Prescribing in Critical Care: Training package and audit tool

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Prescribing in Critical CareTraining package
and audit tool

• S. Laha, E. Boxall, A.Day, D. Grundy, R.Taylor,
  A. N. Thomas

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Aims of Training Programme

• To improve the quality of prescribing by trainee
  medical staff for critically ill patients.
• To develop skills and attitudes that will
  encourage trainees to find out about the drugs
  they are prescribing.
• To demonstrate a clear link between formal
  educated activity and service delivery.
• To set clear standards with respect to acceptable
  prescribing.
• To provide feedback to individual trainees about
  the quality of their prescribing so they can
  identify strengths and weaknesses to allow them
  to improve their prescribing.
• To allow trainees to engage in the audit process.
• To demonstrate that drugs given to critically ill
  patients are inherently dangerous and associated
  with adverse events.
• Allow units to compare rates of prescribing
  error.

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Stages in the programme

• Preparation.
• An introductory seminar
• Structured training on ward rounds and service
  based learning.
• Audit and feedback to trainees about their
  individual prescribing habits.

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The Challenges

• Critically ill patients receive many highly
  dangerous drugs when they have very little
  physiological reserve.
• Trainees
• may not have a clear understanding of the side
  effects and interactions of these drugs.
• Many come from an anaesthetic background where
  they do not normally prescribe drugs that they do
  not administer themselves.
• Adverse drug events are the single largest cause
  of critical incidents in critical care 2,
• they damage patients
• an economic burden on health care systems.
• Hopefully the introduction of electronic
  prescribing should remove a large number of these
  errors, however this may take a number of years
• Improvements to prescribing can be made now.

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National Evidence

• Prescription errors in UK critical care units
  Ridley SA, Booth SA, Thompson and the ICS Working
  Group on Adverse Incidents. Anaesthesia 2004 59
  1193-1200
• 24 critical care units for 4 weeks.
• 3141 (15) prescriptions had one or more errors
  (2.2 erroneous prescriptions per patient)
• 10.2 Potassium chloride errors
• 5.3 Heparin errors
• 5.2 Magnesium sulphate errors
• 3.2 Paracetamol errors
• 19.6 errors were significant, serious or
  potentially life-threatening
• 47.9 due to
• Not writing the order according to BNF
  recommendations
• Ambiguous medication order
• Non-standard nomenclature
• Writing illegibly

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Local Evidence

• Greater Manchester Critical Care Network
• Clinical Audit of Prescription Error in Critical
  Care Jan 2004
• 10 hospitals (96 beds) for 4 weeks (394
  admissions)
• 1033 errors reported (overall error rate of 10)
• 9 Potassium chloride errors
• 13 Enteral nutrition and/or IV fluid errors
• BNF classification of main errors were
• Antibiotics
• Fluids and electrolytes
• Analgesics
• Anticoagulants
• 7 of errors classified as serious /
  life-threatening
• 6 of errors had adverse consequences
• 4 events needed clinical intervention
• 3 events needed major cardiac or respiratory
  support

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Improving the environment for prescribing

• Before implementing this training programme
  senior staff should review
• Do the prescription charts support good
  prescribing?
• Are sources of information about drugs and
  prescribing freely available to the prescribers
  where they need them, i.e. at the time they are
  writing the prescriptions?
• Is the unit supported by a pharmacist as set out
  in published guidance 3 and if this is not the
  case is this deficiency clearly iterated in the
  unit risk register?
• Who has prescribing rights on the unit, do
  visiting medical staff frequently prescribe drugs
  and does this pose a risk to patients?
• Does the unit manage critical adverse incidents
  as set out in intensive care society guidance
  4?
• Do the nursing staff have a clear view of what
  level of prescribing is unacceptable and will
  result in a drug not being administered and a
  critical incident reported?

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Improving skills and attitudes of prescribing

• This is the basis of the training package, which
  is based on two important assumptions
• Learning should be incorporated into normal
  clinical activity 5.
• Feedback forms an essential aspect of learning
  6 7 8.

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Timing of the Training package

• Can be run at any time in the trainees ICU
  training.
• If right at the start other learning needs may
  not allow trainees and consultant staff to focus
  on the issues raised.
• If left beyond the first month of a 3-month
  attachment
• patients will not benefit from the investment in
  training
• trainees will have less opportunity to find out
  about the drugs they are using.

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Before the package starts

• Consultant staff on the ICU for the week after
  the tutorial need to be briefed on their
  responsibilities for teaching ideally as part of
  the ward rounds.
• One consultant or senior trainee should be
  identified as being responsible for the teaching
  package Or a senior trainee.
• one or preferably two more junior trainees who
  would conduct the audit.
• If there is a unit pharmacist then they should be
  fully conversant with the project and participate
  during the teaching week and audit.
• The references in this training package should be
  available to the trainees prior to the package
  starting.
• If possible one or two trainees should review
  references accompanying the package and also
  review other references about safe prescribing
  and adverse drug events in critical care and
  present a 10-15 minutes review of this at the
  start of the tutorial.

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The Standards

• The standards for prescribing should be made
  fully available to all unit medical, nursing and
  pharmacy staff.
• Senior staff should discuss these standards prior
  to the start of the study. If your unit does not
  agree with the standards published in the
  training package then change them. It is better
  to work to standards you agree with than imposed
  standards you disagree with.
• It would also be useful, with the nursing staff,
  to have some agreed minimum standards below which
  drugs will not be given.

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The audits and timetable

• Week 0
• Audit
• End of week hold tutorial
• Week 1
• Teaching ward round for one week
• Week 2
• Re-audit
• Week 6-8
• Re-audit
• Week 10
• Feedback

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The Tutorial

• Slides and lecture notes for the tutorial are
  enclosed with the training package.
• In a small unit with different trainees starting
  at different times there may only be one trainee
  who would require this tutorial. There may be no
  one available to give the tutorial and for this
  reason a full commentary is given with one of the
  versions of the tutorial found in this teaching
  package.
• If there were a number of trainees starting at
  the same time then a properly run tutorial with
  interactive discussion would be preferable.

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Ward Round

• Detailed explanatory note in package which should
  be modified to be more specific for your unit.
• The last days ward round also requires a review
  of potential drug interactions.
• A database is provided to store these so the
  information can be compared over a period of time
  or compared between different units
• (The programme would work perfectly well without
  this and a review of these adverse drug events
  could also be conducted as a separate audit)

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Feedback

• Feedback forms are provided for both trainees and
  consultants. Can you ask the consultants to
  complete these forms if they have taken part in
  the ward round teaching. Can you ask the trainees
  to complete the forms after the audit.
• You can use these forms for local use, we would
  also like copies of the forms to improve the
  course, (Send to AN Thomas, ICU, Hope Hospital,
  Salford M6 8HD).

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References

• Ridley, S. A., S. A. Booth, et al. (2004).
  Prescription errors in UK critical care
  units.Anaesthesia 59(12) 1193-1200.
• Rothschild, JM Landrigan, CP Cronin, JW et al.
  The Critical Care Safety Study The incidence and
  nature of adverse events and serious medical
  errors in intensive care Crit Care Med, 33 (8)
  1694-1700 AUG 2005
• Kane, SL Weber, RJ Dasta, JF. The impact of
  critical care pharmacists on enhancing patient
  outcomes. Int Care Med, 29 (5) 691-698 May 2003
• NHS modernisation agency Critical care program.
  The role of health care professions within
  critical care services June 2002.
•  Building a safer NHS for patients. Improving
  safe medication practice. UK Department of
  health. London 2004.
•  Intensive Care Society guidelines on critical
  incident reporting 2006. ICS website.
•  On the job training for physicians. Hargreaves
  DH, Southworth GW et al. Royal Society of
  Medicine press. 1997 ISBN 1-85315-325-7.
• Dean, B. (2002). Learning from prescribing
  errors. Quality Safety In Health Care 11(3)
  258-260.
•  Ende, J., Feedback in Clinical
  Medical-Education. JAMA 1983 250(6) 777-781.
•  Barber, N., M. Rawlins, and B. Dean Franklin,
  Reducing prescribing error competence, control,
  and culture. Quality Safety in Health Care 2003
  12, Suppl 1, i29 32,

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Acknowledgements

• Greater Manchester Critical Care Network