How not to poison your patient

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How not to poison your patient

• Foundation year 1 PDP

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Aims of this study module

• To encourage you to examine your own prescribing
  practice
• To understand the components of a safe
  prescription
• To understand the process of effective treatment
  
• To consider ways in which you can keep up to
  date with drug information

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National Patient Safety Agency

• 41,000 medication related errors /year UK
• 1200/year LTHT / 3 per day
• Minor to serious harm
• Patient deaths

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Avoiding Prescribing Errors

• Of MDU claims settled in last six years - 25
  (196/790) - were errors in prescribing,
  monitoring or administering of medicines
• 25 patients died, and 2 stillbirths occurred, as
  a result of the errors
• The total indemnity paid by the MDU for these
  cases was 3.5m
• All of these errors were probably avoidable

Green et al 1996, Medication Errors
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Common Errors

• In a survey of prescribing errors the six
  commonest errors were
• Incorrect dosage - diamorphine 30mg instead of
  10mg/ incorrect calculation
• Prescription of a contra-indicated medication -
  beta blocker to an asthmatic
• Administration route error - intra-arterial
  instead of intra-venous

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Common Errors

• Prescribing or dispensing error - digoxin
  prescribed instead of thyroxine
• Prescribing to patient with a known allergy
  Augmentin/Tazosin in penicillin allergy
• Wrong drug use - phenol injected instead of
  lignocaine

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Laying the Foundations for Good Medical Practice
Avoiding Prescribing Errors Improving patient
safety
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Components of a safe prescription

• 1. Date, Ward/Site, Consultant
• Patient first and family name. DOB and hospital
  number
• If patient is 18 years old or less, include age
  and weight
• Allergy status
• Name of the drug in full , BNF approved name, in
  capital letters
• Dose of the drug - use g, mg, mL,
  microgram and nanogram- avoid decimal point
  -write 100 micrograms not 0.1 mg, units
• Route of administration - approved abbreviations
  only
• Frequency of administration timing, min and max
  dose
• 9. Signature

USE BLACK INK
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Avoiding Prescribing Errors
The prescription should be a PRECISE, ACCURATE,
CLEAR and READABLE set of instructions
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Short Quizplease prescribe the following

• Humulin M3 insulin
• Co-codamol
• Beclometasone inhaler
• Warfarin
• Atenolol
• Methotrexate 10mg
• Morphine PRN
• Paracetamol PRN

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? Use in an asthmatic ?
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Starting dose Fennerty nomogram10mg, (5mg in
elderly)
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Make sure you cross off all the days when it is
not to be given
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Not in patient already on co-codamol 8 / 500
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The Process of Effective Treatment
Attempt to outline the steps involved in
effective treatment..
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Information you should give

• Effects of the drug
• Why the drug is needed
• Which symptoms will disappear, and which will
  not
• When the effect is expected to start
• What will happen if the drug is taken
  incorrectly or not at all
• Side effects
• Which side effects may occur
• How long they will continue
• How serious they are, and what action to take

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Information you should give

• 3. Instructions
• How the drug should be taken
• When it should be taken
• How long the treatment should continue
• How the drug should be stored
• 4. Warnings
• When the drug should not be taken
• What is the maximum dose
• Why the full treatment course should be taken

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Information you should give
5 Future consultations When to come back (or
not) In what circumstances to come earlier What
information the doctor will need at the next
appointment 6. Everything clear? Ask the
patient whether everything is understood Ask
the patient to repeat the most important
information Ask whether the patient has any
more questions
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High Risk Drugs
80 of errors resulting in patient harm or death
involve Opiates/analgesics Anticoagulants esp
warfarin Insulin Potassium Methotrexate Chemot
herapy
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Poor Prescriptions

• Examples

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Keeping up to date

• What sources of drug information are available?
• The BNF
• Pharmacists
• Local drug formularies and guidelines
• Local drug information services
• On-line information - e.g. weBNF
• Trust web based information
• LTHT http//lthweb/clinres/dtcweb/
• e.g. IV infusion monographs
• MIMS/Drug bulletins (weekly or monthly)
• e.g. Drug and Therapeutics Bulletin

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Online Drug Information
Reliable on-line sources include weBNF at
http//bnf.org/ Medicines information at
http//medicines.org.uk WHO Guide to Good
Prescribing at http//www.med.rug.nl/pharma/ggp.h
tm Electronic Medicines Compendium at
http//emc.vhn.net/
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Online Drug Information

• OMNI at http//omni.ac.uk/
• eBMJ at http//www.bmj.com/
• Cochrane database at http//www.cochrane.org/
• National Electronic Library for Health at
  ttp//www.nelh.nhs.uk/
• Medical Matrix at http//www.medmatrix.org/_SPages
  /Pharmacy.asp

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Doctors are legally obliged to write clearly, as
emphasized in the UK Court of Appeal ruling in
the following case. A doctor had written a
prescription for Amoxil tablets (amoxicillin).
The pharmacist misread this and dispensed Daonil
(glibenclamide) instead. The patient was not a
diabetic and suffered permanent brain damage as a
result of taking the drug. The court indicated
that a 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. The court concluded that the
word Amoxil on the prescription could have been
read as Daonil. It found that the doctor had been
in breach of his duty to write clearly and had
been negligent. The court concluded that the
doctor's negligence had contributed to the
negligence of the pharmacist, although the
greater proportion of the responsibility (75)
lay with the pharmacist. On appeal the doctor
argued that the word on the prescription standing
on its own could reasonably have been read
incorrectly but that various other aspects of the
prescription should have alerted the pharmacist.
The strength prescribed was appropriate for
Amoxil but not for Daonil the prescription was
for Amoxil to be taken three times a day while
Daonil was usually taken once a day the
prescription was for only seven days' treatment,
which was unlikely for Daonil and finally, all
prescriptions of drugs for diabetes were free
under the National Health Service but the patient
did not claim free treatment for the drug. All of
these factors should have raised doubts in the
mind of the pharmacist and as a result he should
have contacted the doctor. Therefore, the chain
of causation from the doctor's bad handwriting to
the eventual injury was broken. This argument
was rejected in the Court of Appeal. The
implications of this ruling are that doctors are
under a legal duty of care to write clearly, that
is with sufficient legibility to allow for
mistakes by others. When illegible handwriting
results in a breach of that duty, causing
personal injury, then the courts will be prepared
to punish the careless by awarding sufficient
damages. Liability does not end when the
prescription leaves the doctor's consulting room.
It may also be a cause of the negligence of
others.
Doctors Responsibility
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NPSA 2007 alerts

• 1. Making anticoagulant therapy safer -
  http//www.npsa.nhs.uk/display?contentId5754
• 2. Promoting safer measurement and administration
  of liquid medicines via oral and other enteral
  routes - http//www.npsa.nhs.uk/display?contentId
  5761
• 3. Promoting safer use of injectable medicines -
  http//www.npsa.nhs.uk/display?contentId5755
• 4.Safer practice with epidural injections and
  infusions - http//www.npsa.nhs.uk/display?content
  Id5760
• 5. Reducing risk of Hyponatraemia when
  administering intravenous infusions to children -
  http//www.npsa.nhs.uk/display?contentId5756

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Antimicrobials and Reducing HAI/morbidity

• Good antimicrobial practice
• Follow local guidance
• Consult microbiology
• Review dates and stop dates
• Document clinical indication
• Be aware of Restricted antibiotics
• IV oral switch
• In severe sepsis give Abs early

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Responsibility Rests With You

• Keep the patient and yourself safe