Mediation safety - First lecture

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Multiprofessional learning regarding medication safety for undergraduate medical and pharmacy students

Multiprofessional learning regarding medication safety for undergraduate medical and pharmacy students

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  • We’re students– why do we need to know? The use of medicines is the most common health care intervention (almost every patient will receive a medicine at some point in their care). GMC tomorrow’s doctors: Prescribe drugs safely, effectively and economically. (a) Establish an accurate drug history, covering both prescribed and other medication. (b) Plan appropriate drug therapy for common indications, including pain and distress. (c) Provide a safe and legal prescription. (d) Calculate appropriate drug doses and record the outcome accurately. (e) Provide patients with appropriate information about their medicines. (f) Access reliable information about medicines. (g) Detect and report adverse drug reactions. (h) Demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.
  • BMJ 2004 Two large general hospitals in Merseyside, England Over 18000 patients aged > 16 years were admitted over six a month period These were all assessed for cause of admission There were more that 1200 admissions related to an adverse drug reaction The projected annual cost of such admissions to the NHS is £466m (706m, $847m). Most reactions were either definitely or possibly avoidable. Most ADRs were predictable from the known pharmacology of the drugs and many represented known interactions and are therefore likely to be preventable. Over 2% of patients admitted with an adverse drug reaction died.
  • Famous fatal medication errors have included: Chemotherapy given intrathecally rather than IV route (vincristine) BBC report 2001
  • As mentioned in the advertising for this course, medication error is still a big problem at the moment. A recent systematic review was carried out by senior members of the schools of Pharmacy and Medicine here at the University and was published at the beginning of 2009. They looked at and summarised studies which investigated the prevalence, incidence and nature of prescribing errors in hospital inpatients. Overall, studies show that prescribing errors are a common occurrence, affecting around 1 in 14 of all hospital prescriptions. Foot note
  • Overall, around half of all hospital admissions will be affected in some way by some kind of prescribing error. Click 1 - Nightingale ward half affected. Click 2 - Lets affect the lady sitting down as well, just for fun.
  • Minimum standard for prescribing safely: Prescription should not endanger patient care either because of inappropriate prescribing or poor communication. Most errors in hospital involve a small number of “high risk” or “problem” drugs. We will have a think about this in a moment.
  • As part of this lecture series we want you to feel included, and not just be passive participants that we feed information to. So we are going to get you involved in the presentation, get you to think about cases, make some decisions and think about how confident about things. All of this will be completely anonymous and will not put anyone on the spot. We are not even going to ask any of you to put your hands up! In your packs in front of you, you will find some voting sheets. Can you all take them out and have a look at them?
  • We need to get some voting sheets designed and then add an example here. You will see on the voting sheets that there are X numbers of votes to be cast. You may vote for one option on each occasion, and this you must do by marking the option letter with a cross. Do not mark more than one option. So think about which option you want to go for before marking the paper. Also, you will be asked to rate your confidence in your vote each time. We want to know how sure you are that you have made the right decision. You should score your confidence in the vote you have cast by ringing the confidence score you feel fits best with the confidence you have in your decision. Have a read through the 4 confidence statements now.
  • Some things that we are asked about are easy for us to answer with confidence. For example, think of this problem: A glass is being filled from the tap. Unfortunately, the glass is left under the tap and the water starts to overflow in to the sink. In your opinion, which of the following options would be best to deal with this situation effectively and keep your hands dry whilst doing so?
  • Most people would go for option A, and be pretty sure they had made the right decision. So what if I was to also ask you to rate your confidence in the answer you had given? Would you be very confident you had made the right decision, or maybe very unconfident and would always seek advice before acting if confronted by this in the real world? I hope that all of you would be very confident to deal with this and would be confident you had voted for the best option from those presented to you.
  • But things aren’t always that simple. What if I was to request that you think about something more complex or unfamiliar? For example, what if I told you that one part of this piping system was liable to leak due to the plumbing design? Say I outlined some problem points with handy arrows and then asked you to vote which arrowed area you felt was the most likely to leak first. Now unless you happen to be a plumber, or have a strange and rather specialist interest in your spare time, you are likely to be pretty unsure as to which area may be most likely to leak. You can vote, but overall your confidence that you have selected the correct area most prone to leaks is likely to be low. We will be putting some problems forward to you during this lecture series, and presenting some possible courses of action to you. We will be asking you to vote on your preferred course of action throughout the lecture series, and to have a think about your confidence levels in selecting which option to vote for. All of this will be completely confidential and private, provided you do not look over each other’s shoulders! The results from the voting and confidence scoring will be presented to you during the next two lectures. Everything will be completely anonymous, including to us as presenters. It will hopefully make things more interactive, and fun.
  • As well as voting on things, we also want you to discuss a few questions with your colleagues at certain points in the seminar. Discussing things with those around you for a few minutes will help you establish what you do and don’t know, what you are confident about and what you are not so sure of. We will give you a few minutes each time. Make sure that you just talk to the people next to you, otherwise we won’t be able to hear each other due to shouting.
  • Types of medicines most likely involved in admissions So lets start with this question: Which medications are the most likely to lead to a hospital admission due to an adverse drug reaction? Have a think about it and discuss this with the people sitting next to you.
  • Drugs most commonly implicated in causing these admissions included low dose aspirin, diuretics, warfarin, and non-steroidal anti-inflammatory drugs other than aspirin, the most common reaction being gastrointestinal bleeding. Conclusion: The burden of ADRs on the NHS is high, accounting for considerable morbidity, mortality, and extra costs. Although many of the implicated drugs have proved benefit, measures need to be put into place to reduce the burden of ADRs and thereby further improve the benefit:harm ratio of the drugs.
  • Types of medicines most likely involved in hospital medication errors
  • Medication errors by class of medication at a local (unnamed) hospital over 6 months
  • For doctors, prescribing (some administration); For pharmacists, ordering and dispensing (some prescribing); For nurses administration (some ordering and prescribing)
  • I presume the 1000 bed hospital represents Hope/Wythenshawe/MRI/Preston? Can you confirm that I am correct about this point ?
  • The students will be reminded that we will look at a controlled drug prescription next session.
  • Use slides to demonstrate
  • Drugs with similar names
  • Drugs with similar packaging (manufacturer branding)
  • Photos
  • Photos
  • Please ring the number which corresponds to your confidence that you have voted for the best option. Do not ring more than one number.  When considering your confidence, think about how you would feel if confronted with the situation as a recently qualified professional. Think whether you would be happy to proceed or whether you think you would need more help before acting.    Description of options   1    I am not at all confident that I have voted for the most appropriate option. If I were confronted by this situation I would need to ask for advice and help before making a decision.   2    I am not overly confident that I have voted for the most appropriate option. If I were confronted by this situation I would usually ask for advice and help before making a decision, unless it was very difficult and inconvenient to do so.    3   I am quite confident that I have voted for the most appropriate option. If I were confronted by this situation I would not usually ask for advice and help before making a decision, unless it was very easy and convenient to do so.    4    I am very confident that I have voted for the most appropriate option. If I were confronted by this situation I would not need to ask for advice and help before making a decision. Remember: Cast your vote and confidence rating by circling one letter and one number. Fold your voting slip over so that it cannot be viewed by anyone during the collection process. Pass it to the end of your row and it will be placed in the collection box. These votes are completely anonymous; you will not receive individual feedback following your vote. Group results will be shared with everyone at following seminars.
  • RING A NUMBER- DON”T DO THIS! 
  • Patient with learning difficulties has been admitted to hospital. She has undergone a routine operation of some sort e.g. arthroscopy. No relatives have arrived. Notes brief- learning difficulties, knee pain, no other relevant medical history. Nursing staff on day care unit. Patient is complaining of pain 1 hour post operatively. The patient has received some morphine and 1000mg intravenous paracetamol in theatre 1 hour ago. The patient is still quite drowsy, but has had a few sips of water. The nurse tells you that her observations are fine, except that her respiratory rate is only 8 breaths per minute.
  • The nurse tells you that her observations are fine, except that her respiratory rate is only 8 breaths per minute. The patient is still quite drowsy, but has had a few sips of water.
  • The junior doctor decides to prescribe some pain relief for this patient. Vote for medication that you would select from the above four options. How confident are you that you have selected the an appropriate medication? Ring your level of confidence from 1-4. Remember to ring a number- you cannot vote in between numbers!
  • Okay, we have collected the votes in. It’s your turn to do some prescribing. What would you write on the drug chart? Where? Why not have a go at prescribing the medication you picked? Feel free to talk to those around you, also have a look at the BNF.
  • Okay, we have collected the votes in. It’s your turn to do some prescribing. What would you write on the drug chart? Where? Why not have a go at prescribing the medication you picked? Feel free to talk to those around you, also have a look at the BNF.
  • The junior doctor decides to prescribe a Non steroidal anti-inflammatory drug (NSAID).
  • New info- relative rings- patient experienced a rash and became wheezy when previously when received ibuprofen. Nurse has withheld the NSAID but is concerned because the patient still is in pain. What now?
  • The nurse adds this to the drug chart and asks for your advice.
  • What would be the best option out of the following that are going through our doctor’s mind? You can discuss this with the person next to you and look at the BNF text.
  • What now- vote 2 You may feel there are advantages and disadvantages with all the options To outline one that comes to mind for each- A Nursing staff are concerned about this option as they have already contacted you regarding Ibuprofen and are querying this. Are risks (if any) lower, the same or higher for the patient if they receive THIS NSAID? B Will this relieve the patient’s pain without endangering patient due to any opiate side effects? C Should further paracetamol be used instead? The patient had some in theatre, but that was over an hour ago D The patient is in pain- why are you delaying things? Have a go, pick an option to vote for, and then think about how confident you are that this is the best option of those above. Remember, this is all anonymous.
  • Final vote- how change system to prevent in future. Could anything help here? Few options, nothing clearly best option… real life, confidence etc.
  • Final vote- how change system to prevent in future. Could anything help here? Few options, nothing clearly best option… real life, confidence etc. Which would be the best one to go for as a first option? (Prof Pollard, Anaesthetics at MRI- he is happiest with first option as this encompasses many staff, and least happiest with second as it is irrelevant, but this will not be revealed until next lecture).
  • Need to reflect on activities and learning during first session (reflection on action)
  • Need to inform students about future sessions (Anticipatory reflection) They will receive the results of their voting next week (Feedback) They will also see how the pharmacists/medics voted when confronted with the same dilemmas (Inter-professional communication) They will look at a more complex case and have the opportunity to vote again (Interaction and discussion) They will think about some small group work which follows this lecture series (Future aims)

Transcript

  • 1. Safer prescribing and avoiding medication error University of Manchester
  • 2. Background Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients BMJ. 2004; 329:15-19
  • 3.
    • A teenager has died after a cancer drug was injected into his spine by mistake…
    • The leukaemia treatment should have been injected into his vein…
    • Two junior doctors have been suspended. Wayne had been unconscious since the incident last month. He was killed by a slow, creeping paralysis that eventually stopped his heart.
    Friday, 2 February, 2001, 18:43 GMT Drug blunder patient dies BBC NEWS / NEWS FRONT PAGE “ My clients have been appalled to learn that so many other families have suffered as a result of similar mistakes” Family solicitor
  • 4. Background Prevalence, Incidence and Nature of Prescribing Errors in Hospital Inpatients: A Systematic Review . Drug Safety 2009; 32(5):379-389 7% 93%
  • 5.  
  • 6. What do we think?
    • Prescribing should not endanger patient care:
        • Inappropriate prescribing
        • Poor communication
  • 7. Getting you all involved
  • 8. Voting sheets
  • 9. How would I deal with this?
  • 10. How would I deal with this?
    • A - Turn off the sink tap?
    • B - Turn off the water supply to the house?
    • C - Contact a local plumbing company and ask a plumber to attend immediately?
  • 11. How would I deal with this? A B C D
  • 12. Discuss with the person next to you
  • 13. Which drugs are likely to lead to a hospital admission?
  • 14. Which drugs are likely to lead to a hospital admission?
    • Most common medications causing admission include:
        • Low dose aspirin
        • Warfarin
        • Non steroidal anti-inflammatory drugs
        • Diuretics
    • Most common reaction:
        • Gastrointestinal bleeding
    Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients BMJ. 2004; 329:15-19
  • 15. Which drugs are mostly implicated in medication error in hospitals?
  • 16. Medications involved in error
  • 17. At what point could error occur during the provision of medication in hospitals?
  • 18. At what point could error occur during the provision of medication in hospitals?
  • 19. At what point could error occur during the provision of medication in hospitals?
    • ‘ A 600- bed teaching hospital with 99.9% error-free drug ordering, dispensing and administration will experience 4,000 drug errors a year’
    • Organisation with a memory, DH 2000
    • So…. A 1000-bed teaching hospital (e.g. Hope) will experience at least 6500 errors per year!!
  • 20. Prescribing- What information is required to make a prescription legal? And safe?
  • 21. Prescribing- What information is required to make a prescription legal? And safe?
    • Correct prescription form required (green FP10, hospital chart etc.)
    • Patient name and address (or hospital number and ward/clinic)
    • Drug name, dose, frequency, route (+ formulation and administration information where appropriate)
    • Date and signature
    • What about “controlled” medication?
  • 22. Prescribing errors- what kinds of mistakes are made?
  • 23. Prescribing errors- what kinds of mistakes are made?
    • Prescription illegal, illegible or incomplete
    • Incorrect/inappropriate route or formulation
    • Incorrect/inappropriate dose, frequency or duration
    • Drug Interactions
  • 24. Prescribing errors- what kinds of mistakes are made?
    • Incorrect/inappropriate choice of therapy
    • Lack of monitoring
    • Discharge prescriptions/Transcription error
  • 25. “ A man suffered irreversible brain damage after a pharmacist misread his doctor’s prescription. The patient had been prescribed the antibiotic Amoxil® (amoxicillin) for a chest infection. The prescription was badly written and the pharmacist misread the drug name as Daonil® (glibenclamide) a drug used to lower blood sugar in people with diabetes. As a result of taking the wrong medicine the patient went into a coma and was hospitalised for 5 months…”
  • 26. Dispensing errors- what kinds of mistakes are made?
  • 27. Dispensing errors- what kinds of mistakes are made?
  • 28. Dispensing errors- what kinds of mistakes are made?
  • 29. Dispensing errors- what kinds of mistakes are made?
    • Right label / wrong drug or vice versa
    • Right drug; wrong strength
    • Drugs with similar generic names
        • procylidine/prochlorperazine
        • chlorpromazine/chlorpropamide
    • Drugs with similar packaging (manufacturer branding)
  • 30. Dispensing errors- what kinds of mistakes are made?
    • Wrong quantity (calculation error)
    • Wrong concentration (extemporaneous calculation error)
    • Compliance aid error
        • labels don't match drugs
        • drugs dispensed at wrong times
        • drugs omitted
  • 31. “ A man suffered irreversible brain damage after a pharmacist misread his doctor’s prescription. The patient had been prescribed the antibiotic Amoxil® (amoxicillin) for a chest infection. The prescription was badly written and the pharmacist misread the drug name as Daonil® (glibenclamide) a drug used to lower blood sugar in people with diabetes. As a result of taking the wrong medicine the patient went into a coma and was hospitalised for 5 months…”
  • 32. Administration errors- what kinds of mistakes are made?
  • 33. Administration errors- what kinds of mistakes are made?
    • Wrong route e.g. prescribed oral but given IV
    • Wrong formulation e.g. prescribed MR but given as standard immediate release preparation
    • Wrong drug (similar names as per prescribing and dispensing errors)
    • Wrong rate - too slow or rapid
        • (calculation error or device failure)
  • 34. Administration errors- what kinds of mistakes are made?
    • Omission
        • drug "not available”
        • human error; nurse did not see prescription
    • Timing error
        • given at wrong time e.g. Parkinsons disease
        • delayed administration e.g. IV antibiotic
        • continued past stop date
    • Compatibility error
        • drugs mixed inappropriately
  • 35.  
  • 36.  
  • 37. ✓ NO!
  • 38. Post-operative pain
  • 39. ANNE SMITH DCU 135852 1/9/09 1/9 1200 1/9/09 96% 8 132/68 82 7/10 V
  • 40. 8 96%
  • 41. Post-operative pain VOTE: A 50MG ORAL DICLOFENAC B 25 MICROGRAM TOPICAL FENTANYL PATCH C 10MG INTRAMUSCULAR MORPHINE D 1000MG RECTAL PARACETAMOL
  • 42. A 50MG ORAL DICLOFENAC B 25 MICROGRAM TOPICAL FENTANYL PATCH C 10MG INTRAMUSCULAR MORPHINE D 1000MG RECTAL PARACETAMOL
  • 43. Here are some further details you will need: A 50MG ORAL DICLOFENAC B 25 MICROGRAM TOPICAL FENTANYL PATCH C 10MG INTRAMUSCULAR MORPHINE D 1000MG RECTAL PARACETAMOL Patient name: Anne Smith Patient hospital number: 135852 Patient date of birth: 01/08/72 Patient weight: 66Kg Ward: Day case unit Consultant: BJH
  • 44. Post-operative pain HIS CHOICE: A 50MG ORAL DICLOFENAC B 25 MICROGRAM TOPICAL FENTANYL PATCH C 10MG INTRAMUSCULAR MORPHINE D 1000MG RECTAL PARACETAMOL
  • 45. Post-operative pain
  • 46. IBUPROFEN SMITH BJH DCU ANNE 1/8/72 66Kg
  • 47. IBUPROFEN 135852 SMITH BJH DCU ANNE 1/8/72 66Kg
  • 48. Post-operative pain VOTE: A ADVISE NURSE TO GIVE DICLOFENAC B PRESCRIBE OPIATE C PRESCRIBE RECTAL PARACETAMOL D RING COLLEAGUES FOR ADVICE
  • 49. System changes?
  • 50. System changes? VOTE: A DEVELOP AN ALGORITHM FOR POST-OPERATIVE PAIN B ENSURE ALLERGY BOX ON PRESCRIPTION FORM IS MORE VISIBLE C ORGANISE TEACHING SESSIONS FOR JUNIOR DOCTORS REGARDING PAIN MANAGEMENT D TRAIN NURSES TO PRESCRIBE AND ADMINISTER POST-OPERATIVE ANALGESIA
  • 51. What have we looked at today?
    • Background around medication safety
    • Voting and confidence
    • Where errors occur
    • Considered a ‘real’ case
  • 52. What will we look at next time?
    • Agenda:
      • Results of your voting
      • See how the pharmacy students voted when confronted with the same dilemmas
      • Consider a more complex case and have the opportunity to vote again
      • Think about future aims following the lecture series
  • 53. See you all next time.