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Safety Snippets May Two weeks too long An epileptic patient has been left with severely compromised speech and mobility when they were left without medication for 2 weeks. The post-discharge review appointment was not scheduled to take place before the patient ran out of medication. • Safety Resource of the Month NICE NG5 Medicines Optimisation Guidance on transitions. 2015 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets May 2015 Concentration is Critical Prescribing Insulin is complex, error prone and high risk. D – Drug Name. Prescribe by Brand. Check for errors with similar named products. D – Device. Check changes are intended and agreed with the patient. D – Dose. If the dose is included on the prescription make sure it is reviewed and updated. D – Duration. Check for short and longer acting insulin mix-ups D – Deadly. Ensure high-strength insulins are intended before prescribing • Safety Resource of the Month MHRA guide to prescribing insulins: www.gov.uk/drug-safety-update/high-strength-fixed-combination-and-biosimilar-insulin-products-minimising-the-risk-of-medication-error Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets April 2015 Prednisolone Perils Prescribing oral steroids is error prone. Our Datix system has 34 incidents relating to prednisolone or hydrocortisone. Errors include; Dose errors in short courses. Course duration errors. Failure to discontinue and Failure to prescribe protective polypharmacy • Safety Resource of the Month MHRA e-learning tool to manage risks of prescribing steroids www.gov.uk/drug-safety-update/corticosteroids-e-learning-module-launched Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets March 2015 Former Formulary Foul When trying to prescribe atorvastatin the practice formulary offered simvastatin as an alternative. This was a throwback to before the most recent guideline. Check you practice formulary and remove simvastatin as a synonym of atorvastatin. • Safety Resource of the Month Check how safe your prescribing is with the PINCER audit tool http://www.nottingham.ac.uk/primis/tools/audits/pincer.aspx Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Feb Five Alive Remove warfarin 5mg tablets from the repeat list of any patient who does not take a dose of ≥5mg. Don’t add 5mg tablets to repeat unless the dose is ≥5mg. At least annually, advise patients who take white 0.5mg tablets to “watch out” for the red/pink 5mg tablets to avoid errors. • Safety Resource of the Month Page 7 Patient Information Book for warfarin 2015 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Feb Kidney Conundrum 12 reports on Datix highlight the difficulty of prescribing drugs for CKD Patients. Clinicians should set up CKD warnings to appear for patients with CKD stage 3,4 & 5. When prescribing for patients with CKD stage 3,4 & 5 read the on-screen prescribing information for suitability of the selected drug. • Safety Resource of the Month MHRA Safety update on Nitrofurantoin www.gov.uk/drug-safety-update 2015 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Jan All they want is Radio GABA 11 incident reports this year involve Pregabalin or Gabapentin. 6 were dose errors at transitions of care. • Reconcile dose 48 hrs after hosp’ appt . 1 incident included death involving abuse of gabapentin • Safety Resource of the Month PHE-NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf 2015 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Jan I said ‘4T’ not ‘40’! The words used to tell people about dose changes of methotrexate can mislead. • Never assume 2.5mg tablets are in use. • Check if the patient has 10mg tablets. • Always give written instructions stating dose in mg and number of tablets. • Safety Resource of the Month Improving the safety of telephone of verbal orders 2015 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Dec Mortality METHOd • TriMETHOprim increases METHOtrexate toxicity. • The interaction has been fatal. • Degree of harm is not dose dependent. There have been 2 reported incidents of co-prescribing this combination this year in Leeds. Never prescribe trimethoprim to patients on methotrexate (not even a short course or low dose) Educate patients to watch out for this interaction. • Safety Resource of the Month Methotrexate info for patients & Arthritis Research UK 2014 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Dec Thrush Rush Reaction • Oral Miconazole gel interacts with Warfarin, increasing INR. • 1 patient with INR of 22 required blood transfusion as result. • Computer alerts are easily overridden. Nystatin & warfarin are safer. Miconazole and Dabigatran is safe. • Safety Resource of the Month Pharmaceutical Journal Article on this interaction . 2014 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Nov In Datix We Trust Less than 7% of medicines related incidents on Datix are reported to have occurred in Acute Trusts. Use Datix to report hospital incidents relating to DANs, TANs and medicines at admission & discharge . • Safety Resource of the Month #SaferNHS 2014 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Hospitals Safety Snippets Sept Beware the Blaggers Patient’s who attempt to manipulate health systems and prescribers to obtain psychoactive drugs need a whole team approach to their management. Vulnerabilities in the system can include: • Targeting time pressured urgent appointments. • Targeting GP registrar’s or “push over” GPs • Requesting drugs less known for abuse (pregabalin, gabapentin, promethazine etc) • Safety Resource of the Month SMAH Addiction to medicines factsheets www.rcgp.org.uk/smah 2014 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Sept 2014 The Other Trouble Putting ‘Red’ drugs and drugs prescribed elsewhere on the repeat list presents the risk that these drugs will be inadvertently prescribed by the GP. There is a “How to” guide to avoiding this risk. • Safety Resource of the Month SystmOne & EmisWeb Guide to managing “other drugs” in Medicines Management sections of: http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Sept 2014 Always Ask About Allergy 13 drug allergy incidents reported since April’14 Prescribing when not in the GP surgery is a common contributing factor. NICE says: Check a person's drug allergy status and confirm it with them (or their family or carers) before prescribing any drug. Make a @signuptosafety pledge: “I will Always Ask About Allergy” • Safety Resource of the Month www.england.nhs.uk/signuptosafety @SignUpToSafety Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets June 2014 “One” to be watched The SystmOne pre-set dose for warfarin is “One to be taken as directed”. This might be misleading. Change the warfarin dose to “Dose dependent on INR test results” On new prescriptions and repeat templates. • Safety Resource of the Month Health And Social Care Information Centre - Patient Safety Incident Reporting: National Service Desk Telephone – 0845 366 0066 ssd.nationalservicedesk@hscic.gov.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets June 2014 Allergy Alert 2 out of every 5 care home patients have inaccurate allergy status. Inform Care Homes and their supplying pharmacies of your patients allergy status. • Safety Resource of the Month SystmOne & EmisWeb Guide to managing allergy status in Medicines Management sections of: http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets June 2014 Motivation for Monitoring • Medication monitoring shows when drug changes are needed before Adverse Drug Reactions lead to hospitalisation • In 384 care home patients 676 monitoring tests were needed to carry out annual medication reviews, inc. – U&Es for those prescribed ACEi, ARBs, diuretics – TFTs, FBCs, HbA1c – Shared care monitoring for amber drugs inc. antipsychotics • Safety Resource of the Month Guide to monitoring for safer use of medicines: http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Drug%20monitoring%20document %20Feb%202014.pdf Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets June Transition Trouble Transitions of care such as hospital discharge are error prone All medicines changes need accurate reconciliation on GP systems (and MAR charts). The changes should be authorised by a prescriber and made by a clinician. • Safety Resource of the Month http://www.nice.org.uk/nicemedia/pdf/PSG001Guidance.pdf 2014 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets May 2014 Dorment Drugs pose Danger There have been a number of cases of high risk drugs remaining on the repeat list after they were discontinued. eg • • • • Methotrexates tabs on repeat when changed to S/C Warfarin left on repeat after end of 6/12 course. Dabigatran left on repeat when changed to warfarin Aspirin continued when clopidogrel started instead • Safety Resource of the Month Community Pharmacy New Medicines Service: Improves adherence and highlights errors. http://www.cpwy.org/pharmacy-contracts-services/advanced-services.shtml Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets May 2014 Don’t Forget Dementia Two cases reported on Datix of patients on Alzheimer's drugs not receiving a memory clinic review every 6 months. Dementia friends could help support your patients with dementia. • Safety Resource of the Month www.dementiafriends.org.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets MAY 2014 Picking-List Pitfalls Three errors picking the wrong drug have occurred because of the way the GP system presents the drug list: Buprenorphine presented 2mg but not 0.2mg tabs “B12” presented cyanocobalamin not hydroxycobalamin. ‘Polyvinyl alcohol’ presents FML drops as well as liquifilm • Safety Resource of the Month Incident report all such incidents: http://nww.incidentreportform.nhsleeds.nhs.uk/index.php Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets May I don’t need rescuing! A parent with an epileptic child ordered buccal midazolam every month. But the child was never admitted with a seizure. Over-ordering of repeats with PRN doses are not highlighted by GP systems. • Safety Resource of the Month Thinking of making a change? Experiment first using Plan, Do, Study, Act cycles. www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html 2014 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Dec Clozapine Communication 77% of GPs had been correctly informed of their patient(s) being prescribed clozapine ,but only 41% reported the that the information on clozapine would be available at consultation. Recording of Clozapine and other “red drugs” can be improved using the new guides for SystmOne and Emis Web. (See link below) • Safety Resource of the Month http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx 2013 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Dec Sensitive issue Sensitivities to medication have been missed if not entered on the GP system correctly. • Use the guidance documents below to Record ADRs and Allergies. • Safety Resource of the Month http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx 2013 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Sept Stop at home Set a short review date when discontinuing drugs that affect heart rhythm. Provide written advice to staff in care homes on monitoring the patient when stopping drugs • Safety Resource of the Month “Deprescribing” in www.australianprescriber.com/magazine/34/6/182/5 2013 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Oct 2013 Missed the red spot • All DANs and Hospital Letters must be screened by a clinician before changes are made to a patient’s medication. • The Leeds Formulary should be checked if hospital letters include drugs that the GP is not familiar with. • Safety Resource of the Month The Leeds Formulary www.leedsformulary.nhs.uk/ Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets August Yellow Card Reporting • MHRA must now monitor ADRs from medication errors and drug abuse. • Consider ADRs from errors and drug abuse to be reportable. • Use Datix or MHRA Yellow Card to report ADRs • Safety Resource of the Month Yellow card reporting on MHRA website https://yellowcard.mhra.gov.uk/ 2013 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets August Noxious NSAIDS • Make repeat prescribing of NSAIDs the exception rather than the rule. • Always ask the patient about OTC use of NSAIDs at review. • Review NSAIDs regularly with an intention of discontinuing if possible. • Safety Resource of the Month Reminder: MHRA alert on Diclofenac on www.mhra.gov.uk 2013 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets July Lithium levels • Lithium levels are affected by fluid intake. • Risk of dehydration may require additional monitoring for lithium toxicity • Remind care homes to monitor the hydration of patients on Lithium. • Safety Resource of the Month NPSA alert on Lithium www.nrls.npsa.nhs.uk/alerts/?entryid45=65426 2013 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets July Action Allergy • • • • • Capture allergy status from letters/DANs. Record allergy “cause and consequence” Present allergy status prominently. Habitually ask about allergies. Test your systems for barriers. • Safety Resource of the Month www.worldallergy.org/professional/allergic_diseases_center/drugallergy/ 2013 Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets July 2013 Warfarin Wary In May 2013, 617 patients had been prescribed warfarin when they did not have an INR result recorded on the GP system in the preceding 13 weeks. One had not had an INR in the last 14 months. One had not had an INR in years! • Safety Resource of the Month New Warfarin Amber Drug guidelines on Leeds Health Pathways Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets June 2013 Cutting corners A GP squeezed in one more job before surgery started. They didn’t look at all the information presented to them which led to them missing the changes on the DAN. • Give yourself time to concentrate on medication changes. • Safety Resource of the Month Easy time- Management tips on www.nhs.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets June 2013 NOACs & Renal Function There is a clear link between renal function and the safe use of the New Oral Anticoagulants (NOACs), Rivaroxaban, Apixaban and Dabigatran. • Follow the new shared care guidelines when monitoring NOACs • Safety Resource of the Month NOAC Amber Drug guidelines on Leeds Health Pathways Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets June 2013 Symptom or Side Effect 3 patient stories on Datix show how easy it is to miss Adverse Drug Reactions caused by drug errors. • Suspect a Side-effect when new symptoms cannot be explained by the existing morbidities. • Safety Resource of the Month Drug Analysis Prints on www.mhra.gov.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Jan 2013 Equine Colic Pethidine has an established place in therapy for treating horses with colic. However, Pethidine is no longer advocated for pain relief for home births. Any requests for pethidine for home births should be reported on Datix and referred back to the midwife. • Safety Resource of the Month Home Births – Appendix A of “Care of Women in Labour” nww.lhp.leedsth.nhs.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Jan 2013 Abuse potential Pregabalin and Gabapentin abuse is on the increase. They enhance the effects of opiates and have euphoric effects. They can be injected, snorted or taken orally. • Caution in substance using patients. • Tighten control on repeat requests. • Safety Resource of the Month Useful look into abuse potential of drugs from RCGP based on prescribing prisons: www.rcgp.org.uk/news/2011/november/~/media/Files/News/Safer_Prescribing_in_Prison.ashx Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Jan 2013 Drug using patients and SSRIs Methadone & (es)citalopram – QT interval Crack & SSRIs – Serotonin syndrome • Review need to antidepressant • Change to Mirtazipine/sertraline if necessary • Seek advice from CDT clinical lead • Safety Resource of the Month Substance Misuse Management in General Practice www.smmgp.org.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Dec 2012 Red letter days • GPs still receive requests to prescribe red (and black-light) list drugs • Requests from patients can be difficult to refuse. • The reasons for red and black-light classifications are available to patients • Safety Resource of the Month Traffic Light lists on www.leeds.nhs.uk/medicines Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Nov 2012 Weighty decisions Even simple calculations are worth a second look. Errors in calculating the dose based on a child’s weight may not be necessary – Check the children’s BNF for age related doses Include the patient’s weight and the calculations in the script notes • Safety Resource of the Month Children’s BNF available for smart phones: http://www.nice.org.uk/aboutnice/nicewebsitedevelopment/NICEApps.jsp Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Oct 2012 Book’em Danno A review of methotrexate books in one GP practice highlighted inconsistent use. Methotrexate books may not be effective unless incorporated into repeat prescribing systems. • Check for dose and blood results before prescribing. • Safety Resource of the Month Methotrexate shared care guideline on nww.lhp.leedsth.nhs.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Oct 2012 Altered Image Alterations made to prescriptions can lead to dispensing errors • Never make hand written changes to bar-coded prescriptions. • Cross out and clearly re-write the whole change. Initial all changes. • Safety Resource of the Month Ciprofloxacin story on www.leeds.nhs.uk/medicines Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Sept 2012 Focus on opioid errors • • • • • Watch out for mg and ml errors Get the actual opioid history Be cautious when increasing the dose Know your patches Know your s/r from your m/r • Safety Resource of the Month Opioids on www.leeds.nhs.uk/medicines Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets Dose Errors Top the Chart Prescribing the wrong dose or strength was the most commonly reported GP medication error in Leeds in 2011/12. Top Tip: Always review the medication screen after starting, stopping or making changes to a patient’s medication. August 2012 Review of Leeds Medication Incidents on www.leeds.nhs.uk/medicines • Safety Resource of the Month Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets August 2012 Start – Stop – Restart Error A GP restarted warfarin for a patient with AF after it had been stopped by a colleague for compliance issues. • Record the reasons for stopping medication in consultations • Use protected time to review the records before restarting medication • Safety Resource of the Month Receptionist input into Quality and Safety on www.bmj.com Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets July 2012 Interactions Increase INRs A third of patients with INR>8 have been prescribed an interacting drug. Check INRs within 5-7 days of starting warfarin patients on antibiotics marking the blood form “dINR for warfarin clinic” • Safety Resource of the Month Anticoagulant therapy: Information for GPs on www.nrls.npsa.nhs.uk/ Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group Safety Snippets July 2012 1 in 20 scripts includes error A GMC report shows the frequency and severity of GP prescribing errors. Reduce the risk by: • Optimising the support from your computer system • Focus on safety in education, training and peer review • Build a co-operative relationship with pharmacists • Safety Resource of the Month Evidence Scan: Reducing Prescribing Errors on www.health.org.uk Leeds North Clinical Commissioning Group Leeds South & East Clinical Commissioning Group Leeds West Clinical Commissioning Group
