Possible Consequences of Errors - PowerPoint Presentation

Slide1

Possible Consequences of Errors

Coroners CourtNeil PetrieOctober 2018

Slide2

Recent Coroners Case

MethotrexateChemotherapeutic agent for rheumatoid arthritisAlso used for some cancersAlso may be used in psoriasisExtremely toxic

Given weekly

Unless in certain cancers when short courses may be ordered.

Slide3

Meet Mrs H – Day 1

Has been taking

Methotrexate 17.5mg once weekly for 3-years

Visit to her GP who was away

Seen by locum doctor

Asked doctor if there was a simpler way to take her medicine

Prescription provided for methotrexate

10mg x 1 weekly2.5mg x 3 weekly

Slide4

Mrs H – Day 2

Doctor intended to write

”ad” for as directed

However inadvertently wrote

‘OD” for daily

Community pharmacist

Dispensed with label

Take ONE tablet daily

Slide5

Mrs H – Day 2

So Mrs H starts taking her methotrexate daily.

Slide6

Mrs H – Day 5

Second GP reviews prescription and notes the error.The paper prescription is changed by hand.The computer record is not corrected with correct dose.

Slide7

Mrs H – Day 8

Presents to hospital complaining of feeling generally unwell, lethargic and having a sore throat for past 5-days.

Admitted to ENT ward

Resident doctor prescribes her regular medicines

Slide8

Mrs H – Day 9

Nurse identifies that the dose should be 10mg dailyAccording to the medication bottle brought in by Mrs H.

Mrs H confirms she recently started taking 10mg daily.

Nurse administers the 10mg dose.

Slide9

Mrs H – Day 10

Medication chart sent to pharmacy for more supplies.At this point the order is still 100mg dailyPharmacist crosses off the orderPharmacist asks nurse to clarify order with doctor

Slide10

Mrs H – Day 10

Resident doctor phones GP surgery to check doseReceptionist checks patient historyConfirms dose of 10mg daily.

Resident doctor writes a new order

For 10mg daily.

Slide11

Mrs H – Day 11

At this point Mrs H has been seen byAt least 4 doctorsAt least 2 pharmacistsA number of nurses

Still no blood tests have been ordered.

Slide12

Mrs H – Day 12

Develops a rashNurse looks up side effects of methotrexateThis suggests that methotrexate could be the causeBlood test results revealCritically low platelets

Low white blood cell count.

Slide13

Mrs H – Day 12

Methotrexate ceasedTransferred to haematology teamIn total Mrs H has received11 daily doses of methotrexate5 of which were given in hospital

Slide14

Mrs H – Days 13-20

Mrs H continues to deteriorate.

Her family are informed that

her

prognosis is poor.

Slide15

Mrs H – Day 21

Mrs H dies.Death certificate shows cause of deathGastrointestinal haemorrhagePancytopaenia

Methotrexate toxicity

Slide16

One Simple Mistake

One simple error lead toCatastrophic consequencesMedication errors often involve Numerous people

Multiple opportunities to

Identify

Question

Correctly clarify

These systemic failures resulted in a tragic death

Slide17

Link to the NPS Website

http://learn.nps.org.au/

Slide18

Medication Errors and

Quality Use of MedicinesNeil Petrie

October 2018

Slide19

Cost of Medication Errors

Issue

Statistic

Hospital admissions

2-3%

190,000/

yr

Hospital reported incidentsSecond most commonAdverse reactions20-30%Preventable42%Cost$800 million/yr

Literature Review: Medication Safety in Australia 2013

Slide20

Cost of Medication Errors

Harm to patient

20%

Significant harm including death

3%

Result

Loss of trust

Emotional impactMedico-legal

Slide21

Pathway of Medicine Use

Prescribing

Evaluate patient

Establish need

Select

Individualise

Prescribe

DispensingReview prescription Prepare & DispenseDeliver

Adminstration

Review prescriptionPrepare medication

Administer

Document

Monitoring

Everyone’s responsibility

Slide22

Comparing a 70 year old to a 30 year old

Heart pumps at 60%

Liver function reduced

Weight

Storage of medicines

30% muscle loss

30% fat gain

Kidneys – excretion 70%Body water17% decreasePeople over 65 years have higher rates of adverse effects

Greatest users of medicinesAge related changes and co-morbidity increases this risk

Slide23

Guiding Principles

Slide24

Why do medication errors occur?

Slide25

What Factors

contribute to medication errors?

Average of 4 factors

Queensland Study in Hospital

Patient factors

Familiarity with patient

Patient condition

Communication abilityAcuity of problemEnvironmental factorsStaffing levelsWorkloadDistractions

WorkspaceLightingLong hours

Individual factorsPhysical health

Mental health

Insufficient knowledge/training

Team Factors

Lack of supervision

Poor communication

Task Factors

Access to clinical information

Documentation layout

Resource availability - references

Slide26

Careful Checking

Slide27

Now think about your care for 20 seconds

Slide28

Have I removed your Card?

Do we see want we want to see?

Slide29

Potential

problems with Medicines

Unnecessary drug therapy

Wrong drug

Dose too high

Dose too low

Adverse drug reaction

Inappropriate administrationNeeds additional drug therapyCan occur withPrescribingDispensingAdministration

Slide30

Transcription Errors

Transfer from previous chartHospital dischargePrevious doctorLack of consistency between GP surgery records and chartsHandwriting

Computerised chart errors

Slide31

Slide32

Strategies for Improvement

Overview of evidence regarding different strategies for reducing medication errors.http://www.safetyandquality.gov.au/our-work/medication-safety/medication-administration

/

Slide33

Standardised Medication Charts

Slide34

Strategies to Reduce Interruptions (

Hosp)

Interventions included

Do not interrupt vests

Checklists with the medication administration

process

carried

by nurses;Signs requesting not to interruptQuiet zones for medication preparationAllocating other staff to attend to phone calls etc

Weak evidence

Raban

MZ,

Lehnbom

EC, Westbrook JI

. 2013

) Evidence Briefings on Interventions to Improve Medication Safety;

Interventions to reduce interruptions during medication preparation and administration

.

Australian Commission on Safety & Quality in Healthcare. Volume 1, Issue 1: June

2013

Slide35

Electronic

Some evidence for hospitalsReduce dose omissionsImproved medication administration documentation.

Lack of evidence for Residential aged care

Slide36

Evaluation of a hybrid paper–electronic medicationmanagement system at a residential aged care facility

Slide37

Evaluation of a hybrid paper–electronic medicationmanagement system at a residential aged care facility

88 residents

24 doctors

1230 orders (759 regular & 467 PRN & 4 short term)

125 discrepancies

Slide38

Slide39

Elliott RA, Lee CY,

Hussainy

SY (2015) Evaluation of a hybrid paper–electronic medication management system at a residential aged care facility.

Australian Health Review.

http://dx.doi.org/10.1071/AH14206

Slide40

Bar Code Medication Administration (BCMA)

Also called bar code enabled point of care (BPOC)

Scan

Nurse

Patients wrist band

Medicine

}

Electronic medication record

PreventsWrong patientWrong doseWrong time

Wrong drug

Wrong route

Slide41

Bar codes

Requires all medications to be barcodedMay need pharmacy to addAnother source of errorTechnology issues

faulty barcodes and time outs

Time and motion impact

Same or decrease in time administering

Increase in direct patient care

Baysari

MT, Lehnbom EC, Westbrook JI (2013) Evidence Briefings on Interventions to Improve Medication Safety; Bar code medication administration systems. Australian Commission on Safety & Quality in Healthcare. Volume 1, Issue 1: June 2013

Inconsistent evidence

Slide42

Double Checking Administration

Pros (Quotes)

Cons (Quotes)

Fail safe if rigorously applied

Resource intensive

Only takes 30 seconds

Inconsistently applied

No expensive electronic equipmentToo busyGlanceman test *

Time consuming

Allows 2 people to make an error*

Glanceman

test -

find a man and he glances at it for you.

Ramasamy

S,

Baysari

MT,

Lehnbom

EC, Westbrook JI (2013) Evidence Briefings on Interventions to Improve Medication Safety; Double-checking medication administration. Australian Commission on Safety & Quality in Healthcare. Volume 1, Issue 1: June

2013

Slide43

Common Medication Problems

Slide44

Adverse Drug Reactions

Reaction Type

Definition

Adverse drug reaction

Overarching term to describe an undesirable or excessive effect of a drug and may also be referred to as a side effect or intolerance.

Allergy

Allergy is adverse reaction to a drug or substance due to an immunological response.

IntoleranceA lowered threshold to the normal pharmacological actions of a drug/substance. It is a poorly defined term.Side effectAn undesirable response to a drug that occurs when used at normal dosesToxicity

An adverse reaction due to a high dose/exposure or a serious adverse reaction e.g. renal toxicityIdiosyncratic

An unpredictable reaction to a drug/substance that is peculiar to an individual and is not dose related

Slide45

Reaction Types

Type A

Type B

Predictable

Unpredictable

Usually dose dependent

Rarely dose dependent

High morbidityLow morbidityLow mortalityHigh mortalityResponds to dose reductionResponds to drug withdrawal

Slide46

Incidence Reporting

Rare

0.01%-0.1%

Affects > 1

but <

10 / 10,000

Uncommon

0.1% - 1%Affects >1 but < 10 / 1000Common1% - 10%Affects >1 but < 10 per 100Very common> 10%

Affects > 10 people per 100

Slide47

D

r

ug

A

ll

e

r

gySide EffectToxicityPer

indopril (

Coversy

l

)

Angioedema

C

ou

g

h, h

y

po

t

ens

i

on

Hypotension, arrhythmia, vomiting

Opioids

A

naph

y

l

a

x

i

s

C

ons

t

i

pa

t

i

on,

ha

ll

uc

i

na

t

i

o

ns,

Respiratory depression

A

m

i

tr

i

p

t

y

li

ne

(

E

ndep)

R

ash

D

r

y

m

ou

t

h

Arrhythmia, seizures

A

m

o

x

i

c

i

l

li

n

(

A

m

o

x

il)

R

ash

Di

a

rr

hoea

(

m

il

d

–

se

v

e

r

e)

Unlikely

Description

Definition

Symptoms

Angioedema

Small blood vessels leak fluid into the tissues

Often associated with urticaria (hives)

May affect

face, lips, tongue, throat 

Itchy, tingling, or burning (or just swelling)

Anaphylaxis

Potentially life threatening, severe allergic reaction and should always be treated as a medical emergency.

Potentially life threatening:

May include

Difficult/noisy breathing; Swelling of tongue

Swelling/tightness in throat; Difficulty talking and/or hoarse voice; Wheeze or persistent cough; Persistent dizziness and/or collapse

Pale and floppy (in young children)

Slide48

Identifying an Adverse Drug Reaction

Is it feasibleTimingCause and effectHas it happened more than once

Any objective evidence

Did it improve when

dose decreased or drug ceased

Slide49

Age

Environmental Factors

Gender

Race/ethnicity

Disease states

Concomitant Drugs

GENETICS can affect

Rate of metabolism

Slow metaboliserReduced

NormalFast

All drugs are not created equal

Neither are people

PERSONALISED MEDICINE

The future of prescribing

Slide50

Pharmacogenomics

Identifies variations in genes that affects drugs responseMay predict whether an individual person

Will respond or not to a drug

Has an increased risk of adverse effects

Costs from $149 to $169 from

mydna.life

Common Medication GroupsAntidepressantsProton pump inhibitorsAntipsychoticsCardiovascular agentsAnti-epilepticsSulfonylureas

Anti-inflammatoriesStatinsAnalgesics

Potential Benefits

Improved health outcomes

Reduced side-effects

Less trial and error

Personalised approach

Lifetime relevance

Slide51

Patient Group

N

ot toxic and

Not beneficial

Drug toxic but not beneficial

Drug toxic and beneficial

Drug not toxic but beneficial

Same diagnosis, same prescription

Slide52

Clinical Application of Pharmacogenomics

Adapted from Xie

and

Frueh

, Personalized Medicine (2005) 2(4), 325–337

Before:

One-dose-fits-all approach

After:Personalised medicine (from genotype to phenotype)PGx

FAST

NORMAL REDUCED SLOW

100 mg

300 mg

100 mg

10 mg

Slide53

Celebrities sign their names all the time

Your

signature is more important

Give it – sign it

Failure to sign:

When something is not signed there is a

real risk

that the medication YOU have ALREADY GIVEN

will be given again

by a second nurse.

CONSEQUENCES of OVERDOSE

:

Insulin:

Palpitations,

vomiting,

headache,

coma

Lactulose:

Diarrhoea,

abdominal cramps,

hypokalemia,

hyponatremia

Morphine:

Stupor,

coma,

bradycardia, hypotension,

respiratory depression,

respiratory arrest

Warfarin:

Bleeding or haemorrhage

Slide54

How do you ensure everything is signed for?

Have another staff member check that you have signed everything before leaving

The nurse starting the shift should routinely ask to staff leaving if they have signed everything.

Electronic recording

Slide55

Common errors

Wrong residentWrong timeWrong dayWrong drugNot administering

Fatal Errors

Incorrect dose 41%

Wrong drug 16%

Wrong route 16%

Almost half in people > 60 yrs

FDA Review

Slide56

Confusion with Generics

Definition

Example

Generic name

Drug name

Active ingredient

Risperidone

Trade nameGiven by manufacturerOriginal brandRisperdalOriginal brandFirst patented brand of a medicineRisperdalGeneric brandOnce a patent expires other companies can develop their own version of the medicine.

Ozidal

Slide57

Drug

Risperidone

Brands

Apo-risperidone,

Ozidal

,

Rispa

, Risperdal, Rispericore, Risperidone AMNEALRisperidone AN, Risperidone Actavis , Risperidone Sandoz, Risperidone generichealth, Rispernia, RixadoneStrengths500mcg, 1mg, 2mg, 3mg, 4mg, 25mg injection, 1mg/ml liquidFormsTabletOrally disintegrating tablet (Quicklets)Modified release injectionOral liquid

740 PBS listed drugs1850 different forms3500 different brands

Slide58

Error Prone

Abbreviation

What should it be

U

E

QD

1.0mg

Acceptable Abbreviations

Error ProneAbbreviationWhat should it beU

UnitsEEye or EarQD

daily

1.0mg

1mg

Slide59

High Risk Medicines

Defined as those with a heightened risk of causing significant or catastrophic harm when used in error. This includes:medicines with a low therapeutic index medicines that present a high risk when administered via the wrong route or when other systems errors occur.

Slide60

High Risk Medicines

High Risk Medicines

P

Potassium

IV

I

Insulin

NNarcoticsCChemotherapyHHeparin/WarfarinFollowing have accounted for a large % of events

Digoxin, aspirin, Beta blockers, NSAIDs

http://www.safetyandquality.gov.au/our-work/medication-safety/medication-alerts/

Slide61

Medication Incidents

Opportunities for improvement

Identify problem

Debriefing

Education

Systems review

Checking

Open disclosure policydescribes the way clinicians communicate with patients who have experienced harm during health care In this document, ‘patient’ also refers to support persons such as family members and carers.

Slide62

Partnership Approach

Meeting resident’s complex medication needsPrescribing doctorDispensing pharmacistAdministering nurse

Management

Medication review Pharmacist

Resident/Resident representative

Slide63

DPCS ACT & Regulations

Prescribing, dispensing and administrationAustralian Health Practitioner Regulation Authority Guidelines

Guiding

principles

residential

aged care

facilities

CommunityPrivacy ACTCommonwealth Aged Care ACTMy Health Records ACTLegislation

Slide64

High Care Residents

Administration of medication to high care residents must be managed by a Division 1,3 or 4 nurse

They should ensure professional supervision of all administration to high care residents.

The responsibility of administering the medicine may be delegated in accordance with the scope of practice

Slide65

Where is clinical judgement needed?

Examples may includeWithholding medicationMedication given with no effectHealth status of resident e.g. vomiting

Missed medication

Slide66

Rights of Drug Administration

Right resident

Right medication

Right dose

Right time

Right

route

Slide67

Phone orders – what is the Law?

The DPCS Regulation 47“must as soon as practicable”(a) confirm those oral instructions in writing; and(b) include them or provide them for inclusion in the treatment records of the person concerned.

Individual Policy and Procedure may indicate 24 hours

Pharmacists can also only supply on a direct order from a authorised person ie doctor

Slide68

When taking emergency telephone orders

Verify the prescriberdetails of the resident

Write the instruction in permanent ink directly onto the person’s medicine record

Confirm the instruction with the prescriber

Name, dose, route, timing & frequency

Guidelines for administration

Sign and date the record

Where possible a second person should confirm the instruction with the prescriber.

Slide69

Drugs of Addiction

Unexplained discrepancies in balances must be reported to the Victorian Department of Health

It is good practice that S8 drugs are checked and signed by two people

.

Slide70

When Administering Medicine

Must remain with the resident until the medication is seen to be swallowedMust only document that administration has occurred when it has been completed

Must not sign for administration before it has been administered

Medication expiry dates must be checked prior to administration

Slide71

Non-administered Medicine

If medicine is not given or refused, this needs documenting and the reason whyMedication chartProgress notes

Slide72

Medication charts

Communication toolSafety risk with multiple routes in the same orderNever transcribe medication orders

What about computer generated orders?

Can the nurse add these for the doctor to sign?

Slide73

Medication charts must include

Route, strength, dosage, frequencySignature of staff administering or supervising the medicinesRelevant date, month, year

Date of next administration of infrequent drugs

Alternative methods of administering medications

Slide74

Altering Solid Oral Dose Forms

Altering (crushing) may make it easier to administerEnsure that process employed does not

Result in reduced effectiveness

Result in greater toxicity

Result in an unacceptable presentation in terms of taste or texture.

Slide75

Medication

Expiry dates

Medicated eye

drops

Lubricant eye drops

Insulin

Salbutamol nebules

Medications packed in dosage administration aidsAnginineExpiry Dates

Slide76

Expiry Dates

Medication

Expiry dates

Medicated eye

drops

30 days after opening

Lubricant eye drops

Most are 6-months after openingInsulinVial in use 30 days at room temperatureSalbutamol nebules90 days for set of 5 in useMedications packed in dosage administration aidsAustralian Guidelines – 8-weeksFDA – 6-months or 25% of shelf lifeAnginine90 days after opening

Slide77

Storage issues

Medicine

Storage Conditions

Mylanta mixture

Refrigerate after opening and expires in 6-months

Pradaxa

Must be

stored in original packOroxine tabletsRefrigerateOnly 14 days out of fridgeValproate tabletsNot packed in DAA out of foil

8

0C

Medicine

Storage Conditions

Mylanta mixture

Pradaxa

Oroxine tablets

Valproate tablets

2

0

C

Slide78

Issues with Patch therapy

DocumentingRecording in situ each dayRotating application sites

Is covering appropriate

How does external heat affect absorption

How are used patches disposed of

Inappropriate orders for half a patch.

Slide79

Summary

Safe medication administration is achieved The rights of medication administrationThis includes documenting at the correct timeFocusing on the task at hand

Good communication

Correct assessment

Correct supervision

Slide80

Summary

Communication or lack there of is the biggest cause of medication errors.Make sure you COMMUNICATE effectively.