Download Medication Safety - WA Style

Medication
Safety
-WA Style
Kerry Fitzsimons
Medication Safety Pharmacist
Office of Safety and Quality in Healthcare
Delivering a Healthy WA
Medication Safety Standard 4
“…..reduce the occurrence of medication
incidents and improve the safety and quality of
medicines use.”
52% of prescribing errors
reach the patient
Monitoring
Prescription review by
pharmacist and nurses
minimise errors which
reach patient.
Only 2% of administration
errors are intercepted.
Administration 38%
Kerry Fitzsimons Sept 2013
Prescribing 39%
Transcribing
12%
Dispensing 11%
Medication Safety Standard
Medication Safety 5 Criterion
1 Systems and governance for medication safety
2 Documentation of patient information.
3 Medication management processes
4 Continuity of medication management
5 Communicating with patients and carers
Kerry Fitzsimons Sept 2013
Governance and systems for
medication safety
Develop strategies for reducing risk of patient harm and plan
ongoing system improvement (4.5.2)
1. Implement national recommendations and safety alerts
– National Recommendations for User-Applied Labelling of Injectable Medicines
Fluids and Lines
– Intravenous potassium chloride and vincristine alerts
– Standardised abbreviations for prescribing and administration of medicines
2. Standardisation of work practices and products:
– NIMC, premix bags, standardised dosing protocols, standardised
medication checking times, WA Anticoagulation Chart… etc
3. Implement Patient ID processes consistent with
Standard 5 throughout medication management cycle
4. Implement barcode checking in the pharmacy dispensing
process
5. QI activities to address gaps in practice
etc…..
Kerry Fitzsimons Sept 2013
Governance and systems for
medication safety
4.4 Medication incidents are regularly monitored, reported and
investigated:
• Action taken to reduce errors
• Encourage clinicians to utilise
Clinical Incident Monitoring System (CIMS)
• Review reports to identify trends, causes (4.4.1)
– Involve clinical staff, medication sub-committee
• Identify actions to reduce risk of recurrence (4.4.2)
–
–
–
–
Medication safety risk register with actions
Safety and/or quality improvement plan
Report to quality/patient safety committee
Feedback to staff
Kerry Fitzsimons Sept 2013
•“Drug therapy errors occur in 5-20%
of drug administrations in Australian
hospitals”
•3% result in significant harm.
•“43% of adverse drug events are
preventable”
•“Medication interventions save lives,
reduce length of stay, reduce
admissions and reduce costs”
•January 2010
- estimated 190,000 medication
related hospital admissions occur per
year in Australia with an estimated
cost of $660 million.
•Medication related incidents remain
2nd most reported incident in
Australian hospitals.
Lowinger et al. Medical Journal of Australia. 2010: 192 (4).
Kerry Fitzsimons Sept 2013
What do you think is the most common
cause of medication incidents?
A. Failing to read or misreading the medication chart
B. Failing to consider the patient’s renal function
C. Similar sounding drug names
D. Similar looking packaging or different medications
E. Prescription or order errors
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2nd

Medication Incidents – 2012
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Types
of Medication
Incidents
Types
of Medication
Incidents
Kerry Fitzsimons Sept 2013
Medication Incidents Outcome Severity
2012-2013
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Top Five Medication Contributory Factors
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Tip of
the Iceberg
Tip of the
Iceberg
CIMS is a Voluntary Reporting System
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Medication Omissions
NIMC AUDIT 2012
Medication omission rate for
WA patients was
11% of all prescription orders
BLANKS
NOT
AVAILABLE
Kerry Fitzsimons Sept 2013
Medication
Omissions
Medication
Omissions
Reasons why a necessary medication may not be prescribed
include:
• Incomplete or inaccurate medication history
• Lack of knowledge / awareness of best practice guidelines or
overlooking guidelines in practice
• Transcription errors
Reasons why a medication may not be administered as
intended include:
• Oversight
• Nurse is unaware of the order
• The medication can not physically be administered
• No stock available
Kerry Fitzsimons Sept 2013
Learning from Errors
• Mrs Green was prescribed 120mg of sustained release
gliclazide ( 2 x 60mg tablets) in the morning.
• The nurse administered immediate release gliclazide
( 1½ x 80mg).
Later that day the nurse realised the error when
searching through the patient’s medication draw but
did not act upon it as the patient’s blood sugar levels
were stable.
The error was not reported…………………
Kerry Fitzsimons Sept 2013
Learning
from Errors
Errors
Learning from
• The following week, the same nurse administered
3 x 60mg immediate release diltiazem to Mrs White
- the patient should have had diltiazem 180mg SR.
An hour later, the patient had a fall in the shower and
suffered a fractured neck of femur.
At the time the patient’s BP was 65/40 mm/Hg.
Mrs White spent a week on the orthopaedic ward and
a further 6 weeks in rehabilitation.
Kerry Fitzsimons Sept 2013
Preventing Wrong Injectable Route Errors
Wrong parenteral route mix ups can be
prevented through clear labelling of all
lines and medication containers (syringes
and infusion bags) in accordance with
the National Labelling Recommendations
for User Applied Labelling of Injectable
Medicines, Fluids and Lines
 Lines should be clearly labelled to identify the route of
administration
 Syringes should be clearly labelled to identify their contents
using colour codes labels to indicate the intended route
Kerry Fitzsimons Sept 2013
Labelling
Syringes
Preventing
Wrong Route Errors
A patient suffering an asthma attack was
prescribed nebulised salbutamol (Ventolin),
ipatropium bromide (Atrovent ) and
intravenous hydrocortisone.
• All three medications were drawn up into
syringes and placed in a kidney dish to
be taken to the patient.
• As the syringes were not labelled, the
patient was administered the salbutamol
and ipatropium bromide intravenously
and experienced atrial flutter.
This would not have occurred if:
• Each drug was prepared and administered individually.
• Each syringe was labelled appropriately.
• Nebules were used instead of nebuliser solutions
Preventing
Wrong
Route
Errors
Oral Liquids and Oral Syringes
Any product administered into a patient’s vein must be:
□
Non-irritant
□
Particle free
□
Sterile
Oral doses are not equivalent to IV doses.
Oral syringes must be used to measure liquids for oral administration
Kerry Fitzsimons Sept 2013
Adverse Drug
Drug Reaction
4.7
Adverse
ReactionDocumentation
Documentation
Responsibility of Clinician to:
Ensure that the nature of each ADR is clarified.
Ensure clinically important ADRs are appropriately
documented on/in:
 all medication charts,
 the current medical notes,
 the cover of the medical notes, and
 in the discharge summary
(as per Operational Directive 2079/06)
Patient should wear a red alert bracelet
Kerry Fitzsimons Sept 2013
AdverseDrug
DrugReaction
Reaction
Documentation
Adverse
Documentation
4.7
• Ensure patient has not had a previous reaction documented to a
medication prior to administration
• Ensure that the medication is not in the same class of medicines
that the patient has had a prior reaction.
• Be aware of cross-sensitivity between classes
i.e. Cephalosporins have a 10% cross-sensitivity with penicillins
• Check for products containing multiple medications
i.e. Tazosin - Piperacillin (a penicillin) and tazobactam
Amoxycillin 250mg/5mL
Chest infection
Kerry Fitzsimons Sept 2013
Standardised
Abbreviations
for Safety
Acceptable
Prescribing
Abbreviations
Should be written as
12 units
What can go wrong….
12 U of insulin misinterpreted
as 124 Units of insulin and
given to patient.
Kerry Fitzsimons Sept 2013
SQuIRe
Medication
Reconciliation
Medication
Reconciliation
4.6, 4.8, 4.12
Improve medication reconciliation processes:
• Best possible medication history documented
• Confirmation of medications with a second
source
• Reconciling differences identified with doctor
• Ensuring clinical handover of a patient’s
medications between the patient, doctor, nurse,
pharmacist and community clinicians at discharge
(GP/ Nursing Home/Community Pharmacist)
Kerry Fitzsimons Sept 2013
WA Medication History and
Management Plan (WA MMP)
WA MMP was developed by the WA
Medication Safety Network to meet WA Health
requirements for medication reconciliation.
The Medication History and Management Plan
is designed to meet the requirements of:
• The APAC Guidelines
• The WA Pharmaceutical Review Policy –Std 2,
• The NSQHS Standard 4 Medication Safety
• 4.6 (BPMH), 4.7 (ADR), 4.8 (Reconciliation),
4.12 (Communication to patient and community
clinician), & 4.15 (Patient information provision)
• The Australian Safety &Quality Goals for
Health Care Priority Area 1.1- Medication Safety
Kerry Fitzsimons Sept 2013
Medication Reconciliation Audit Tools
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Medication management processes
Criterion 3 achieved by:
4.11 High risk medicines identified are
• stored,
• prescribed,
Health service has list of
high risk medicines
• dispensed, and
A
Antimicrobials and Antipsychotics
• administered safely.
P
Potassium and conc. electrolytes
• Also high risk processes
I
Insulins
N
Narcotic analgesics and sedatives
C
Chemotherapeutic agents
(4.11.1
and 4.11.2)
Resource
H Heparins and other anticoagulants
Medication Safety Alerts webpage
http://www.safetyandquality.gov.au/our-work/medication-safety/medication-alerts/
Kerry Fitzsimons Sept 2013
Top 10 Most Frequently Reported Medications
Involved in Medication Incidents (2012)
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High Risk Medications
Definition
“Medications which have a heightened
risk of causing significant or
catastrophic harm when used in error.”
A list of high risk medications should be determined by each
health site.
This list may include;
• “A PINCH” medications
• Medicines with a low therapeutic index
• Medicines that present a high risk when administered via the wrong
formulation or route.
Risk Reduction strategies
1)
Prevent errors from occurring
2)
Encourage transparency when errors are made, and
3)
Mitigate harm.
Kerry Fitzsimons Sept 2013
Key Strategies for Safeguarding
High Risk Medications
• Reducing or eliminating the risk of error
• Making errors visible
• Minimising the consequence of error
• Monitor patients receiving high risk medicines
• Reviewing and learning from improvement
Kerry Fitzsimons Sept 2013
Key Strategies for Safeguarding
High Risk Medications
Kerry Fitzsimons Sept 2013
The Patient
• Majority of hospitalised patients are aged
between 75-85 years.
• High Risk Patients are defined as
–
–
–
–
–
–
>55 years of age
> 5 regular medications
> 2 co-morbidities
Prescribed High Risk Medications
Difficulty managing medications
(vision & cognition impairment, literacy &
language difficulties)
• The more medications a patient is taking….
→ The Higher Risk of Adverse Drug Events
Kerry Fitzsimons Sept 2013
Governance and systems for
medication safety
Training programs for staff
• medication safety risks, strategies to reduce the risks
• NIMC on line learning module
• Antimicrobial prescribing modules
• Medication reconciliation training resources
National Prescribing Service (NPS)
• Medication Safety Modules
• NIMC Online Training Course
• Antimicrobial Prescribing Modules
Kerry Fitzsimons Sept 2013
Further information
Contact
For further information:
Visit
OSQH Medication Safety Website
http://www.safetyandquality.health.wa.gov.au/medication/index.cfm
OSQH Accreditation Website
http://www.safetyandquality.health.wa.gov.au/initiatives/accreditation.cfm
Kerry Fitzsimons (Medication Safety Pharmacist) [email protected]
Going to Hospital and Managing your Medicines – Consumer DVDs
Available : http://www.safetyandquality.health.wa.gov.au/hospital/medication.cfm
Kerry Fitzsimons Sept 2013
National Safety & Quality Goals
Priority 1 - Medication Safety
• Reduce risk of older consumers experiencing Adverse Medication Events
– Annual medicines reviews eg HMRs
– Medication reconciliation on admission to & discharge from hospital
• Reduce risk of paediatric patients experiencing dose related Adverse
Medication Events
– Dose calculation documented on Paed NIMC
• Reduce risk of adults experiencing VTE when hospitalised
– Risk assessment for all patients admitted to hospital,
– appropriate prescription for prophylaxis
• Reduce risk of consumers in community on warfarin experiencing Adverse
Medication Events
– Risk/benefit assessment
– Improved clinical handover from hospital to GP
– Documentation accessible to patient and all care providers
Kerry Fitzsimons Sept 2013
IntravenousMedicines
MedicinesGiven
GivenIntrathecally
Intrathecally
Intravenous
• A number of medications, such as
opioids, corticosteroids and
chemotherapeutic agents
(e.g. methotrexate) are routinely
injected intrathecally.
• Medication administered for
intrathecal administration must be
specially formulated and not
contain any preservatives.
•
Vinca alkaloids (i.e. vincristine) have been administered
intrathecally in error resulting in devastating neurological
effects (85% of cases of this type of error have resulted in
death). All vincristine products must be labelled
“FOR INTRAVENOUS USE ONLY – Fatal if given by other
routes”
Kerry Fitzsimons Sept 2013
Key Strategies for Safeguarding
High Risk Medications
• Failure Mode and Effects Analysis (FMEA) and Self
Assessments
• Forcing Functions and Fail Safes
• Limit Access or use
• Maximum access to information
• Constraints and Barriers
• Standardise
• Simplify
• Externalise or Centralise Error Prone Processes
Kerry Fitzsimons Sept 2013