Patient Safety quality of drug delivery in health care

1
Patient Safety quality of drug delivery in
health care

• Sten Olsson
• WHO Collaborating Centre for International Drug
  Monitoring
• Uppsala, Sweden

2
Patient Safety

• Can we totally prevent patients from being harmed
  when treated?
• - No, always risks involved in administering
  biologically active substances but we should
  NEVER accept when harm is done unnecessarily
• Learn from mistakes and prevent future patients
  from being affected

3
Rational and safe drug use

• Appropriate indication
• Appropriate drug prescribed
• Appropriate administration, dosage and duration
• Appropriate patient
• Appropriate patient information
• Appropriate evaluation and follow-up

4
Building safe systems

• To Err is Human (IOM 2000)
• 48 -99 000 deaths in US in 1999 from medical
  errors, 7000 from medication errors
• Systems must be built to protect patients from
  mistakes made by health care professionals
• Often combination of errors

5
Minimizing harm

• Good basic education in pharmacotherapy for
  doctors pharmacists
• Continuing education
• Good facilities for diagnosis, prescribing, and
  dispensing
• Tailoring drug therapy to individual
• Treatment guidelines and formularies
• Public education
• Assured drug quality
• Good record keeping
• Reporting system for ADRs and errors

6
Common causes of harm

• Inappropriate prescribing
• Unrecognized ADRs
• Patient non-compliance
• Overdose or underdose
• Lack of necessary therapy
• Failure to recognize symptoms or inadequate
  follow-up
• Medication administration error

7
Partnership

• Politicians laws, resources
• Regulators regulations, reinforcement
• Health care providers - systems
• Manufacturers GMP, marketing
• Physicians prescribing, councelling,
  follow-up, reporting
• Pharmacists dispensing, information,
  follow-up, reporting
• Nurses controlling, reporting
• Patient complience, reporting
• Media monitoring, reporting

8
Medication ErrorDefinition

• 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

9
(No Transcript)
10
(No Transcript)
11
When do errors occur?

• Prescribing transcription 60
• Administration 30
• Dispensing 10

12
(No Transcript)
13
Examples

• Misinterpretations
• Miscalculations
• Use of abbreviations
• Misadministrations
• Difficulty in interpreting handwritten orders
• Misunderstanding of verbal orders

14
Why?
15
Drug regulatory authorities

• Focus on errors related to nomenclature,
  labelling or packaging
• Similar sounding names
• Unclear descriptions
• Similar packages
• How does the authority get to know about the
  problem areas?

16
Drug Authority
17
In the pharmacy

• Good storage practice
• Trained staff
• Question unclear prescriptions
• Dispensing SOP, time for patient
• Proper labelling and information
• Culture of observation and reporting of patient
  problems
• Regular review of ADRs, errors and near-misses

18
High risk situations

• Certain drug groups
• Insulin
• Antineoplastics
• Digoxin
• Heparin
• Anticoagulants
• Etc.

19
High risk situations

• Certain patient populations
• Pregnant women
• Breast-feeding women
• Elderly
• Children
• Patients with kidney or liver disease

20
What to report

• Adverse reactions
• Type A
• Type B
• Lack of effect
• counterfeiting
• resistance
• interaction
• Quality problems
• Dependence and abuse
• Poisoning
• Medication errors

21
USP Medication Error Reporting Form
22
Purpose of error reporting

• Identify and correct systems failures
• Prevent recurrent events
• Provide safe environment for patient care
• Provide a record of the event
• Improve the management of patients
• Avoiding habit of blaming

23
World Alliance on Patient SafetySix programmes

• "Clean Care is Safer Care
• Patients for Patient Safety
• Taxonomy for Patient Safety
• Research for Patient Safety
• Solutions for Patient Safety
• Reporting and Learning
• Includes medication errors in prescribing,
  dispensing and administration

24
Some relevant organizations

• WHO Collaborating Centre for Patient Safety
  Solutions
• Joint Commission on Accreditation of Healthcare
  Organizations, Washington
• www.who.int/patientsafety
• USA
• National Coordinating Council for Medication
  Error Reporting and Prevention
• www.nccmerp.org
• United States Pharmacopoeia
• www.usp.org/mer
• Institute for Safe Medication Practices
• www.ismp.org
• Agency for Healthcare Research and Quality
• http//webmm.ahrq.gov

25
Literature
26
Literature
27
Thank you for your attention

• info_at_who-umc.org
• www.who-umc.org