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Quality Use of Medicines at Peter Mac “tips, hints and updates” Medication Safety Committee, Peter Mac Janelle Penno – QUM pharmacist Kate Witney – QUM pharmacist Outline 1. 2. 3. 4. 5. 6. 7. 8. 9. Access to medication information using Verdi® Insulin prescribing Opioids Chemotherapy Anticoagulants Antibiotics Potassium Safe prescribing practices Time critical medications and how to reduce delayed or missed doses 10. Contacts and resources Access to medication information in Verdi® Drug Alerts/Allergies tab Medication Histories at admission are completed by the ward pharmacist and located behind the medication chart or use the Pharmacy section In Verdi® 3. Click on Admission medication 1. Click on Pharmacy. 2. Click on Medication Reconciliation Report 4. Sometimes “Other dispensings” is useful to see what we have dispensed and when Importing discharge medication lists from Verdi into discharge summaries 3. Double-click on the episode for the appropriate date. 1. Click on Pharmacy. 2. Click on Discharge Medication Summary Important to include all information on the discharge prescription (PBS CHART), as everything on the discharge prescription is automatically faxed to the GP (electronically) Importing discharge medication lists from Verdi into discharge summaries Export this list to Excel by right-clicking on the list Copy and paste this list (via Excel) into the discharge summary Important to list any medication changes made to the medication regimen in the discharge summary This improves the continuity of care across healthcare settings Medication Lists for discharge summaries Click on Medication Reconciliation Reports tab 3. Click on Patient discharge chart for appropriate date. 1. Click on Pharmacy. 2. Click on Medication Reconciliation Reports Lists any medication changes at the end of the chart in the discharge summary At Peter Mac we have a PBS Medication Chart Peter Mac’s medication chart is used to prescribe and administer medications. It is also used to supply and claim medications from the chart for discharge. ie. The chart becomes the discharge prescription PBS Chart: Benefits - Improve patient safety Dramatically reduces transcription errors (from chart to prescription) - - Reduce workload/paperwork requirements for medical staff - Improve time efficiencies - Streamline communication Prescribing, administration and discharge script all in one place. How to Use the Chart 1. Fill in Prescriber section on front page of chart Prescriber details must include the date and a signature - Prescriber details must be filled on each chart if you are the doctor discharging the patient - Pharmacist will not be able to dispense discharge medications if this is not completed 2. If an authority is required – use this number on the front of the chart ‘Script Number’ to quote if an authority approval number is required NOTE: the numbers are different on each chart-watch out when you need an approval number for items on different charts 3. Fill in the VTE section (or the warfarin section if applicable) REMEMBER: to prescribe TEDs if appropriate - Complete the VTE risk assessment for all patients Enoxaparin is first choice at PMCC Chart TEDs if indicated Peter Mac patients represent an inherently higher risk group for VTE and all inpatients should receive it unless it is contraindicated. 4. Prescribing with the chart a) Complete the ‘Start Date’ (usually the same day the order is written but could be used if you wanted a medication to start on a particular day in the future) ‘Valid for Duration’ or Stop Date are optional but good practice to fill in b) Prescribe the dose and frequency in the same box and then enter the administration times (liaise with the nurse or pharmacist for appropriate times if unsure) METOPROLOL 8:00 oral 50mg BD 20:00 c) Where appropriate, on discharge complete the ‘Streamline Authority Code’ or Authority Approval No’ d) Ignore this! 5. Completing the chart for discharge It is important to consider whether the drug route, dose and frequency is appropriate for discharge. Modify orders for appropriateness at discharge. Discharge Supply space 1. 2. 3. 4. 5. Circle Y or N for “continue on discharge?” Leave the “dispense? y/n” blank as the pharmacist will fill this in Fill in quantity – use the blank section nearby for writing words and figures (NB: Multiple strengths may need to be written separately due to limited space) Sign and date each medication order If adding something on for discharge purposes only, cross out the administration section and write "for discharge purposes only“ If unsure about the quantity use the PBS website (www.pbs.gov.au) or liaise with the pharmacist 6. Some other things to consider - Communicate with your pharmacist when you have completed the discharge sections or there have been any additions, as this can delay the patients discharge home (not as obvious as a completed discharge prescription). - Complex items: - titrating doses: use variable dose chart if possible- a separate prescription may be needed. - multiple strengths (e.g. Oxycontin® 70mg– space limits may require separate orders to allow for approval numbers and quantities to be written in words and figures. ) - oral chemotherapy 7. Situations where separate scripts may still be needed. Prescription will still be needed if: - outside of PMCC pharmacy hours (chart cannot be taken outside of Peter Mac) - the patient/carer/nursing home wants to get medications from a community pharmacy - repeats, deferrals and regulation 24 are essential for a particular item - day leave - complex directions may need a prescription - PBS chart can still be used for; - Insulin orders – on the day of discharge write insulin prescription on the chart cross off the admin section and document “for discharge only” - Pain and Palliative care emergency orders - Post chemotherapy medications- cross off the admin section and document “for discharge only” 8. Final Key Points - Utilise and communicate with your ward pharmacist - Fill out the prescriber details at the front if discharging patient - Fill out the discharge section for each medication and approval numbers if necessary - Is the drug order right for discharge? Check drug, route, dose, frequency is appropriate. - Discharge prescription will still be available if necessary High risk medications: APINCH (strongly feature at Peter Mac) - Antimicrobials Potassium Insulin Narcotics Chemotherapy Heparin (LMWH) - Worldwide incidents associated with all - High-risk medicines have a narrow therapeutic index - High-risk medicines can cause significant harm when system errors occur - Medicines can present a high risk when administered via the wrong route Insulin prescribing at Peter Mac - Insulin recognised internationally as a high risk medicine - Insulin has a narrow therapeutic index and doses are highly individualised - There are a large amount of insulin preparations on the market, increasing the risk of mix-ups (e.g. rapid acting vs regular insulin) Transcribing and Administration errors with Insulin can have serious consequences - A Peter Mac patient received 80 units instead of 8 units ICU admission - Another Peter Mac patient was prescribed 10 units of insulin – however 100 units was accidentally drawn up picked up by an incidental 3rd nursing check prior to administration A subcutaneous insulin chart was implemented at Peter Mac in 2013 – all prescribing, monitoring and administration is combined into a separate chart to standardise practice and reduce the risk of error. Monitoring Communication and Safety Insulin Administration Insulin Orders 1. Using the chart: before you start 1. Cross reference the insulin form on the NIMC or 2. Affix bradma (with the patient’s name printed underneath) 3. Document who to notify of out of range BGLs or other diabetes-related concerns 2. Monitoring / Notification Instructions - Prescriber indicates the BGL frequency of monitoring required - Default BGL monitoring for inpatients is Pre-meals and at 21:00hrs - ALERTS prompting clinical review for HIGH BGL and LOW BGL 3. Insulin Orders (Prescribing) - A patient may be prescribed any combination of Routine, Supplemental, and Stat / Phone Insulin Orders - If a patient with diabetes is not receiving subcutaneous insulin, this form should still be used for BGL monitoring Valid until changed or ceased 4. Routine Insulin Orders Valid until ceased or changed Six (6) spaces to prescribe routine insulin Four (4) spaces with Meal / time pre-printed Breakfast Lunch Dinner Pre-Bed Orders are valid for 5 days unless ceased or changed. 5. Supplemental Insulin Orders - Tick the appropriate Frequency - Write the Name of insulin, start date and start time - Standardised BGL ranges are pre printed - if required, different BGL ranges may be used - Write insulin doses - For suggested doses, see Table 1 (pg 1, MR61F) - Sign and initial the order - Review supplemental doses as required - Changes are validated by initialling changes in the corresponding column - Also write the Name of supplemental insulin in the Administration Record 6. Guidelines for Managing Hyperglycaemia Alerts To assist inexperienced and non specialist clinicians with management of hyperglycaemia in hospital inpatients. The guidelines provide information related to: assessment required when called for a Hyperglycaemia Alert initiation of basal and mealtime insulin and adjustment of insulin doses suggested stat and supplemental doses based on weight or previous total daily dose. These are not designed to decrease autonomy or specialist input. If there are any clinical concerns, senior medical officer advice should be obtained. 1 2 3 7. Management of Hypoglycaemia in Diabetes - Adult - - Has four treatment pathways: - conscious and cooperative - insulin infusion - nil by mouth or nil by tube - oral or tube fed Appropriate food choices are listed - Food choices should be centrally located - Each ward has access to glucose 50% intravenous 50mL and glucagon 1mg injection to use in emergency situations - Glucose based products are preferred as initial treatment - Non diet products must be used to treat hypoglycaemia ALL Insulin doses > 30 units must be verified as correct prior to administration. This is EVERYONE’S RESPONSIBILITY 1. VERIFY with a reliable source. E.g. carer, patient, GP, pharmacy records 2. DOCUMENT ON INSULIN PRESCRIBING FORM: “insulin “ (e.g. Lantus) dose > 30units validated Only 30 unit insulin syringes are available in ward areas – this is to improve awareness of high doses and reduce the risk of larger doses being given in error. Additional Insulin Resources - Insulin guideline - iPolicy - Medical Registrar - Endocrinology and diabetes educator - from RMH Narcotics/Opioids - why the high risk? - Risk of product selection error during the administration process often there are multiple ampoule strengths - Complex calculations when converting opioid products from one opioid to another and from IV to oral-not an exact science - Multiple products – similar sounding names e.g. morphine, hydromorphone - High volume usage at Peter Mac with cancer pain population Intranet Clinical CornerResourcesToolsOpioid identification and conversion chart Physical copies in all ward areas Opioid Resources - Ipolicy - Procedure for supply or methadone and buprenorphine pharmacotherapy - Ketamine Infusion for analgesia - Guidelines for the conversion, prescription and administration of methadone for pain - Management of post operative epidural infusion for acute pain management - Management of intrathecal single shot morphine for acute postoperative analgesia - Patient controlled analgesia - Outpatient Referral: - - Email .painmx (Pain referral) Email .palliative (Palliative care referral – multiple symptoms). Inpatient Referral through VReferrals Chemotherapy - why the high risk? - Narrow therapeutic index - Sound alike/look alike drugs e.g. doxorubicin, daunorubicin - Wrong route administration can be fatal e.g. vinca alkaloids - Variation in dosing between protocols and tumour stream - Variations in dosage calculations e.g. carboplatin Chemotherapy “THE CHARM CHART” • Watch for duplicate orders between CHARM chart and inpatient medication chart e.g. granisetron on Charm, ondansetron on chart • All pre-meds/fluids +/- hypersensitivity meds (in cases of allergy in drugs known to be allergenic) are administered using the CHARM chart Post-chemo supportive care discharge medications on last page of CHARM chart Needs to be prescribed on PBS Chart (can be used for discharge and administration if patient remains an inpatient) LOCATING the CHARM CHARTS from the wardseither: Electronic Copy on Verdi in the Chemotherapy Section OR Physical Copy In the Patients Medication Chart / (or the Medication Room) Click on Chemo Drug Charts Click on appropriate chart for date All Supportive care and discharge medications are on the CHARM chart. Antimicrobials-why the high risk? - Inappropriate use is attributed to promoting antimicrobial resistance - Some have a narrow therapeutic index and extra monitoring and thought is needed (e.g. aminoglycosides, vancomycin, colistin, amphotericin) - Allergies to antibiotics are prevalent - refer to Dr Jason Trubiano – ID allergy clinic Antimicrobial Resources - Guidance MS (incorporates Therapeutic Guidelines) Antimicrobial Stewardship Team (pg 1110106) - - ID registrar for referrals (pg 1110035) Allergy Clinic – Dr Jason Trubiano - - Can refer for review via email, referral form on iPolicy> Antibiotic allergy clinic referral Guidelines available on ipolicy - - Can request review using the AMT Review Request button under Drug Approvals on Verdi Febrile Neutropenia Sepsis Pathway Antifungal prophylaxis PJP prophylaxis Surgical prophylaxis Splenectomy Vaccination Guidelines Antibiotic Allergy Clinic Protocol and Referral Vancomycin, aminoglycoside dosing Other useful guidelines - Therapeutic Guidelines (available on the intranet under clinical corner drug information) Potassium - why the high risk? - If given too concentrated via a peripheral line it can cause: - Burning, blistering, extravasation - If given too fast or too high a concentration it can cause: - hyperkalaemia as insufficient time is available for intracellular potassium uptake = may cause cardiac arrest within minutes. The effect of hyperkalaemia on the heart is complex – virtually any arrhythmia may be observed1 Potassium resources - Potassium Guidelines – iPolicy - Pre-made bags available on each ward (various concentrations) Potassium error at PeterMac Patient received: 100mmol KCl in previous 24 hours10 x 10mmol potassium ampoules mixed with approx. 100ml normal saline 0.9% in the burette - Left peripheral cannulae - Propofol infusion - Right peripheral cannulae - Drug and Flush line: KCl 10-20mmol IV prn - Antecubital fossa Endorsed by pharmacist: CVC only - Insulin infusion + 25% dextrose @ 10mL/hour Reflection - How could this have been prevented? - Nurse could have used pre-made bags - Doctor could have put a central line in - Pharmacist should have asked what lines the patient had and given advice on pre-made bags - Would lignocaine with the potassium help? - No – this would just mask the pain of the injury - Few studies have shown little benefit of adding lignocaine to a bag of potassium for pain Heparin/anticoagulants – why the high risk? - Worldwide anticoagulants are the class of medicines most commonly associated with fatal medication errors - Narrow therapeutic index - Selection error (6 strengths of heparin available and the packaging looks very similar) - Heparin infusions require constant monitoring and frequent dose changes Heparin/Anticoagulation Resources - Intranetclinical cornerresourcesclinical guidelinescancer surgeryAnaesthesia guidelines - STEP Protocol (available as an app) • search for: "Surgical Thromboembolism Prevention" or just "Thromboembolism" - New Oral Anticoagulants - Fast Track Warfarin Reversal (includes bridging enoxaparin advice) – this information is available in the Vnote - Ipolicy - Heparin infusion Guideline (located on the back of the heparin chart, which is kept in AAA) - Plan to hyperlink guidelines on ipolicy in the near future so easier to find everything Preventing Dose Omissions Focus on Time Critical Medications - Dose omissions occur when a dose is not administered at its scheduled administration time - A multi-centre Victorian Hospital Study found that for 17,000 doses in 300 patients up to 14% of intended doses where omitted - Time critical medications are those medications at greater risk of causing harm if not administered within a timely manner - Omitted doses of time critical medications may increase the length of stay and healthcare costs Time Critical Medications Although there is no absolute definition of a time critical medication, this table should be used as a guide Other medications maybe considered time critical for an individual patient depending on the context and the condition being treated What you can do to reduce omissions of time critical medications - The time critical nature of a new medication needs to be communicated when prescribing with the relevant nurse and pharmacist - Also communicate any changes to time critical medications - Document the indication of any time critical medications on the inpatient chart - Ensure there is a documented plan for time critical medications - Withholding any time critical medications peri-operatively - NBM/dysphagia liaise with pharmacist for alternative formulations - Ensure your order is legible Medication Related Contact Numbers Contact (email/phone/pager) Medicines Information ext: 95204 Email: [email protected] Ward Pharmacists Ward 3 pager: 1110089 Ward 5 pager: 1110084 CDU pager: Ph. 60340 / 60343 / 60344 AAA: 1110103 Ward 6: 1110087 Senior Clinical Pharmacist (Brett) pager: 1110097 Outpatient dispensary ext. 95202 Cytosuite Level 5 ext. 64310 QUM/AMS Pharmacist pager 1110106 Pain and Palliative Care Pharmacist pager 1110102 ext. 98172 Pre Admission Clinic (PAC) pharmacist pager 1110153 ext. 98176 Individual Patient Usage approval (IPU) Application form on iPolicy On-Call Pharmacist (after hours) Through Switch PBS/Medicare for approvals 1800 888 333 Good luck and enjoy your time at Peter Mac! Other useful resources/learning modules NPS Website: (1) NIMC and (2) Medication Safety modules ISMP – 10 tips for obtaining a Best Possible Medication History If you want to be involved in the redesign of the PBS drug chart or if you have any suggestions for improving medication safety, please email: [email protected] or call: ext 98176 [email protected] or ext 98175
