Download Intervention Study 2016 Trust-wide

Intervention Study 2016
Trust-wide
Gillian Ritchie
Clinical Pharmacist
Introduction
Annual data collection
– Two weeks
– All Medicines Management Team interventions
Details recorded
Classified by type
Outcomes graded by significance by audit lead
pharmacist
Wards and units included
Mental Health & Learning Disabilities Division
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Hawthorns One & Two
Antelope House
Elmleigh
Kingsley
Ravenswood & Southfield
Leigh House & Bluebird
Mother and Baby Unit
East ISD
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Beechwood & Elmwood
Berrywood & Beaulieu
Dryad & Daedalus
Stefano Olivieri Unit
Sultan & Ark Royal
Rowan & Cedar
West ISD
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Romsey & Alton
Lymington
Number of interventions (Trust-wide)
2013
2014
2015
2016
During the 2 week study
331
375
442
429
Projected number per
annum
8,606
9,750
11,492
11,154
1 – Drug omission on chart rewrite
2 – Prescribing error on chart rewrite
3 – Interactions
4 – Adverse effects
5 – Drug choice
6 – Swapping medication
7 – Dose
8 – Frequency
9 – Route
10 – Formulation
11 – Treatment duration
12 – Omissions – blank box(es)
13 – Omissions – drug unavailable
14 – Omissions – doses refused
15 – Omissions – patient asleep
16 – Drug omission on admission
17 – Drug omission on TTO
18 – Fridge issues
19 – Therapeutic duplication
20 – Therapeutic substitution
21 – Stopping medication
22 - Administration
23 - Compatability
24 – Dispensing error
25 – Incorrect drug administered
26 – Drug blood levels
27 – Physical health tests
28 - Monitoring
29 – Pt / carer counselling
30 – Patient identity
31 - Other
1 – Detrimental to patient
2 – No significance to patient care
3 – Significant but did not lead to improvement in standard of care
4 – Significant and resulted in improvement in standard of care
5 – Prevented a major organ failure or drug reaction of similar importance
6 – Potentially life-saving
Intervention that was potentially life-saving
PMH - two heart transplants (first one was rejected)
Multiple immunosuppressants :
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Tacrolimus ( Adoport®)
Azathioprine
Cotrimoxazole
Prednisolone
Code “2” ( no stock) being documented on chart for tacrolimus – hence
doses omitted
Pharmacist:
– Re-emphasised importance of not omitting doses
– Ensured nurses faxed the prescription chart to pharmacy
– Ensured pharmacy obtained the branded product (tacrolimus - brand specific)
– Endorsed prescription chart :
With brand name, Adoport®
Critical medicine – do not omit doses. If no stock on ward,
order from pharmacy; if out of hours, contact
-call pharmacist
on
Intervention that was potentially life-saving
Medicines reconciliation for AMHT
Patient had not taken medication for the past 18 months
GP record – lamotrigine 50mg daily (last issued Feb 2014)
Reviewed by AMHT
– FP10 written for lamotrigine 150mg twice daily
Pharmacist contacted the doctor
Doctor agreed to re-titrate lamotrigine
Lamotrigine can cause serious skin reactions , including
Stevens Johnson syndrome , which can be fatal. Highest risk
with rapid titrations
If miss more than five days’ lamotrigine, need to retitrate
Pharmacist ensured safe prescribing
Intervention that was potentially life-saving
Pharmacy Technician was organising medicines for TTO
Patient prescribed enoxaparin 120mg once daily for 6 months
on prescription chart, for treatment of pulmonary embolism
– To continue until December 2016
Not prescribed on TTO
Pharmacy Technician discussed with ward doctor
Doctor added enoxaparin to TTO
Potentially fatal omission of enoxaparin and communication
failure with GP averted
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Novorapid® S/C PRN 6 units prescribed
Poor handwriting of prescriber
– Looked like “60”
Pharmacist:
– Endorsed prescription chart: 6 units
– Potentially fatal insulin overdose averted
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Medicines not prescribed on admission :
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Phenytoin 100mg TDS
Bisoprolol 10mg OM
Candesartan 8mg OM
Furosemide 40mg OM
Spironolactone 25mg OM
PMH:
– Epilepsy, heart failure
– Above medicines critical for this patient
Pharmacy team:
– Discussed with SHO
Outcome:
– Medicines prescribed
– No deterioration in patient’s physical health
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Clozapine levels raised :
– April 1.91mg/l (dose 400mg)
– May 2.12mg/l (dose 300mg). Sodium valproate added
– June 1.39mg/l (dose 300mg)
Patient mentally well, but has side-effects :
– Hypersalivation, sedation, tachycardia
Pharmacist:
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Suggested GASS clozapine
Slowly decrease dose by 25mg/week
Repeat level in 2 weeks
Optimised safe prescribing and clinical effectiveness
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
High dose antipsychotic therapy (HDAT) prescribed:
– Haloperidol 20mg daily
– Quetiapine 800mg daily
– 200% BNF maximum
Tachycardic
Pharmacist:
– Contacted doctor
– Advised decrease haloperidol dose to 10mg
– Ensured HDAT monitoring
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Clozapine patient on medical ward at local acute Trust
Casual remark overheard in dispensary that the patient has
just stopped smoking
Pharmacist:
– Contacted the CMHT
– Advised needs urgent clozapine review :
Dose change
Clozapine level
Close monitoring
Potentially dangerously high clozapine level
(secondary to smoking cessation) averted
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Erythromycin prescribed
Patient also prescribed atorvastatin & clozapine
Pharmacist advised:
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Withhold atorvastatin for duration of erythromycin
Increased risk clozapine toxicity – monitor for side effects
Increased risk QTc interval prolongation with clozapine
Monitor ECG
Outcome:
– Pharmacist ensured safe prescribing
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Two month old baby
Paracetamol QDS prescribed
Maximum licensed dose for baby of this age is TDS
Pharmacist contacted the prescriber
Outcome:
– Dose decreased to TDS
– Paracetamol overdose averted
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Elderly patient
Severe osteoporosis secondary to hyperparathyroidism with hypercalcaemia
No bisphosphonate / denosumab prescribed
Recent endocrinology letter recommended a bisphosphonate and cinacalcet
– Not on GP records
– Not prescribed
Pharmacist:
– Discussed with ward doctors
– Advised liaise with endocrinology
Outcome:
– Patient referred back to endocrinology
– If left untreated, the patient could sustain fractures
more easily following a fall
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Elderly patient
eGFR 45mls/min
Prescribed ibuprofen
Pharmacist:
– Discussed with ward doctor
– Advised stopping ibuprofen
Outcome:
– Ibuprofen stopped
– Further deterioration in renal function averted
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Elderly patient
eGFR 46mls/min
Prescribed ramipril 10mg daily
Maximum licensed dose 5mg daily if eGFR 30 – 60mls/min
Pharmacist:
– Checked blood pressure recordings
– Discussed with doctor
Outcome:
– Doctor to repeat eGFR
– Monitor blood pressure
– Consider dose reduction
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Elderly patient transferred from local acute Trust on bumetanide
2mg bd and ramipril 2.5mg bd
Ward doctor prescribed bumetanide 1mg bd and ramipril 2.5mg
od (hence doses halved compared with acute Trust)
Pharmacist discussed with ward doctor (GP)
– Concerns not acted on for many days
Left ventricular failure ultimately diagnosed
Outcome:
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Diuretic doses increased
Fluid balance ultimately improved
Patient weight ultimately decreased
Heart failure stabilised
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Patient prescribed rivaroxaban 20mg once daily for
pulmonary embolism (PE)
PE diagnosed three weeks previously
Patient refusing doses
Critical medicine to decrease risk of further PE
Pharmacist:
– Discussed with nurses (patient asleep at time of pharmacist visit)
– Emphasised importance of patient taking rivaroxaban consistently
Outcome:
– Patient started to take rivaroxaban again
– Decreased risk of recurrent PE
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Warfarin not prescribed on admission
Atrial fibrillation (AF)
Pharmacist:
– Checked prescription charts from acute Trust for most recent warfarin
doses
– Checked blood results for recent INR
– Advised dose
– Advised repeat INR
Outcome:
– Critical medicine doses were not omitted
– Decreased risk of stroke secondary to AF
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Co-careldopa 12.5/50mg omitted from discharge summary
Critical medicine for Parkinson’s disease
Continuation of Parkinson’s medication vital
Pharmacist:
– Checked medical notes
– Discussed with doctor
Outcome:
– Co-careldopa added to TTO
– Parkinson’s medication continued
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Elderly patient
Enoxaparin 40mg daily prescribed
Severe renal impairment
– Decreased clearance
– Increased risk bleeding
Pharmacist:
– Advised doctor to switch to unfractionated heparin (UFH)
Outcome:
– Enoxaparin switched to UFH
– Venous thromboembolism prophylaxis prescribed safely
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Elderly patient
Bed bound since admission three days previously
No venous thromboembolism (VTE) risk assessment completed
No VTE prophylaxis prescribed
Pharmacist discussed with doctor
Outcome:
– Enoxaparin 40mg daily prescribed
– Decreased risk of VTE
Very significant intervention that prevented a major organ
failure or prevented a drug reaction of similar importance
Elderly patient
Prescribed multiple medications for Parkinson’s Disease :
– Madopar hard capsules
– Madopar controlled release
– Tolcapone
Naso-gastric (NG) tube and nil by mouth
Patient likely to miss doses of these critical medicines / NG tube will block unless
formulation changes
Pharmacist:
– Advised doctor to switch all madopar preparations to dispersible tablets
– Advised doctor to switch tolcapone to equivalent entacapone dose
More evidence that crushing and dispersing entacapone in water will not alter drug effect
Outcome:
– Patient received revised treatment
– No loss of mobility or increase in Parkinson’s symptoms
Very significant intervention that prevented a major
organ failure or prevented a drug reaction of
similar importance
Elderly patient
eGFR 13mls/min
Prescribed morphine
Pharmacist:
– Advised Dr that risk of opiate accumulation is much higher in renal failure
– Switching morphine to oxycodone would significantly decrease this risk
– Advised re dose conversion
Outcome:
– Morphine switched to equivalent oxycodone dose
– Safe and effective analgesic use in renal failure
Common interventions 2016
Allergy box blank or incorrect
Inhalers not prescribed
Antimicrobials – length of course not stated
Paracetamol prescribed regularly and PRN
Transcribing errors when chart rewritten / TTOs prescribed
Prescriptions not signed / dated by doctor
Maximum dose in 24 hours not specified for PRN medicines
Physical health medicines not prescribed / prescribed incorrectly on admission
Management of side effects
Switching antipsychotics
Multiple benzodiazepines prescribed
HDAT monitoring
Lamotrigine titrations
Interactions
Incorrect T2 / T3 forms
Incorrect / inappropriate doses prescribed
Dose adjustments in renal impairment
Cost to the organisation
Based on NICE economic
analysis (PSG001)
www.nice.org.uk
Costs of a medicine error largely through increasing
bed stay and increasing
monitoring testing
Does NOT include the cost
to the individual
Significant
error
£65 - £150
Serious error
£713 - £1,484
Life
threatening
error
£1,085 - £2,120
Economic analysis
Significance
EQUIP
SHFT 2015
SHFT 2016
Potential lethal
2%
7%
7%
£930,930 - £1,818,960 per year
£789,880 - £1,543,360 per year
79%
86%
£593,190 - £1,368,900 per year
£626,990 - £1,446,900 per year
£1,524,120 - £3,187,860 per year
£1,416,870 - £2,990,260 per year
Significant
Total costs of
SHFT
interventions
53%
Conclusions
Medicines Management Team makes a significant
number of interventions:
– 429 interventions in two weeks = approximately 11,150 in
a year
This saves the Trust £1.5 - almost £3million per year
86% were significant and improved patient care
7% either prevented an organ failure or drug
reaction of similar importance, or were
potentially life-saving
Recommendations
Repeat study for two weeks in 2017
Present Divisional findings to each Division
Communicate common issues identified to relevant staff:
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Include in “ Medicines Matters” bulletin
Junior doctors’ induction
Medical and nursing staff on wards
Nurses’ Medicines Management training days
Further develop, and invest in, the Medicines Management Team:
– Seek to enhance level of Medicines Management service provided
throughout the Trust:
Thereby further enhance patient safety and optimise prescribing that is both
clinically- and cost-effective
Thereby generate further cost savings
1 – Drug omission on chart rewrite
2 – Prescribing error on chart rewrite
3 – Interactions
4 – Adverse effects
5 – Drug choice
6 – Swapping medication
7 – Dose
8 – Frequency
9 – Route
10 – Formulation change
11 – Treatment duration
12 – Omissions – blank box(es)
13 – Omissions – drug unavailable
14 – Omissions – doses refused
15 – Omissions – patient asleep
16 – Drug omission on admission
17 – Drug omission on TTO
18 – Fridge issues
19 – Therapeutic duplication
20 – Therapeutic substitution
21 – Stopping medication
22 – Administration
23 - Compatibility
24 – Dispensing error
25 – Incorrect drug administered
26 – Drug blood level tests
27 – Physical health tests
28 - Monitoring
29 – Pt counselling
30 – Pt identity
1- Interactions
10- Omissions – not available
19- Dispensing error
2- Adverse effects
11- Omissions - refused
20- Incorrect drug given
3- Drug choice
12- Omissions - asleep
21- Drug level test
4- Dose
13- Omission on chart rewrite
22- Physical health tests
5- Frequency
14- Omission on admission
23- Moniotiring
6- Route
15 Duplication
24- Counselling
7- Formulation
16- Subsitution
25- Patient indentity
8- Treatment duration
17 - Administration
26- Omission on TTO
9- Omissions – blank box
18- Compatibility
27- Swapping
Common interventions 2015
Allergy box blank or incorrect
Inhalers not on prescription chart
Enoxaparin dose incorrect due to renal impairment
Antibiotics – length of course not stated
Paracetamol prescribed regularly and PRN
Dose adjustments in renal impairment
Medicines prescribed incorrectly on admission
Transcribing errors when chart rewritten / TTOs prescribed
Prescriptions not signed / dated by doctor
Lithium levels, clozapine levels
Choice of antipsychotic & how to switch
Management of side effects
Common interventions 2014
Allergy box blank.
Enoxaparin dose incorrect due to renal failure.
Inhalers not on drug chart especially salbutamol prn
More than one paracetamol-containing products prescribed
Psychotropic medication and QTc prolongation
risk/monitoring
Old doses not crossed when new ones prescribed
Antibiotics – length of course not stated
SSRIs and NSAIDs – increased risk of GI bleed
Procyclidine prescribed at night