Prescribing Safely Aims of talk . Why me What is a medication error Incidence of errors
Bernstein, Jamie, Contributing Editor has reference to this Academic Journal, PHwiki organized this Journal Prescribing Safely Kevin Gibbs Pharmacy Manager: Clinical Services University Hospitals Bristol NHS Foundation Trust Aims of talk . Discuss the pitfalls of drug history taking Introduce medicines reconciliation Help you to reduce risk from prescribing medicines Identify sources of in as long as mation which will help you prescribe safely Revision from 3rd year talk! Give you pointers to ask on your placements
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Why me You will do this every day You will be responsible as long as your prescribing You will make prescribing errors You will be expected to prescribe to NPSA competencies (Eg Anticoagulant & IVs) You need to be aware of potential pitfalls You need to think about prescribing safely You need to know when to ask as long as help What is a medication error a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer Incidence of errors The precise incidence of medication errors in the NHS is unknown ~10-20% of all ADRs are due to errors In USA 1.8% of hospital admissions have a harmful error leading to 7000 deaths per year In Australia 1% of all admissions suffer an ADR due to medication error
Common error types Wrong patient Contra-indicted medicine Wrong drug / ingredient Wrong dose / freqency Wrong as long as mulation Wrong route of administration Poor h in addition to writing on Rx Incorrect IV administration calculations or pump rates Poor record keeping Paediatric doses Poor administration techniques Most common types of medication error reported
Commonest causes of medication errors Lack of knowledge of the drug 29% Lack of knowledge about the patient 18% rule violations 10% Slip or memory loss 9% JAMA 1995;274:35-43 Top Therapeutic Groups Reported Prescribing responsibilities Drug Dose Route Frequency For parenteral therapy Diluent in addition to infusion volume Access line as long as adminsitration Rate of administration Duration of treatment Allergies in addition to sensitivities
Provide a prescription that is LEGIBLE (!!!!!) Legal Signed Giving ALL in as long as mation to allow safe administration Controlled drugs The requirements as long as a hospital take-home prescription are the same In your h in addition to writing: Name in addition to address of patient Drug in addition to dose Form in addition to strength of the drug Modified release Strength if liquids/injections Total quantity (or no. of dosage units) in WORDS in addition to figures) Drug history taking What in as long as mation should be gathered during a drug history What is the aim of the drug history Where do you find the in as long as mation What is Medicines Reconciliation
Drug Histories: What in as long as mation Current medication Dose Form Strength Frequency Indication Past medication in addition to treatment failures Over the counter medication Recreational drugs Adverse reactions Allergies in addition to sensitivities – with clinical detail Estimate of patient adherence / concordance with their medicines DHx: In as long as mation Sources GP admission letter GP records From surgery / fax Patients own tablets Dosetts = Multi-compartment compliance aids Written lists Patient / carer Nursing home as long as m Pharmacist patient records Recent discharge letters
GP admission letter Do not always contain a drug history Can only contain those deemed relevant to admission Out-of-hours No in as long as mation as long as out-of-hours GP services to call on; so incomplete or reliant on patients memory / own medication GP records Should be definitive; but: May be inaccurate / incomplete if: Recent discharge not reached GP in addition to acted upon Recent discharge had changed medicines with no explanation Some drugs are secondary-care only or issued in specialist units eg post-transplantation / specialist clinics (CF, psychiatric etc) These may not be on the GP record The doses may be altered by the originating unit not the GP, so GP records may not be accurate GP records – 2 Private prescriptions may not be recorded on GP computer Watch the date last issued Has this been stopped Is the patient no longer taking the medicine Adverse reaction Lack of effect Will have allergies in addition to sensitvities
Patients own medicines Are these as long as the correct patient Easy to pick up a relatives medicines by mistake Easy to miss if the same surname Are they still taking these Stopped without GP being aware Stopped with GP agreement but still on GP list Stopped a while ago but kept just in case Contents of medicine cupboard emptied! Compliance aid boxes have lists inside Previous drug chart or discharge letter How current are these More recent changes Check with the patient Incidences of errors with typist-generated letters Co-careldopa 3.125mg tds Prescribed on next admission Was 31.25 tds Electronic discharge summaries Errors from picking incorrect drop-down list
Nursing Home list MARs sheet Medication Administration Record Similar to a hospital drug chart Should be an accurate list Community pharmacist records If one pharmacy is used regularly this can be a additional source of in as long as mation Open on saturdays Will include all prescriptions dispensed fo that patient including But may also miss hospital-only medicines Top 10 drug groups most commonly associated with preventable drug-related admissions Howard et al Which drugs cause preventable admissions to hospital A systematic review. Br J Clin Pharmacol 2006;63(2):136-147.
Other common pitfalls Prescribed & labelled As directed Own tablets not brought in Several possible strengths eg inhalers Trade names beware duplicates Patient cant remember Dosett boxes X tablet identification Asking about your tablets Patients will then miss off inhalers, creams etc! Take extra care if: Impaired renal function Hepatic dysfunction Children The elderly Drug is unknown to you Very new drug Medicines Reconciliation: Definition Definition Collecting an accurate list of the patient’s home medicines, using that list to write prescriptions; in addition to documenting changes or discontinuation of medicines in addition to doses National Guidance National Institute as long as Health in addition to Clinical Excellence: Patient Safety Guidance 1. Technical patient safety solutions as long as medicines reconciliation on admission of adults to hospital.
Summary: Safe prescribing Clear in addition to unambiguous Use approved names No abbreviations eg ISMN Unless G or mg then write units in full (micrograms or nanograms) Avoid decimal points if needed then make very clear: .5ml X 0.5ml Avoid a trailing zero: 1.0mg X 1mg Avoid fractions: 0.5mg X 500 micrograms Rewrite charts regularly If amend prescription re-write or sign in addition to date amendment For frequency use st in addition to ard abbreviations eg od / bd / tds etc If using a dose by weight calculate the dose needed (NOT 1.5mg/kg) Take time (e.g. to read patient in as long as mation) Use your resources When in doubt – ASK
Bernstein, Jamie Contributing Editor
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