Safe prescribing: How to avoid prescribing errors

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Safe prescribingHow to avoid prescribing errors

• Maggie Allen
• UHCW/CWFS

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Aims

• To provide an awareness of
• Common medication errors
• How to minimise these
• National and local resources available to you to
  aid in safer prescribing
• To give you some prescribing pointers to look out
  for in posts

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• By the end of the session you should be able to
• Define a medication error
• List the Five Rights
• Identify common types of medication errors
• Begin to think about how to minimise errors by
  using your knowledge, skills and available
  resources

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During your placementsThink about

• What do I need to prescribe in a safe way?
• Patient information
• Co-morbid conditions
• Drug information
• Pharmacology
• Pharmacokinetics and pharmacodynamics
• Therapeutics
• Systems
• Policies, guidelines, prescribing aids etc

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What is an error?
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What is an error ?

• Doses omitted
• Wrong dose
• Unprescribed drug given
• Wrong dosage form given
• Wrong route of administration
• Wrong rate of administration

• Wrong time of administration
• time of day
• in relation to food etc....
• Using unstable/expired drug
• Wrong administration technique
• Incorrect reconstitution
• Extra dose given

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Where do errors occur in the process of giving a
drug?

• Prescribing
• Dispensing
• Administration
• Counselling/communication

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Adverse events in hospitalsWhat is the size of
the problem?
Adverse events per admission () 10
AE number / year in UK 850,000
Cost in additional hospital stay () 2 billion
Cost of clinical negligence schemes/yr 400 million
Medication errors of incidents 25
An organisation with a memory. Dept of Health 2001
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Reported incidences

• Difficult to estimate due to varying definitions
  - US/UK
• Prescribing errors
• 3-20 per 1000 prescriptions
• Medication errors
• 1 per patient per day
• Been estimated that drug errors account for 1/5
  of all deaths due to adverse drug events

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Outcomes

• Data collated by US National Co-ordinating
  council for Medication Error Reporting and
  Prevention 1993-98
• Performance deficit 29.8
• Communication problem 15.8
• Knowledge deficit 14.2
• Dose miscalculation 13

• 5366 reports
• 68.2- Serious patient outcomes
• 9.8 - fatal
• Improper dose
• Wrong drug
• Wrong route of administration

Phillips, J etal. Am J Health Syst Pharm 200158
1835-41
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Prescribing errors
Process Error Rate Serious Errors
Prescribing errors (Primary Care) Computer generated 7.9
Prescribing errors (Primary Care) Hand written 10.2
Prescribing errors (Hospital) 1.5 0.4
Dean B, Schachter M, Vincent C, Barber N.
Quality and Safety in Healthcare 2002
11340-344 Shah SNH, Aslam M and Avery AJ. Pharm
J. 2002 267 860-862
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Handwriting
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Errors in medication history taking

• Literature review
• 22 studies, 3755 patients
• Errors in medication histories
• In up to 67 of cases
• 10-61 had at least 1 omission error
• 54 of patients had at least 1 medication history
  error
• Clinically important errors in 11-59

Tam et at Canadian Medical Association Journal
2005173(5)510-15
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Dispensing and adminn errors
Stage of process Error Rate Serious Errors
Dispensing errors (P) 1 0.18
Dispensing errors Undetected (H) 0.0002
Administration Oral Medicines (H) 3 8
Preparation and admin of parenteral medicines 13- 49 1
UK references 1 12 from Building a safer NHS,
Medication Safety
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Similar packaging

• Same drug different manufacturers

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Similar packaging

• Same drug several strengths
• May be colour-coded but DO NOT rely on colour

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Similar packaging

• Similar sounding names / similar spelling / same
  strength
• Ceftazidime Cefotxime

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Similar packaging

• If in a hurry These look similar
• Water for injection, Sodium Chloride injection
• So does Potassium 15 injection Why there are
  NPSA/Trust policy on restricting this

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SummaryCommon error types

• Wrong patient
• Contra-indicated medicine
• Allergy, medical condition, drug-drug interaction
• Wrong drug / ingredient
• Wrong dose / frequency
• Wrong formulation
• Wrong route of administration
• Wrong quantity

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• Poor handwriting on Rx
• Incorrect IV administration calculations or pump
  rates
• Poor record keeping/checking
• double doses
• wrong patient
• Paediatric doses
• Poor administration technique

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• Complicated prescriptions
• Calculations
• Verbal orders
• Lack of knowledge about drugs
• Mistakes in identifying drugs
• names
• packaging
• misreading

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National local examples
Discharged on warfarin loading dose 10mg od Not referred for dose adjustment to clinic 14days of 10mg od INR 12.3 Admitted with frank haemorrhage
Weight-related dose for tinzaparin 80kg estd Patient was 51kg, risk of haemorrhage
Rx Ranitidine 50mg Given via epidural line rather than central line
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Discharged on warfarin loading dose 10mg od Not referred for dose adjustment to clinic 14days of 10mg od INR 12.3 Admitted with frank haemorrhage
Weight-related dose for tinzaparin 80kg estd Patient was 51kg, risk of haemorrhage
Rx Ranitidine 50mg Given via epidural line rather than central line
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CABG patient, standard therapy Thyroxine missed on admission, discovered day 10
Galantamine re-started after a gap, Rx 8ml qds Should have been 12mg (2ml) bd prescriber confused over liquid strength
Rx Co-amoxiclav Penicillin-alllergic Did not realise this is a penicillin anaphylaxis
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Anaesthetist adjusted rate of fentanyl syringe pump in Theatre New pump. Increased rate x 1000 Respiratory arrest - death
Rx morphine 0.4ml 4ml given
30 sodium chloride used instead of 0.9 to dilute an epidural Severe pain
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In Theatre Sodium chloride flush for a central line switched with fentanyl Respiratory arrest. Syringes made up in advance and not labelled
IV line flushed with sodium chloride 0.9 Was in fact Potassium 15 ? death Ampoules look similar in design
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Case study 1 "Cambridge"

• Rx Methotrexate 17.5mg once a week
• New Rx 10mg once a day
• 10mg daily dispensed by locum pharmacist
• Rx error noticed by 2nd GP, but the computer
  record was not altered
• 5/7 patient admitted to ENT ward

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• Drug chart written for 100mg daily
• 1/7 Nurse d/w patient back to 10mg od
• 1/7 Pharmacist queries and asks nurse to ask Dr
  to check dose
• GP records confirm 10mg od
• 2/7 blood tests re-checked Haem
• 5/7 patient dies

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Case study 2 Nottingham

• Rx Intrathecal methotrexate under GA in theatre
  by Oncology Reg intravenous vincristine on ward
  by specialist nurse
• "Outlied" on non-specialist ward
• Both drugs delivered to theatre from ward
• Given food pre-op op postponed

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• Orignal SpR off-duty now
• Cover SpR unable to leave ward, anaesthetist to
  admin intrathecal drug
• Anaesthetist had given I/Thecal drugs before but
  had never given chemotherapy
• Methotrexate given intravenously
• Vincristine given intrathecally
• Patient died

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Improving medication safety
Department of Health. Jan 2004
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Improving medication safetyMain areas of
medication error

• Anaesthetic practice
• Anticoagulants
• Cytotoxic drugs
• Intravenous infusions
• Methotrexate
• Opiate analgesics
• Potassium chloride

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Causes ? Solutions

• Lack of knowledge of the drug 31
• Wrong dose, choice, drug.
• Interaction
• Allergy checking
• rule violations 10
• Incl. communication problems
• Slip or memory loss 9

• Drug information
• Eg Interactions
• Resources available
• Patient condition
• Renal / liver function
• Guidelines, formulary

Leape et al. JAMA 199527435-43
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Avoiding errors

• Patient knowledge
• Have a therapeutic goal
• Is prescribing the right answer?
• Have you included the patient in this decision?
• Knowledge about the drug
• Monitor for effects and adverse effects
• Use your resources
• Good communication

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Taking a good medication history

• How reliable is your source does it have enough
  detail?
• Patient, patients repeat prescription, own
  drugs, GP admission letter, on-call service
• Drug details
• dose, frequency, formulation (eg modified
  release), start date, indication
• Include Prescribed drugs, OTC drugs,
  complementary medicines, vitamins,
• ? Recreational drugs
• Allergies including severity
• Compliance
• Therapeutic failures

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Factors affecting a drugs pharmacodynamics or
pharmacokinetics

• Children
• The elderly
• Renal impairment
• Hepatic impairment
• Prescribing in pregnancy or breast feeding
• Drug interactions
• More later..

Further references Clinical Pharmacology
textbook use course recommendation Basic
Clinical Pharmacokinetics. 4th edn. ME Winter.
Covers Drug-specific kinetics eg Digoxin,
gentamicin
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Drug dosing in renal impairment

• Based on estimation of renal function using
  creatinine clearance
• Cockcroft-Gault equation
• Crcl F x (140-age)x wt in kg
• S.Cr in micromol/L
• Where F 1.23 for males, 1.04 for females
• Or use an on-line calculator such as
• http//www.kidney.org/professionals/kdoqi/gfr_calc
  ulator.cfm

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Drug-drug interactionsdrug-food interactions

• Resources
• BNF Appendix 1
• Pharmacy Medicines Information Departments
• Have specialists texts and other resources to
  help

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Resources available to you

• Summary of Product Characteristics for each
  medicine - eMC
• Pharmacy Medicines Information
• On-line
• National
• Electronic prescribing
• Other medical and non-medical prescribers

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Pharmacy

• Avaliable for help and advice
• Ward Pharmacist
• Local Medicines Information department
• Regional medicines Information
• Mainly Community sector enquiries
• Out-of-hours On-call or resident pharmacist

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Electronic Medicines Compendium (eMC)

• The eMC provides up-to-date information on
  licensed UK medicines http//emc.medicines.org.uk/
  
• Summary of Product Characteristics (SPCs)
• Patient Information Leaflets (PILs).
• SPCs are legal technical documents with
  information to help guide on the best way to use
  a medicine.

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In summary
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Prescribing responsibilities

• Drug
• Dose
• Route
• Rate of administration
• Duration of treatment
• Checking patient allergies sensitivities

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• Providing a prescription that is
• Legible
• Legal
• Signed
• Giving all information to allow safe
  administration

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Hints

• Care with units
• Legal
• Is it weight/BSA-related dosing. Is weight
  accurate?

• Clear and unambiguous
• Approved name
• No abbreviations
• Care with IVs

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• Clear decimal points
• 0.5ml not .5ml
• Rewrite charts regularly
• Take time, eg to read labels

• Avoid abbreviations
• od / bd / tds / qds
• Not 250mg3

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• Take particular care if
• Impaired renal function
• Hepatic dysfunction
• Children
• The elderly
• Drug is unknown to you
• Very new drug ?

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Remember the Five Rights

• the right patient
• the right drug
• the right time
• the right dose
• the right route

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If in doubt ..

• Ask

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Further reading resources

• Naylor, R. Medication Errors. Radcliffe Press.
  ISBN 1857759567
• Department of Health. (2004). Building a safer
  NHS. Improving medication safety.
• http//www.dh.gov.uk/PublicationsAndStatistics/Pub
  lications/PublicationsPolicyAndGuidance/Publicatio
  nsPolicyAndGuidanceArticle/fs/en?CONTENT_ID407144
  3chkPH2sST
• National Patient Safety Agency
• Website http//www.npsa.nhs.uk/

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• National Prescribing Centre
• Website http//www.npc.co.uk/
• Institute for Safe Medication Practices (ISMP)
  (American)
• Website http//www.ismp.org/
• National Electronic Library for Medicines
• Websitehttp//www.druginfozone.nhs.uk/home/defaul
  t.aspx
• Aronson Richards. Oxford Handbook of Practical
  Drug Therapy. ISBN 0198530072