clinic (PAC) pharmacist
pager 1110153
ext. 98176
Individual Patient Usage approval (IPU)
Application form on iPolicy
On-Call Pharmacist (after hours)
Through Switch
PBS/Medicare for approvals
1800 888 333
Good luck and enjoy your time at Peter Mac!
Other useful resources/learning modules
NPS Website: (1) NIMC and (2) Medication Safety modules
ISMP – 10 tips for obtaining a Best Possible Medication History
If you want to be involved in the redesign of the PBS drug chart or if you have any suggestions
for improving medication safety, please
email: [email protected] or call: ext 98176
[email protected] or ext 98175