Central Medication error Registration

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• Central Medication error Registration
• Dutch central registration system for medication
  related errors
• Barcelona
• 20 april 2007
• Brigit van Soest, Pharmacist, project Medication
  Safety

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Content

• Description of CMR
• Why a central medication error registration
  system?
• CMR today
• Results of the CMR
• Conclusions

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Description of CMR

• National central web based registration system
  for medication related errors in hospitals.

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Description of CMR

• Initiative of the Dutch Association of Hospital
  Pharmacists (NVZA) and the Dutch Association of
  Hospitals (NVZ)
• Built by the NVZA in July 2004

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Description of CMR

• Hospital pharmacists enter the medication related
  errors of their hospital into the system
• Uniform classification of medication related
  errors based on type, cause and harm

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Fill-in form on www.cmr-nvza.nl
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Medication safety NVZA
Toolkit Risk-analysis
Process Patient Pill
Risk-analysis
Analysis error reports

• Retrospective Risk reduction
• - CMR
• - Root Cause Analysis
• Prisma methododology

• Prospective Risk reduction
• Checklist Medication safety NVZA
• Prevention ADEs
• FMEA
• Bow-Tie

Critical steps in drug distribution chain
Interventions
Less error
Risk reduction
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Why the CMR?

• FINISHED FILES ARE THE RESULT OF YEARS OF
  SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF
  YEARS

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Why the CMR?
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Why the CMR?

• To support hospitals in reducing risks in the
  process of
• prescription/transfer/dispensing/preparation/
  administration
• of medication

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• By collecting data on medication errors and
  classifying them in a uniform way by type, cause
  and harm allows
• Better insight in risk factors
• The development of a national policy on
  medication safety

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Activities of the CMR

• Warn all hospital pharmacists about alarming
  medication errors
• Give feedback information in the form of
  Benchmarks
• Give feedback information in the form of
  Newsletters
• the event of the month
• a risk process/ drug/ patient highlighted.

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CMR Today

• 49 participating hospitals (38 hospital
  pharmacies (almost 50))
• 3000 reports received
• 7 alert reports
• Amount of reports grows exponential

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Alarming medication error

• Evaluated by the Working Group Medication safety
  NVZA on the following criteria
• Seriousness of (potential) harm of the incident
• Chance of repeating of the incident
• News value of the incident

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Review of the alert reports

• Fatal metformine-intoxication after the use of
  jodium-containing X-ray contrast media (2004)
• Medical air instead of oxygen administered (2005)
• Durogesic 75 instead of Durogesic 12 plaster
  administered (2005)

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Review of the alert reports

• Risperdal mixture 25mg instead of 0,25mg
  administered (2006)
• Addiphos concentrate for infusion fluid
  undiluted administered (2006)
• Methotrexate tablets 3x2,5mg daily in stead of
  weekly administered (2x) with fatal end (2006).

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Main error categories in accordance with NVZA
classification (risk processes) n2866
Prescription
Preparing for administration
Administration
Copy/Transfer/Logistic
reports
Distribution/Dispensing
Between hospital and primary care
Main error categories (risk processes)
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Main error categories in accordance with NVZA
classification (risk processes) n2866
Administration
reports
Main error categories (risk processes)
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Critical administration steps (42)

• Drug administered that was not prescribed 30
• Wrong dosage 29
• Prescribed drug not administered (omission) 21
• Incorrect administration mode 9

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Main error categories in accordance with NVZA
classification (risk processes) n2866
Prescription
of reports
Main error categories (risk processes)
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Critical Prescription steps (24)

• Strength 29
• Dose frequency 14
• Patient data 10

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In entire process Sound/Read en Look alikes

• Examples of sound/ read alikes
• azathioprine and azithromycine (distribution
  error)
• dobutamine and dopamine (administration error)
• Indapamide and imipramine (copy error)
• levofloxacine and levothyroxine (dispensing
  error)
• levofloxacine and levothyroxine (dispensing
  error)

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In entire process Omissions

• 17 of alle reports (500 reports) concern
  omissions divided into
• Prescribed drug not administered (Administration
  error) 53
• Medication order not processed in medication
  list/ medication survey (Copy/Transfer/Logistic
  error) 30
• Prescribed drug not distributed/ dispensed
  (Distribution/ Dispensing error) 9
• Incomplete therapy (Prescription error) 4,5
• Patients home medication unintentionally
  discontinued (Between hospital and primary care
  error) 3,5

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Causes of errors
of reports
63 forget/ be mistaken
Equipment/software
Internal organisation
Human handling
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Error consequences
Error has reached (bed of) patient No damage
Error has not reached patient
of reports
Error has reached patient monitoring
Error has reached patient damage
Error has reached patient patient has died (n7)
0,24
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Suggested measures to prevent error

• Skills training 23
• Implement procedures 19
• Improve communication 17
• Adapt procedures 12

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Summary/ Conclusions

• Central Medication error Registration system of
  the Dutch Association of Hospital Pharmacists
  (NVZA)
• 3000 reports received
• 7 alerts reports
• Administration most critical proces (especially
  wrong drip rate).
• Errors are often obvious the point is awareness!
• Eye openers
• Amount of patient exchanges!!
• Amount of sound/read alikes!!

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Summary/ Conclusions

• CMR as tool to get better insight in risk factors
• CMR as tool to become aware of the obvious risk
  factors
• CMR as tool to take specific measures on
  medication safety
• CMR as tool to develop national policy on
  medication safety