How to Harm Children with Medicines a guide for pharmacists

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How to Harm Children with Medicines a guide for
pharmacists

• James Wallace Queen Mothers Hospital Glasgow
• Peter Mulholland Southern General Hospital
  Glasgow

With apologies to Professor Imti Choonara
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Learning outcomes

• Definitions identification of medication errors
• Extent nature of medication errors in children
• Strategies to avoid errors

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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
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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. 

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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

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NPSA 2007. Safety in doses improving the use if
medicines in the NHS

• Recurring themes
• Problems with injectable medicines
• Gentamicin
• Children being treated in non-paediatric areas
• Errors in dose calculation
• 10 fold errors
• Vaccines

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Dispensing errors

• Mike Spencer reported on a multi-centre
  dispensing error analysis scheme
• 33-60 hospitals contributed
• 5427 errors
• 34 million items dispensed
• Range 13.8 20.0 per 100,000
• Hospital rates 0 296 per 100,000

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Dispensing errors

• Attempts to involve community pharmacy were
  unsuccessful
• Pharmaceutical Press unwilling to publish case
  studies
• Department of Health and national Assembly of
  Wales acknowledged the value of the scheme, but
  declined to offer financial support

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Most common error type

• Dosing errors 28
• Route of administration 18
• MAR transcription documentation 14
• Wrong date 9.9
• Frequency 9.4

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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

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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

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Why do individuals make errors ?

• Psychological state
• Interruptions
• Lack of information
• Calculation errors
• Corporate livery
• Confirmation bias
• Tiredness/stress

• Reference sources,
• communication
• Electronic calculators
• Noise
• Temperature
• Workload/staffing
• Levels / Rotas

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• 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

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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

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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

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• Children cant always tell us
• if were about to make a mistake
• if they suffer adverse effects
• Children have less internal reserves with which
  to buffer the effects of errors

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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

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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
20012852114-20
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Interventions

• Increased input from clinical pharmacists
• Prospective review of 10778 medication orders in
  two childrens 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. 2003111722-9
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• 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

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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

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Other ways to avoid?

• Check weight is appropriate for age
• Ensure dose is not gt adult dose
• Do not accept poor/ambiguous prescriptions
• Accurate patient history taking
• involve families
• maintain patient profiles for regular patients

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Other ways to avoid?

• Avoiding interruptions
• tabards
• quiet room
• medication nurse/technician
• Double checking
• Root-cause analysis of all major errors

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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

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Summary

• Acknowledge the problem
• Quantify its extent and causes
• Cease finger pointing
• Analyse all errors via quality assurance
• Evaluate proposed solutions

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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

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• 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 Medico-Legal Committee