Medication errors
& how to minimise
them!
Kevin Gibbs
Clinical Pharmacy Manager
Bristol Royal Infirmary
Aims
 To provide an awareness of:
 Common medication errors
 How to minimise these
 The National Patient Safety Agency
 Resources available to you to aid in safer
prescribing
Objectives
 By the end of the session you should be able to:
 Define a medication error
 List the ‘Five Rights’
 Understand the NHS role in safer prescribing
 Prescribe safely…………
What is an error?
What is an error ?
 Doses omitted
 Wrong dose
 Unprescribed drug
given
 Wrong dosage form
given
 Wrong route of
administration
 Wrong rate of
administration
Yes
Yes
Yes
Yes
Yes
Yes
 Wrong time of
Yes
administration


time of day
in relation to food etc....
 Using unstable/expired
drug
 Wrong administration
technique
 Incorrect reconstitution
 Extra dose given
Yes
Yes
Yes
Error in ….
 Prescribing
 Dispensing
 Administration
 Counselling/communication
Adverse events – What is the
problem
 Adverse-events per




admission (%)
AE number / year in
UK
Cost in additional
hospital stay (£)
Cost of clinical
negligence schemes/yr
Medication errors = %
of incidents
10%
850,000
£2 billion
£400 million
25%
Incidence
 Difficult to estimate due to varying definitions -
US/UK
 Prescribing errors

3-20 per 1000 prescriptions
 Medication errors

1 per patient per day
 Been estimated that drug errors account for 1/5 of
all deaths due to adverse drug events
Prescribing errors
Process
Error Rate
Prescribing errors
(Primary Care)
Computer generated
7.9%
Prescribing errors
(Primary Care)
Hand written
10.2%
Prescribing errors
(Hospital)
1.5%
Serious Errors
0.4%
Dean B, Schachter M, Vincent C, Barber N. Quality and Safety in Healthcare 2002; 11:340-344
Shah SNH, Aslam M and Avery AJ. Pharm J. 2002; 267: 860-862
Dispensing and Admin Errors
Stage of process
Error Rate
Serious Errors
Dispensing errors (P)
1%
0.18%
Dispensing errors
Undetected (H)
0.0002
Administration
Oral Medicines (H)
3 – 8%
Preparation and admin of
parenteral medicines
13%- 49%
UK references 1 – 12 from Building a safer NHS, Medication Safety
1%
The NHS position on error
 Avoidable failures occur;
 Untoward events which could be prevented recur, often
with devastating results
 Incidents which result from lapses in standards of care in
one hospital do not reliably lead to correction throughout
the NHS
 Circumstances which predispose to failure are not well
recognised
An Organisation with a Memory
Department of Health (2000)
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidan
ceArticle/fs/en?CONTENT_ID=4006525&chk=wlMQiJ
Patient safety
 The process by which an organisation
makes patient care safer. This should
involve:
 risk assessment; the identification and
management of patient-related risks;
 the reporting and analysis of incidents;
 and the capacity to learn from and follow-up
on incidents and implement solutions to
minimise the risk of them recurring.
National Patient Safety Agency




Collect and analyse information on adverse
events
Assimilate other safety-related information
Learn lessons and ensure that they are fed back
into practice
Where risks are identified, produce solutions to
prevent harm, specify national goals and
establish mechanisms to track progress
NPSA: Patient safety incident
 any unintended or unexpected incident
which could have or did lead to harm for one
or more patients receiving NHS funded
healthcare.
 this is also referred to as an adverse event / incident
or clinical error, and includes near misses.
NPSA: Seven steps to patient
safety
 Step 1
 Step 2
 Step 3
 Step 4
 Step 5
 Step 6
 Step 7
Build a safety culture
Lead and support your staff
Integrate your risk management activity
Promote reporting
Involve and communicate with patients
and the public
Learn and share safety lessons
Implement solutions to prevent harm
NHS action on medication errors
 Reduce to zero the number of patients dying or
being paralysed by maladministered spinal
injections by the end of 2001
 Reduce by 40% the number of serious errors in
the use of prescribed medicines by 2005
Building a safer NHS for patients
Department of Health (2001)
www.doh.gov.uk/buildsafenhs
Improving medication safety
January 2004
www. doh.gov.uk/buildsafenhs/medicationsafety
Improving medication safety
1.
2.
3.
4.
Medication safety – a worldwide health priority.
Medication errors: definition, incidence, causes.
The medication process, prescribing,
dispensing, administration.
Reducing risks for specific patients groups.



Patients with allergies
Seriously ill patients
Children
Improving medication safety
5.
Reducing the risks for specific medicines







6.
Anaesthetic practice
Anticoagulants
Cytotoxic drugs
Intravenous infusions
Methotrexate
Opiate analgesics
Potassium chloride
Organisational and environmental strategies




Information management and technology
Improved labelling and packaging
Interfaces between healthcare settings
Education and training for medication safety
Managing medication safety in
secondary care
 NHS Trusts should have dedicated machinery for
organisation wide management of patient safety.
 The CNST has developed new standards for
medicines. This requires trusts to have medicines
management policies, together with annual reports,
improvement programmes with defined objectives
and progress.
Prescribing responsibilities
 Drug
 Dose
 Route
 Rate of administration
 Duration of treatment
 Checking patient allergies & sensitivities
 Providing a prescription that is:




Legible
Legal
Signed
Giving all information to allow safe
administration
Internationally
Research says:

USA
44-98,000 deaths
“To Err is Human”



Australia 250,000 adverse events
50,000 permanent disability
10,000 deaths
“Iatrogenic Injury in Australia”

Denmark confirmed 9% of admissions
Commonest causes of medication
errors
 Lack of knowledge of the drug – 36%
 Lack of knowledge about the patient
 “rule” violations – 10%
 “Slip” or memory loss – 9%
 JAMA 1995;274:35-43
Common error types
 Wrong patient
 Contra-indicated medicine

Allergy, medical condition, drug-drug
interaction
 Wrong drug / ingredient
 Wrong dose / frequency
 Wrong formulation
 Wrong route of administration
 Wrong quantity
 Poor handwriting on Rx
 Incorrect IV administration calculations or
pump rates
 Poor record keeping/checking


double doses
wrong patient
 Paediatric doses
 Poor administration technique
 Complicated prescriptions
 Calculations
 Verbal orders
 Lack of knowledge about drugs
 Mistakes in identifying drugs



names
packaging
misreading
Examples
 Rx: Insulin 7  stat
 read as 70 units, given
 Erythromycin 500mg IV
 Highly irritant – should
in 50ml
 ISMN 10mg
be 250-500 ml
 ISTIN 10mg given


 Vancomycin IV 1g
Isosorbide mononitrate
given instead of
amlodipine
given as bolus rather
than infusion

cardiac arrest
 Ceftazidime 2g tds IV

written badly

 Methotrexate 20mg
daily (Dx: RA)
 Digoxin 125mg IV

Should be weekly


loading dose 10mg od

Neutropenia
Should be micrograms

 Discharged on warfarin
Cefotaxime given
given - cardiac arrest
Not referred for dose
adjustment to clinic


14days of 10mg od
INR 12.3
 Weight-related dose for
tinzaparin – 80kg body
weight estimated
 CABG patient,
standard therapy
 Galantamine re-started
after a gap 8ml qds
 Patient was 51kg
 Thyroxine missed on
admission, discovered
day 10
 Should have been
12mg (2ml) bd

PRHO confused over
liquid strength
 Anaesthetist adjusted
rate of fentanyl syringe
pump in Theatre
 Rx: Co-amoxiclav

Penicillin-alllergic
 Rx: morphine 0.4ml
 30% sodium chloride
used instead of 0.9% to
dilute an epidural
 New pump. Increased
rate x 1000

Respiratory arrest
 Did not realise this is a
penicillin – anaphylaxis
 4ml given
 Severe pain
 Rx: Ranitidine 50mg
 In Theatre: Sodium
chloride flush for a
central line switched
with fentanyl
 IV line flushed with
sodium chloride 0.9%
 Given via epidural line
rather than central line
 Respiratory arrest.
Syringes made up in
advance and not
labelled
 Was in fact Potassium
15% - death.
Ampoules look similar
in design.
Case study 1 – "Cambridge"
 Rx Methotrexate 17.5mg once a week
 New Rx 10mg once a day
 10mg daily dispensed by locum pharmacist
 Rx error noticed by 2nd GP, but the computer
record was not altered
 +5/7 patient admitted to ENT ward
 Drug chart written for 100mg daily
 +1/7 Nurse d/w patient – back to 10mg od
 +1/7 Pharmacist queries and asks nurse to ask Dr
to check dose
 GP records confirm 10mg od
 +2/7 blood tests re-checked } Haem
 +5/7 patient dies
Case study 2 – “Nottingham”
 Rx Intrathecal methotrexate under GA in
theatre by Oncology Reg & intravenous
vincristine on ward by specialist nurse
 "Outlied" on non-specialist ward
 Both drugs delivered to theatre from ward
 Given food pre-op – op postponed
 Orignal SpR off-duty now
 Cover SpR unable to leave ward, anaesthetist to
admin intrathecal drug
 Aneasthetist had given I/Thecal drugs before but
had never given chemotherapy
 Methotrexate given intravenously
 Vincristine given intrathecally
 Patient died
How to handle errors
 Is there an acceptable rate ?
 Should errors be graded or scored for
severity ?
 Blame vs. No blame
 Analyse why the errors have occurred and
try to prevent reoccurrence
When things go wrong
The "patient-centered“ approach
 Identify an individual to blame
 Focus on events surrounding the adverse
event
 Focus on the human acts or omissions
immediately preceding the event
 Blame, name & shame
Myths
 Perfection myth

If people try hard enough they will not make
any errors
 Punishment myth

If we punish people when they make a errors,
ther will make fewer of them
Or/ “Active learning”
= Understanding causes of failure
Human error may precipitate
a serious error
but
Deeper, systematic, factors are usually present

Addressing these would have prevented the error
 Humans are fallible

Errors are inevitable
 Change work conditions to make humans
less error-provoking


Why did the defences fail?
What factors contributed to the failure?
 CPD
How can we help you?
Clinical
pharmacists
How can we help you?
Medicines
Information
Department
How can we help you?
Formularies
and
Prescribing
guidelines
MEDICAL DIRECTORATE ANTIBIOTIC GUIDELINES
1)
3)
4)
5)
Don’t use IV antibiotics without good cause
2) Don’t use multiple antibiotics without good indications
Don’t give IV therapy for more than 2 days without review (nurses/pharmacists will request new prescription) (IV to Oral policy)
Don’t prescribe antibiotics for acute asthma without strong evidence of bacterial infection (usually viral)
Review antibiotics when results e.g., urine, blood, sputum cultures etc are available.
Use oral antibiotics for 5-7 days unless otherwise stated.
Doses assume adult with normal renal function
INFECTION
COMMENTS
DRUG
DOSE
DURATION OF TX
Intravenous Benzylpenicillin should be switched to oral Amoxicillin where appropriate.
Infective Exacerbation of
COPD
Community Acquired
Pneumonia
Risk Factors in CAP
(CURB-65)
C = confusion MTS 8 or less
U = Urea >/= 7mmol/l
R = Resp. Rate >/= 30/min
B = BP Systolic < 90 mmHg
+/- Diastolic </= 60 mmHg
65 = age >/= 65 yrs
Amoxicillin
Moxifloxacin
Amoxicillin
500mg po 8 hourly
400mg po once daily
500mg po 8 hourly
Mild – if atypical
suspected or penicillin
allergic
Severe
Moxifloxacin
400mg po once daily
Benzylpenicillin
PLUS Ciprofloxacin
Severe – penicillin
allergic
Levofloxacin
2.4grams (4mu) iv 6 hourly
750mg po 12 hourly
500mg iv 12 hourly
If penicillin allergic
Mild
5 days
7-10 days
7-10 days
Switching to oral
Moxifloxacin
400mg po once daily
Legionella Pneumonia
Ciprofloxacin
PLUS Rifampicin
750mg po 12 hourly
300mg-600mg iv/po 12 hourly
2-3 weeks
Suspected
Staphylococcal
Pneumonia
Flucloxacillin
PLUS Gentamicin
2 weeks
5 days then review
Amoxicillin
2grams iv 6 hourly
4mg/kg/day
iv single daily dose (check
trough level)
2.4grams iv 6 hourly
500mg iv 8 hourly or 1gram
pr 8-12 hourly
500mg po 8 hourly
Moxifloxacin
400mg po once daily
Benzylpenicillin
PLUS Ciprofloxacin
(Consider Vancomycin
instead of Benpen. – if MRSA
colonised)
2.4grams (4MU) iv 6 hourly
750mg po 12 hourly
(1gram iv 12 hourly
and check levels)
Ceftriaxone
4grams iv once daily
Benzylpenicillin
PLUS Metronidazole
Aspiration Pneumonia
Mild Nosocomial
Chest Infection
If penicillin allergic
Severe Nosocomial Chest
Infection
Meningitis
All Cases
Initial treatment THEN
discuss further
management with
microbiologists
Cellulitis
If penicillin allergic
Cellulitis in Diabetics
If Over 55yrs ADD
Ampicillin
Benzylpenicillin
PLUS Flucloxacillin
Clindamycin
Co-amoxiclav
2grams iv 4 hourly
2.4grams (4MU) iv 6 hourly
1gram iv 6 hourly
600mg iv 6 hourly or 450mg
po 6 hourly
625mg po 8 hourly
Depends on
individual case.
OR
Ciprofloxacin
PLUS Clindamycin
Trimethoprim
Ampicillin
PLUS Ciprofloxacin
Urinary Tract Infection
Urinary Catheter
Infections
and Pyelonephritis
Sepsis of unknown
source
PLUS
Stat dose Gentamicin
Mild
Severe
(Life Threatening)
Benzylpenicillin
PLUS Ciprofloxacin
Ceftriaxone
PLUS Gentamicin
750mg po 12 hourly
450mg po 6 hourly
200mg po 12 hourly
1gram iv 6 hourly
750mg po 12 hourly
4mg/kg iv single dose
2.4grams (4MU) iv 6 hourly
750mg po 12 hourly
4grams iv once daily
4mg/kg/day iv single daily
dose (check trough)
3 days
How can we help you?
 Resources
BNF
Medicines
for Children
Safe prescribing: A summary


Clear and
unambiguous

Care with units

Legal

Is it weight/BSArelated dosing. Is
weight accurate?
Approved name

No abbreviations

Care with IVs
 Clear decimal
points
0.5ml not .5ml
 Rewrite charts
 ***** In English
 If abbreviate use
‘standard’ ones
 od / bd / tds / qds
regularly
 NOT 250mg3
 Take time, eg to
read labels
 Care if:






Impaired renal function (NB: GFR)
Hepatic dysfunction
Children
The elderly
Drug unknown to you
Very new drug
The “5 Rights”
• the right patient
• the right drug
• the right time
• the right dose
• the right route
If in doubt ……..
Please ask
Further reading/references
 Naylor, R. Medication Errors. Radcliffe
Press. ISBN 1857759567
 Department of Health. (2004). Building a
safer NHS. Improving patient safety.
 National Patient Safety Agency (NPSA) (UK)

Website:
http://www.npsa.nhs.uk/
 Institute for Safe Medication Practices
(ISMP) (American)

Website:
http://www.ismp.org/