Medicines Safety for grand round June 19.pptx

medicine safety in hospital

1. Medicines Safety Sadie Han Acting - Medicines Safety Officer and C linical Governance Pharmacist

2. WHO Global Challenge Medication without harm Aim to reduce level of severe and avoidable harm by 50% in 5 years £42 billion worldwide savings from reducing medication errors

3. WHO Global Challenge High risk situations Self: skills, knowledge, capacity Context : environment, patient factors Task: high risk drugs (APINCH) 2. Polypharmacy Often not included in clinical trials, reduced adherence, increased waste, increased drug interactions and ADRs 3. Transitions of care

4. Quarter 1 reported medication incidents 1 st April to 19 th June 2019 Total = 263 incidents 175 no harm 84 low harm 2 moderate harm 2 death (declared as serious incidents)

5. Quarter 1 reported medication incidents Total = 263 incidents 40% prescribing errors 35% administration errors 11% controlled drug discrepancy

6. Omission and delays in the prescribing of pre-admission medication Omission and delays in the administration of critical medicines Gentamicin (lack of levels and multiple doses given within 24hours) Anticoagulation, lack of INR monitoring, no discharge arrangements, omitted and delayed prescribing, duplication of anticoagulants Delays, omissions and inaccuracies in the discharge prescription Omission and mis -selection of insulin Medication Incident Themes

7. WHO Global Challenge Types of prescribing errors: Mis -prescribing (wrong route/dose/patient) Over-prescribing (risk>benefit) Under-prescribing (benefit>risk)

8. Studies show most significant medication error in terms of causing harm is omission of drugs (parenteral anticoagulants followed by antibiotics) The NPSA state that omission of critical medicines can cause significant or catastrophic long-term harm Omission of Medicines

9. List not exhaustive Other pt groups: post-transplant, adrenal insufficiency, antidotes ….. Critical Meds List

10. Reported prescribing errors Q1 2019

11. Omission Incident Patient diagnosed with PE, initiated on edoxaban but did not receive initial 5 days of LMWH as per policy Dalteparin was discontinued before it was due at teatime and edoxaban was prescribed for the following day therefore patient had no anticoagulation for over 24hours Patient re-admitted to hospital with ?increasing infarct

12. Omission Incident An epileptic patient was admitted to AED resus with 2 x seizures lasting approx 20minutes Patient was clerked in as being on anti-epileptics in the admission proforma and a repeat prescription was filed in the patient notes   No antiepileptic medication prescribed on admission Patient had no anti-epileptics for over 24hrs

13. Omission Incident Insulin suspended in anticipation of GKI commencing but insulin was not resumed when the plan was confirmed that the GKI was not to go ahead Patient missed two days of insulin DKA protocol commenced

14. Omission Incident Pt admitted to AED with ?CAP Prescribed on the AED CASCARD IV benzylpenicillin and clarithromycin N o regular medicines or antibiotics were prescribed on JAC and this was not identified until next day Patient became acutely unwell

15. Patient admitted to AED with fractured fibula and tibia Coroner identified patient discharged without anti-coagulation VTE proforma not completed and patient was high risk for VTE Coroner confirmed that the patient has provisionally been assessed by the Pathologist as having died as a result of a VTE Serious Incident

16. SCR will contain list of medicines issued by GP Most patients registered with a GP in the North West will have an SCR Verbal consent required from patient Best interests option in emergency Check date last updated & issue dates (especially if recent hospital admission) Sometimes contains “prescribed elsewhere” – specialist drugs i.e. methotrexate injection Summary Care Record (SCR)

17. Smart Cards To access SCR you need an authorised smart card IT issue smart cards if you do not have one If you have a s mart card you can be granted the necessary permissions by your local s uper user/sponsor Business or office managers should be able to tell you who your departmental s uper u ser is

18. How to access SCR link Or click link : serviceshttp:// ahtpharweb01/epma/newlogin.asp

19. Click here to register using JAC username & email address

20. Select all from SCR page and paste inside the box Click magic button

21. National Update HSIB Report: Inadvertent Administration of an Oral Liquid Medicine into a Vein

22. Thank you for listening