Medication Errorsthe tip of the Iceberg

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Medication Errors-the tip of the Iceberg?

• David Williams
• Department of Clinical Pharmacology

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Medication Error

• Any preventable event that can cause or lead to
  inappropriate medication use or patient harm
  while the medication is in the control of the
  healthcare professional, patient or consumer

National Co-ordinating Centre for Medication
error reporting and prevention
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Reports on Medication Errors

• Institute of Medicine- To err is HumanBuilding
  a safer Health System
• Chief Medical Officer- The NHS-An Organisation
  with a memory
• Audit commission- A Spoonful of Sugar Medicines
  management in NHS Hospital.

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Learning to improve patient safety

• Patient Safety Incident any unintended or
  unexpected event that led to death, disability,
  injury, disease or suffering for one or more
  patients
• Near Miss Any situation that could have
  resulted in an accident, injury or illness for a
  patient, but did not due to chance or timely
  intervention by another

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Learning to improve patient safety-key facts

• Following analysis of 256 (96) of NHS trusts,
  there were 974,000 reported incidences and near
  misses( extra 300,000 if Hospital acquired
  infections were included).
• The most common incidents reported were patient
  injury (due to falls), followed by medication
  errors, equipment related incidents, record
  documentation error and communication failure.
• Patient safety incidents cost the NHS an
  estimated 2 billion a year in extra bed days, in
  addition hospital acquired infections add a
  further 1 billion to these costs.
• Cost of settled clinical negligence claims in
  2003-4 was 423 milion with provisions for
  outstanding clinical negligence claims as at
  2003-4 in excess of 2 billion.

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Learning to improve patient safety-key facts

• A retrospective study of patient records in 2
  English hospitals found 10.8 of patients
  experienced an adverse incident of which
  approximately half (5.2) were judged to be
  preventable.
• Of 169 able to provide data on the number of
  deaths as a result of patient safety incidents in
  2004-5, there were 2,181 deaths recorded although
  it is acknowledged that there is significant
  under-reporting of deaths and seroius incidents.
• International review of 9 retrospective studies
  of patient records found that the average
  incidence of adverse events was 8.9 (range
  3.8-16.6)

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Reducing errors in medicine

• Ladies and gentlemen, welcome aboard Sterling
  Airlines Flight number 743, bound for Edinburgh.
  This is your captain speaking. Our flight time
  will be two hours, and I am pleased to report
  that you have a 97 chance of reaching your
  destination without being significantly injured
  during the flight and that our chances of making
  a serious error during the flight, whether you
  are injured or not, is only 6.7. Please fasten
  your seatbelts, and enjoy the flight. The weather
  in Edinburgh is Sunny
• 
  Donald Berwick(BMJ 1999)

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Who would Fly?
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Medication errors

• Serious or potentially serious medication errors
  occur in the care of 6.7 out of every 100
  hospitalised American patients.
• 140,000-180,000 Americans die annually from
  preventable errors in hospital (?combined deaths
  and injuries from motor/air crashes, suicides,
  falls, poisonings and drownings).
• Adverse events occur in 11 of UK admissions .
• Medication errors account for around a quarter of
  incidents which threaten patient safety.
• Department of Health aims to reduce medication
  errors by 40 by 2005.

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Incidences of Medication Errors

• Vary between 2-14 among patients admitted to
  hospital with between 1-2 of patients in the US
  being harmed as a result of medication errors the
  majority of which are due to poor prescribing.
• Medication error has been estimated to kill 7,000
  patients per annum and accounts for nearly 1 in
  20 hospital admissions in the US. The incidence
  is likely to be similar in the United Kingdom1

1Barber N, Rawlins M, Franklin B. Reducing
Prescribing Error Competence, Control, and
Culture. Qual Saf Health Care 20031229-32.
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Trends in Deaths from medication errors and from
Related Causes
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Cost of Medication Errors

• Cost of medical errors was estimated to be almost
  4700 per preventable adverse drug event.
• Adverse events cost approximately 0.5 billion a
  year in additional hospital stays alone/7-8.5
  additional bed stays.
• NHS pays out 400 million in clinical negligence
  claims per annum.
• Cost of drug related morbidity and mortality has
  been estimated at 77 billion a year in US(?total
  cost of cardiovascular/diabetic care in 1995)

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Number of deaths in England and Wales from
medication errors and the adverse effects of
medicines, 1990 to 2000
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Factors inhibiting reporting

• Uncertainty of definition
• Complexity of reporting system
• Fear of ridicule from colleagues
• Fear of punishment
• Fear of litigation

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Reporting of medication errors at ARI
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Causes of medication incidents
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Relationship between ADEs and Medication Errors
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Classification of Medication Errors
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Psychological Approach
Taken from Ferner RE,.Aronson J. Clarification of
Terminology in Medication Errors. Definitions and
Classification. Drug.Saf 2006291011-22
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Error Classification

• Knowledge-based errors- giving a medication ,
  without having established whether the patient is
  allergic to that medication
• Rule based - injecting a medication into the
  non-preferred site or using excessive doses of a
  drug).
• Slips - writing the more familiar
  chlorpropramide instead of chlorpromazine
• Lapse -giving a drug that a patient is already
  allergic to
• Technical errors are the result of a failure of
  a particular skill( e.g in the insertion of a
  cannula) and are therefore a subset of slips .

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Classification according to where in the
medication use cycle

• Prescribing
• Dispensing
• Drug administration

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Prescribing errors(56)
Administration errors (36)
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Medication errors
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Prescribing errors
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Death Followed Wrong Insulin Dose
A woman died after poor handwriting on her
hospital records led to her being given 10 times
too much insulin, a fatal accident inquiry has
found.
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Legibility

• Prendergast vs Sam Dee Ltd.
• The doctor owed a duty of care to a patient to
  write a prescription clearly and with sufficient
  legibility to allow for possible mistakes by a
  busy pharmacist who might be distracted.

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Prescribing errors
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Administration Error
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Patients at risk of adverse events
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Person Approach
System Approach
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Closer to Home-Systems that work!

• 1975-13 divers die in North Sea
• Total North sea figures have reduced 10 fold
  comparing 70s to 90s
• 2002-No diver has died in Norwegian sector for
  ten years

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Prescription Sheet
Allergy to penicillin
Check Medical Notes
Poor training of personnel
Transcription
Drug Labelling System
Patient Information System
Drug Info System
Other systems
Medical Records System

The latent failure model of complex system
failuremodified from James Reason, 1991
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Rational prescribing

• A rational prescription can be defined as the
  issuing of an appropriate drug, at an appropriate
  dose, for an appropriate period, for a specified
  therapeutic aim.

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Analytic approach to prescribing decisions
Expectations about treatment outcomes
Drug choice
E.g-efficacy -side-effects -compliance
-costs -personal experience -opinions
of colleagues -wishes of patient
Values assigned to these outcomes
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Pressures to prescribe medication

• Several studies have identified a mismatch
  between doctors and patients expectations for a
  prescription.
• Various signals from patients are interpreted by
  doctors as a desire for medication.
• Time pressure to end a consultation may lead to a
  prescription.
• Pressure to avoid difficult or uncomfortable
  dealings with a patient may also lead to a
  prescription rather than a fraught consultation.
• Precedents set by other doctors.

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Influences on prescriber practice
Patient
Pharmaceutical industry
Prescriber (knowledge values attitudes
experiences habits)
Academia
Colleagues
Cost
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Percentage of GPs rating each information source
as important for information on new drugs and
percentage who actually used each information
source for the last new drug prescribed
McGettigan and Feely
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Name of preparation

• Carbimazole/Carbamazepine
• Daonil/Danol/De-Nol
• Chlorpromazine/Chlorpropamide
• Thyroxine/Thymoxamine
• Losec/Lasix
• prescribe generically except when there are
  differences in bioavailability between
  preparations.

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Directions for use/dose

• Directions for use should be clear and
  unambiguous.
• Avoid MDU/as directed.
• Avoid PRN/as required doses unless guidance on
  dosage is given.
• A leading zero should precede a decimal
  expression lt1 (e.g.0.5ml).
• Conversly, a terminal zero should never be used,
  as failure to see the decimal point could result
  in a 10-fold overdose
• use units instead of u(often mistaken for 0)

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Avoid abbreviations

• HCT 250mg
• / (6 units soluble insulin/20 units isophane
  insulin)
• Chemical symbols (Na warfarin).
• ?g/mg
• AZTzidovudine/azathioprine
• CPMchlorpheniramine maleate/chlorpromazine.
• PBZphenylbutazone,phenoxybenzamine
• ISMN/ISTIN

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The Future
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Electronic prescribing

• Prescription errors often occur because the
  prescriber has no immediate access to relevent
  information relating to the drug or patient.
• Computerised systems containing rules to prevent
  incorrect or inappropriate prescribing increase
  the appropriateness of drug treatment and reduce
  errors.
• Improved information services could contribute to
  the prevention of 78 of errors leading to
  adverse drug events.
• PRODIGY-Decision-support system for GPs.

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Role of Automation in the medication process
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The Future

• Automated dispensing devices will be used by
  nurses to provide drugs to patients. All drugs,
  patients and staff will be bar-coded, making it
  possible to determine what drugs have been given
  to whom, by whom and when
• BMJ March 2000

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Medication errors
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Incorrect blood product Antidiabetic Medication
to non-diabetic Penicillin administration to
penicillin allergic patient
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