Prevention of Medication errors - PowerPoint Presentation

1. Prevention of Medication errorsPhilip A RoutledgeJames CoulsonAll Wales Therapeutics and Toxicology CentreCardiff, Wales, UK

2. Case StudyA 44 year-old woman had a urinary tract infection and was prescribed the antibiotic nitrofurantoin for 10 days. Two weeks later she noticed numbness, pins and needles and tingling of the lower limbs up to mid-thigh. She was examined by a neurologist three months later, who stated that this was likely to have been a peripheral neuropathy related to the previous course of nitrofurantoin. She is referred to you (as a clinical pharmacologist) for advice.Q1. What would you do (list more than one action and explain your reasons?

3. What is a Medication Error (ME)?“Any preventable event that may cause, or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”National coordinating Council for Medication Error Reporting and Prevention http://www.nccmerp.org/about-medication-errors

4. Not all medication errors (MEs) lead to an Adverse Drug Event (ADE)Potential ADEsBut ADEs caused by MEs are preventable by avoidance of the errorActual ADEsAn Adverse Drug Event (ADE) is an injury resulting from medical intervention related to a drug Kohn LT et al . (Institute of Medicine). To err is human: building a safer health system. Washington DC: National Academy Press, 2000. https://www.ncbi.nlm.nih.gov/books/NBK225182/Medication errors (MEs)Not preventableFigure adapted from Miller MR et al. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007; 16: 116-26preventable

5. What is their impact on health services?In the UK, prescribing or monitoring errors were detected in the care of one in eight patients, involving one in 20 of all prescription items (in primary care)The University of Nottingham and General Medical Council, Investigating the prevalence and causes of prescribing errors in general practice, May 2012. Available at: http://www.gmc-uk.org/Investigating_the_prevalence_and_causes_of_prescribing_errors_in_ general_practiceThe_PRACtICe_study_Reoprt_May_2012_48605085.pdf Worldwide, the cost associated with medication errors has been estimated as 42 billion US$ annually, almost 1% of total global health expenditure http://www.who.int/patientsafety/campaigns/en/

6. Administer correct dose of medicine by correct route to correct patientDecide if prescription indicated?Discuss choice with patientCheck reference source(s) & write prescription for appropriate dose/ /route/durationPatientSelect/ prepare/ dispense correct medicine at appropriate dosePrescribingAdministrationHealth Professional (e.g. Doctor)Healthcare Professional (e.g. Pharmacist)Healthcare Professional (e.g. Nurse)MonitoringStorage, preparation & DispensingMedication errors can occur at any stage of this complex processhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477336/  Figure adapted from. Routledge PA. Safe prescribing: a titanic challenge. Br J Clin Pharmacol. 2012; 74: 676-84

7. Why do medication errors occur?Because to “err is human” and we all make slips, lapses and mistakes But bad errors don’t make people badWe need to build systems and strategies which minimise errorThat means developing a strong “no-blame” safety culture in the NHSIt also means a duty of reporting errors and near-misses

8. Some Principles of Good Prescribing to avoid Medication ErrorsTake into account the patient’s medication history before prescribing: Obtain an accurate list of current and recent medications (including over-the-counter and alternative medicines); prior adverse drug reactions; and drug allergies from the patient, their carers, or colleaguesWrite unambiguous legal prescriptions using the correct documentation: Be aware of common factors that cause medication errors and know how to avoid themFor complete details, consult the BPS guide “Ten Principles of Good Prescribing”, see https://www.bps.ac.uk/BPSMemberPortal/media/BPSWebsite/Assets/BPSPrescribingStatement03Feb2010.pdf

9. How can you help to minimise Medication Errors?.....(i of ii)Remember that ‘high risk’ (‘high-alert’) medicines are associated with a greater risk of ADEs after a Medication Error. These include Anti-infectives, Potassium & other salts/ electrolytes for injection, Insulins, Narcotics (e.g. opioids & sedatives), Chemotherapeutic agents & immunosuppressives, Heparins & oral anticoagulants (A-PINCH)Report medication errors or near-misses so that you and your colleagues can learn how to minimise similar risks in future

10. Therapeutic Group Some examples from the group Some Serious ADEsAnti-infectivesAminoglycosides (e.g. gentamicin) & amphotericinAllergy to antibiotics Renal & oto-toxicityAllergic (e.g. anaphylaxis)Potassium & other salts/ electrolytes for injection Potassium, magnesium & calcium salts & hypertonic sodium chloride  Electrolyte disturbancesInsulins Soluble insulins HypoglycaemiaNarcotics (e.g. opioids) & sedativesOpioids (e.g. morphine, diamorphine), benzodiazepines & propofol Sedation and respiratory depressionCancer chemotherapy & immunosuppressivesEtoposide, vincristine & methotrexateHaematological toxicityHeparins & oral anticoagulantsHeparinsVitamin K antagonists (e.g. warfarin) & New direct-acting Oral Anticoagulants [NOACs/ DOACs] (e.g. apixaban, dabigatran edoxoban & rivaroxaban)HaemorrhageHaemorrhageSome high-risk medications

11. How can you help to minimise the risk of Medication Errors (ME’s)?.....(ii of ii)Pay particular attention to high-risk situations for medication error. These include:-Injections and infusions as a source of MEsPrescribing in neonates, infants, children and the elderlyPrescribing in patients with liver disease, renal disease and heart failure (where clearance of medicines from the body may be impaired)

12. The Global ChallengeWHO has identified Medication Safety as the third Global Patient Safety Challenge to galvanize global commitment to improve medication safety and define a set of actions that are simple, practical and can be universally applied across all countries and settingsThe “Challenge” will be to reduce medication-related harm by 50% globally in the next five years, with a proposed option for adaptable targets at country levelhttp://www.who.int/patientsafety/medication-safety/en/

13. Case Study: answersA 44 year-old woman had a urinary tract infection and was prescribed the antibiotic nitrofurantoin for 10 days. Two weeks later she noticed numbness, pins and needles and tingling of the lower limbs up to mid-thigh. She was examined by a neurologist three months later, who stated that this was likely to have been a peripheral neuropathy related to the previous course of nitrofurantoin. She is referred to you for advice. Q1. What would you do (list more than one action and explain your reasons?)Ensure that she is aware that peripheral neuropathy is a recognised adverse drug reaction (ADR) associated with nitrofurantoin use. The neurologist in this case considered that “she should never be prescribed nitrofurantoin again” Ensure that her hospital and community medical records contain details of this suspected ADR and all other drug allergies/ intolerances and that the patient also has a personal record of theseThis is a serious suspected ADR so ensure that a yellow card has been submitted to MHRA. If not, complete one yourself, informing the patient of the reasons why. Note a medication error has not occurred at this stage (i.e. a preventable event that may cause or lead to inappropriate medication use) Postscript: A medication error probably did occur 16 years later when she was prescribed nitrofurantoin long-term prophylactically (despite the previous history) and on this occasion developed interstitial lung disease (another serious ADR associated with this medicine), which responded to nitrofurantoin withdrawal. For further details see Bialas MC et al. Nitrofurantoin re-challenge and recurrent toxicity. Postgrad Med J 1997; 73: 519-520

14. I am a clinical pharmacologistClinical Pharmacology and Therapeutics (CPT) is one of 30 physician specialties in the medical career pathway.Consultants trained in this specialty lead on all aspects of medicines management.It is the only medical specialty in the NHS focusing on the safe, effective, and cost-effective use of medicines.Clinical pharmacologists play a crucial role in refining the use of currently available medicines, and in developing the pioneering medicines of tomorrow.Clinical pharmacologists have diverse career paths working, for example, in the NHS, regulatory bodies, clinical trials units, universities or the pharmaceutical industry.