In hospitalised children they occur at similar rates to adults (4.3-5.7% of orders), but have 3 times the potential to cause harm.Prescribing errors are the most common…..about 80% of errors are associated with harmLevine SR et al, J PaediatrPharmacolTher 2001;6:426-42Fortescue EB et al, Paediatrics 2003;111:722-729Is more complex than in adults due to weight-based dosing, custom medication formulations (dosage forms usually adult sizes, liquid forms measured or diluted), immature organ function to metabolise drugs (small change, big difference clinically) and inability of children to communicate adverse effects.Kaushal R, Bates DW, Landrigan, C et al. JAMA 2001;285:2114-20
This review, a systematic literature review whichsynthesised all the peer reviewed knowledge on medicationerrors for children published since the release of the pivotal ‘To Err IsHuman’ report, estimates that 5–27% of medication orders for children containan error somewhere along the spectrum of the entire deliveryprocess involving prescribing, dispensing, and administeringbased on three studies (Cimino 200428; Kaushal 200142; Marino200043). This review also estimated that there are 100–400prescribing errors per 1000 patients and highlighted that themajority of research to date has focused on the prescribing stepof medication delivery (Kozer 200239; Kaushal 200142).This is changing and our own NRPDU are contributing to this literature
Paper earlier this year from (IHI) the Institute for Healthcare Improvement showed that the use of a Global trigger Tool identified at least 10 times more confirmed, serious events than voluntary reporting and Patient Safety Indicators. Last barrier – nearer to the patient in terms of process, plus nursing staff do the majority of the reporting, and prescribing errors are often swiftly corrected and therefore not entered. By both nursing and Pharmacy staff – documented Pharmacy interventions added to incident data bring the prescribing incident numbers almost up the same level as administration.Administration figure also includes incidents where a prescribing error has occurred and this has then gone on to be administered. This accounts for 25% (225 incidents) of the administration figures per year, and is important to note, as the double checking process at the point of administration is not as robust as a safety net as expected.
Involving transfer of the medication administration process from a central medication room to the patient bedside
Focus groups – to identify barriers to the safe administration of medications that currently exist in the unit, why, pre-emptive problem solving sessions
WCCAT – obs ref – 2 validated observers, comparing medication administration time, distractions and interruptions and compliance with hospital policy, both within the room with the medication box, to administration of medication to patients of similar acuity in the rest of the unit.
Parents – on top of it – one picked up an interventionDischarge not rushed from meds perspective
One of patients – found meds scary in 3ml syringe as looked like a huge volume, but in a 10ml syringe was acceptableCSA – needs to given orally – tastes foul – sticker chartsn – nurses also involved not just parents – notr the ‘baddies’ anymore
Multiple anti-epileptics included in listPatient with JMML ‘Juvenile m myeloid leaukaemia’ Patient developed encephalitis following BMT – admitted to PICU – all meds for SZ completely new to mum – issues with side effcets (drowsiness, Tube feeds and phenytoin, tablets to be crushed or dispersed)Even more meds – topicals for mouthcare and steroid creams/emollients for skin care
When did counselling normally start? 2weeks up to 1 month prior for Noumean patientsThe norm is 2 days prior (if we’re lucky)BMT patients – charts one week prior, counselling variableOthers – 2 days prior at bestNo formal data collection just anecdotalVW/Camperdown over next two weeks (? Clancy)
A policy has been produced outlining the admission, administration and discharge processes around the use of the box. Evaluation of parent/carers ability to administer medications has also been factored in and will be one focus for the next phase of the project. Ongoing education, information, support and feedback is occurring through inclusion of the box in ward orientation processes.Ongoing monitoring of IIMS, of the process via observation, and feedback from families is occurring to enhance the process further.The next phase will focus on costing of medications on admission and discharge medications, looking at the potential to use patients own medications and relabelled inpatient supplies for discharge, to further streamline the medication administration process.
Rachael Worthington - Moving Closer to the Bedside: Improving Medication Administration for Children in Hospital
Moving Closer to the BedsideImproving medication administration for children in hospital Rachael Worthington The Children‟s Hospital at Westmead
Medication…and Errors• Medication-related errors are a significant proportion of the preventable errors that occur in healthcare• Children are particularly at risk
Medication Errors in Children… 49% The prescribing, dispensing and administration of medications represent a substantial portion of the preventable medical errors that occur with children… 5-27% of medication orders for children contain an error somewhere along the spectrum of the entire medication management process… Miller et al Qual Saf Health care20% 2007;16:116-126 14% Quality in Australian Health Care study Med J Aust 2005; 182 (6): 260-261.
At CHW• Most reported cause of incidents at CHW• 2008-2011 yielded over 2300 incident reports – 3260 separate incident types – 189 medications• Average 45 incident reports per month• Plus 35 pharmacy interventions per month
Administration of Medications• Checking process often cited as „rushed‟, „inco mplete‟ „interrupted‟ „distracted‟• Workflow and time issues
A Family Affair…• Promoting self or carer- administration of medications• Transcription or charting errors on admission → Administration errors or delays → Family frustrated, disempowered. A Family Centred approach decreases anxiety, increases compliance with what is required, which in turn …and recognises improves outcomes, patient and staff that every family is satisfaction.. unique
Aims• To evaluate to impact of using an in- room locked medication cabinet in a paediatric isolation/oncology ward – To improve compliance with current medication administration policy – To increase carer involvement – To minimise medication wastage
Variety Ward• Our patients • Project Team – Oncology Nursing Unit Manager – Bone marrow Clinical Nurse Educator transplantation Service Improvement Staff – Solid organ Pharmacists transplantation Nursing Staff – Chronic liver disease – Chronic renal disease Pre-evaluation – Rheumatology undertaken with – Gastroenterology stakeholders
The Cabinet• Purpose built, wall mounted, lockable box designed by the project team in consultation with the manufacturer• Opens flat to create a work-surface• Staff Focus Groups
Assessment Methods • Direct observation of medication administration process • Acceptability through staff and parent surveys • Nurses experiences documented and discussed
Incident data• Increased incident reporting – 23 between Mar-Aug 2011 vs. 36 between Sept 2011-Feb12 – No change in severity – Improvement in safety culture?
Effect on Workflow• Fewer distractions: 0.83 vs 1.21• Decreased administration time: 4.9 minutes vs. 5.84 minutes – Based on an average 196 medication episodes per day = 184.24 minutes per day or 47 days per year!
What did staff think?POSITIVES NEGATIVES - Being watched by parents - Finding the second checker - Stock maintenance - Noise and lighting at Close to night patient
What did parents think?Pre-trial• Overwhelmingly in favour of having medications prepared closer to child• 85% would like to continue giving in hospital Safer Keeping the routine the same Don‟t have to wait for nurses – they get very busy Easier Less distressing for the child • Primary reason for saying no was wanting a break
More from the parents Night activity was not Post-trial seen as an issue – Parents many parents slept feel through or felt the involved interruption took less time with everything already in the roomIt‟s visible to thechild and it‟s notscary; keeps thechild happy
Parent Education Henri‟s Medication List – 1/2/12Case Study – “Henri” • Domperidone 3mg TDS via NG• 2 y.o. boy from New • Bactrim 30mg BD via NG • Ondansetron 3mg TDS via NG Caledonia • Diazepam 2.5mg BD via NG •• French speaking mum • Lamotrigine 75mg BD via NG Topiramate 40mg BD via NG “Etienne” • Aciclovir 150mg BD via NG • Nystatin 1mL QID swabbed• Hx of JMML, BMT June around mouth 2011 • Cholestyramine 5% paste topical • Clonidine 25mcg nocte IV• Rocky course post • Levetiracetam 300mg BD IV transplant • Phenytoin 35mg BD IV • Omeprazole 15mg BD IV
Medication ListPage 1 of 3!Nurses wouldintroduce medicationas it was changed tofrom IV to oral.Mum would addnotes to chart forherself
Sustaining change• Policy around admission, administration and discharge processes using the box.• Evaluation of parent/carers ability to administer medications.• Ongoing education, information, support and feedback via ward orientation processes.• Ongoing monitoring of IIMS, observations, feedback from families.• Costing of medications on admission and discharge medications, looking at the potential to use patients own medications to further streamline the medication administration process.
Preliminary Costings• 51 patients• Average number of regular medications• New medications in 42%• 10% started on chronic medication• Some patients transferred• Average cost saving = $125.45
Conclusion• Having medications in the room has improved workflow, compliance with policy and showed benefits in terms of parent education.• Well accepted by staff and parents.• Two systems in ward – difficult to maintain - more boxes/more data.• Improvements to the system required: locking system, drug information• COWs and medical carts being considered as next phase.
With thanks…• Sonya, Lorraine, Bronw yn and the Variety Ward Nursing Team• Katrina, Peter, Demian a, Lucy and the CHW Pharmacy Department• The CHW Service Improvement Unit