Medication Safety Practical Applications

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Medication Safety Practical Applications

• Marc Grimer
• Senior pharmacist
• John Hunter Hospital

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What is Medication Safety?

• The system of checks and balances that reduce the
  chance of an error in one part of the system
  resulting in patient harm
• Medications management is a complex process and
  errors are common.
• 95 of all errors are detected with
• each check the swiss cheese theory

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To err is human

• Where humans are involved, errors will always
  occur
• Errors are seldom caused by one single factor or
  one single individual.
• Contributing systems factors to human errors
• Poor drug labelling
• Poor warnings about drug allergies or
  incompatibilities
• Staffing,
• Environmental hazards
• Policies and procedures

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Admission medication history
Formulary
Prescribing protocols
Allergy check
Prospective review
Administration instructions
Clinical pharmacy
Individual patient- based drug distribution
J. Reason, 9/01
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Extreme examples

• A dose of vincristine was accidentally given via
  intrathecal route along with prescribed
  intrathecal chemistry. The child suffered
  paralysis and died several days later.
• A patient was prescribed a 10 mL flush of normal
  saline for his cannula. An ampoule of potassium
  chloride 20 mmol was accidentally selected
  instead of sodium chloride and administered over
  30 seconds. The patient had a cardiac arrest and
  could not be resuscitated.

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Audit Commission. A spoonful of sugar improving
medicines management in hospitals. London Audit
Commission, 2001www.audit-commission.gov.uk/public
ations/spoonfulsugar.shtml
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Medication errors

• Occur at all stages of process
• Prescribing
• Dispensing
• Administration (by patient, carer, nurse) - 5
  Rs
• right dosage,
• right medication,
• right time,
• right patient, and
• right route.
• Storage

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Safety and Quality in Australian Health Care study

• 1992 - 16 of all hospital admissions associated
  with adverse event
• Medication errors 10.8 of these
• Almost half of drug related adverse events were
  preventable
• 18,000 preventable deaths per year

Wilson RM, Runciman WB, Gibberd RW, et al. The
Quality in Australian Health Care Study. Med J
Aust 1995 163 458-471.
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Studies show significant potential for error at
these steps
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JHH Examples

• Need to empower patient
• Patient knows she takes 2 tablets
• 3x given (different colours).
• Pt took them and then said why the 3rd one? And
  what was it?
• Result - Penicillin allergy swollen
  mouth/throat and breathing difficulty

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JHH Examples

• Oxycontin / MS Contin
• Sinemet CR crushed for NG administration
• Gentamicin toxic level and next dose given as
  charted
• Warfarin not given (new medication chart)

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Recent IIMS reports

• Heparin and Clexane concurrently
• Ciprofloxacin charted 500mg tds but no
  administration time, given daily in error
• Pravastatin charted 40mg daily but no
  administration times, given bd in error
• Incorrect weight on adolescent chart leading to
  overdosing in mg/kg drugs not stated
• MRN label stuck on wrong chart in NICU

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Recent IIMS reports

• Atenolol, aspirin, clexane, escitalopram, digoxin
  missed off rechart due to multiple charts
• Potassium chloride, rate too fast leading to
  pain in cannula site ? accuracy
• Double dosing of weekly Aranesp since
  non-administration days not crossed out
• Lack of documentation of pts own medication
  leading to dangerous drug interaction
  Venlafaxine and newly initiated Tramadol

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Recent IIMS reports

• Duplication of medication due to use of both
  generic and brand name
• Stat order for Frusemide not noticed in CCF
  patient
• Eyedrops missed off recharts
• Charting Levodopa on wrong patients chart.
• Buprenorphine patch newly charted for pt who
  already had one on, due to a delay in charting
  and a perception that its a new order

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Dealing with errors

• Person approach tendency to blame individuals
  for errors
• Favoured by media
• System approach humans are fallible and
  errors occur. Blame free culture
• System defences are needed (barriers/safeguards)
• More effective than the person approach at
  preventing medication errors.
• Used with great success in aviation

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Strategies for prescribers

• Reduce reliance on memory.
• minimize the need reliance on memory and
  vigilance (prolonged attention).
• Busy prescriber with frequent interruptions
• Consider use of
• Checklists text pages?
• protocols
• computerized decision aids

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Strategies for prescribers

• Improve information access.
• displaying information where it is needed, when
  it is needed, and in a form that permits easy
  access by those who need it.
• Eg Ensuring that medication intolerances or
  allergies are documented on EVERY active chart
  not just the notes.

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Generic prescribing reducing risk of error
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Sound-alikes examples

• Pramin/Premarin
• Adalat/Aldomet
• Hycor/Hyoscine
• Prostin VR/Prostin F2 alpha
• Zocor/Zoton
• Oxynorm/Oxycontin
• Sotahexal/Metahexal
• Diclohexal/Diltahexal

• Coumadin / Coversyl
• Akamin/Accomin
• Lasix/Losec
• (40mg dose)
• Lamictal/Largactil
• Aratac/Aropax
• Amlodipine/Amiloride
• (5mg dose)
• Potassium chloride/sodium chloride

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Strategies - general

• Error-proof processes.
• Critical tasks should be structured so that
  errors cannot be made.
• Nasogastric feeds with tubing that cannot connect
  to IV catheter
• Potassium amps not being kept on wards
• ATM sequence

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Medication safety strategies

• Specific instructions
• Date of starting antibiotics
• Day of week to be given if once weekly dose
• Look out for UNITS! Common cause of error for
  insulin and heparin.
• If a dose is to be given in units, dose should
  be charted as
• 5000 units not 5000u

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Abbreviations

• Prescribing issue but relevant for dispensing and
  adminstration
• Use of abbreviations can be dangerous. Do not
  make up your own - they may be mis-interpreted by
  nursing or pharmacy staff.
• Eg AZT Azathioprine or Zidovudine
• EPO Erythropoetin or Evening Primrose Oil?
• List of approved abbreviations available from
  Pharmacy

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Decimal point errors

• Decimal point errors do occur and can be
  catastrophic
• Write all amounts lt1 with zero in front of the
  decimal point
• 0.5 not .5
• Do not use decimal points after a whole number
• 5 not 5.0
• Make sure your decimal points can be seen!

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Prescribing Potassium

• Guidelines available in wards
• Use ampoules as a last resort! (Ampoules removed
  from many wards)
• Always prescribe in millimoles
• Maximum concentration 40 mmol/L
• Maximum rate 10 mmol/hour

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Methadone/Buprenorphine

• Guidelines available from Drug and alcohol
  service
• If prescribing methadone
• Check whether patient is on methadone program
• Contact prescriber and clinic/pharmacy on
  admission and discharge

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Look-alike and Sound-alike

• Corporate packaging
• practice of using similar logos, pack designs and
  colours.
• Marketing strategy for pharmaceutical
  manufacturers
• As generic brands increase, manufacturers are
  increasingly using corporate packaging and naming
  to identify their products

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Organisations promoting medication safety

• Australian Council for Safety and Quality in
  Health Care
• http//www.safetyandquality.org
• Institute for Safe Medication Practices
• http//www.ismp.org
• National Medication Safety Breakthrough
  Collaborative
• National Prescribing Service
• http//www.nps.org.au

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Questions and Discussion?
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Root Cause Analysis

• Aims to find the Root Cause of an incident the
  most basic cause that can be reasonably
  identified and that management has the control to
  fix
• Focuses on systems, not individuals
• Nb negligence is managed separately
• Incidents are monitored and given a severity
  rating

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Root Cause analysis

• Team discussion to determine sequence of events
• How, what, why for each step
• Root cause for each step - cause and effect
• Communication
• Knowledge/skills/competence
• Environment
• Patient factors
• Equipment
• Policies/procedures/guidelines
• Safety Mechanisms
• Recommendations/Actions

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Medications on admission

• Project undertaken by Pharmacy student
• Medical (n 40)and surgical (n 41) patients
• Interview on admission, comparing medications
  taken at home with medications charted
• Patients taking gt 6 medications at home most
  likely to have error on admission

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Medications on admission

• Surgical
• 192 regular medications
• Av. per patient 5.1
• 36/192 (19) discrepancies
• 21/192 (11) omissions
• If taking 6 medications 86 of patients had
  at least one error in medication charting on
  admission

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Medications on admission

• Medical
• 242 regular medications
• Av. medications/patient 6.1 (danger zone)
• 68/242 (28) discrepancies
• If taking 6 medications 75 of patients had
  at least one discrepancy in medication charting
  on admission

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Medications on admission

• Admission discrepancies varied in severity
• Error rates reduced if patient had aid to
  managing medications (Webster pack, medication
  list, etc)
• Webster packs limited no puffers, topicals, etc.

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Root Cause analysis an example

• Corporate packaging
• New storeman unfamiliar with pharmacy
• Dispensed and checked
• by same pharmacist

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Systems causes identified what next?

• Eliminate
• Purchase alternative brands (if possible)
• Control
• Separation of similar stock on shelves,
• Computerised alerts when dispensing,
• Education
• Newsletters
• Generic prescribing (generic
• names can also be confused)
• Accept

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Detecting errors

• 95 of all errors are detected with each check
  the swiss cheese theory
• Ideal world each defensive layer is intact.
• Reality each defensive layer has many holes
• Holes in one slice do not necessarily lead to a
  bad outcome
• If holes line up incident