how to harm children with medicines a guide for pharmacists l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
How to Harm Children with Medicines – a guide for pharmacists * PowerPoint Presentation
Download Presentation
How to Harm Children with Medicines – a guide for pharmacists *

Loading in 2 Seconds...

play fullscreen
1 / 45

How to Harm Children with Medicines – a guide for pharmacists * - PowerPoint PPT Presentation


  • 107 Views
  • Uploaded on

How to Harm Children with Medicines – a guide for pharmacists *. James Wallace – Yorkhill Hospital Glasgow Peter Mulholland – Southern General Hospital Glasgow. *With apologies to Professor Imti Choonara. Learning outcomes. Definitions & identification of medication errors

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'How to Harm Children with Medicines – a guide for pharmacists *' - dee


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
how to harm children with medicines a guide for pharmacists

How to Harm Children with Medicines – a guide for pharmacists*

James Wallace – Yorkhill Hospital Glasgow

Peter Mulholland – Southern General Hospital Glasgow

*With apologies to Professor Imti Choonara

learning outcomes
Learning outcomes
  • Definitions & identification of medication errors
  • Extent & nature of medication errors in children
  • Strategies to avoid errors
slide3

Definition

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 the health care professional, patient or consumer

in the uk
In the UK
  • The UK Department of Health in 2000 recognised that a weakness of the NHS is in preventing serious incidents in which patients are harmed or experience poor outcomes of care.
npsa 2007 safety in doses improving the use of medicines in the nhs
NPSA 2007. Safety in doses: improving the use of medicines in the NHS.
  • National Reporting and Learning System - 60,000 incidents reported in 18 months
  • Children ≤ 4years involved in 10% incidents where age stated
npsa 2007 safety in doses improving the use if medicines in the nhs
NPSA 2007. Safety in doses: improving the use if medicines in the NHS

Recurring themes

  • Problems with injectable medicines
  • Gentamicin – NPSA alert issued Feb 2010
  • Children being treated in non-paediatric areas
  • Errors in dose calculation
  • 10 fold errors
  • Vaccines
most common error type
Most common error type
  • Dosing errors 28%
  • Route of administration 18%
  • MAR transcription & documentation 14%
  • Wrong date 9.9%
  • Frequency 9.4%
classification of errors
Classification of errors
  • Wrong dose administered
  • Dose omitted
  • Additional dose given
  • Wrong drug given
  • Wrong infusion rate
  • Dispensing / labelling error
  • Wrong I/V concentration
  • Wrong patient
  • Wrong route
  • Other
how do errors occur
How do errors occur?
  • Medication errors are almost never caused by the failure of a single element or the fault of a single practitioner
  • Usually the result of the combined effects of ‘latent’ errors in the system combined with ‘active failures by individuals
why do individuals make errors
Psychological state

Interruptions

Lack of information

Calculation errors -Electronic calculators

Corporate livery

Confirmation bias

Tiredness/stress

Noise

Temperature

Workload/staffing levels / Rotas

Why do individuals make errors ?
slide19
Unreasonable to expect absolute perfection or error free performance from any person
  • Systems need to be in place to minimise the risk of medication errors by providing opportunities for checks, good communication, and a stress free environment
  • In any post error evaluation process - any system deficiencies should be identified and corrected before placing all responsibility on human error
why are children at greater risk of medication errors what can we do about it
Why are children at greater risk of medication errors?& What can WE do about it?
  • Drug doses calculated individually
    • Based on age, weight, surface area
    • More calculations
    • Weights change rapidly (esp neonates)
    • 10-fold errors
  • Inadequate information
  • Incorrect use of dose information resources
why are children at greater risk of medication errors what can we do about it22
Why are children at greater risk of medication errors?& What can WE do about it?
  • Lack of suitable dosage forms and concentrations
  • Need for complex calculations & dilutions by medics/nurses/pharmacy
slide23
Medication errors with the potential to cause harm are eight times more likely to occur in neonatal intensive care units (NICUs) compared with hospital patient care areas for adults.

Kaushal R, Bates DW, Landrigan C et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285:2114–20.

medication errors in children more likely with unlicensed medicines
Medication errors in children more likely with unlicensed medicines

13% of errors caused moderate harm and 60% of these involved unlicensed and off label drugs. Medication errors causing moderate harm were significantly more likely to be associated with unlicensed and off label drugs than licensed drugs

Reference: Arch Dis Child, published early online 4 December 2010

slide25
Children can’t always tell us
    • if we’re about to make a mistake
    • if they suffer adverse effects
  • Children have less internal reserves with which to ‘buffer’ the effects of errors
strategy for error reduction
Reporting system

Review of errors

Identification of system weaknesses

Change of policies / procedures / training / availability of information

Feedback to staff

Non disciplinary

Confidential telephone line

Strategy for error reduction
what has been done
What has been done?
  • Ward-based clinical pharmacist 95%
  • Computerised physician order entry with decision support 68%
    • e.g. drug-allergy; drug-dose; drug-drug interaction checks
  • Computerised medication administration record 18%

Kaushal R et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-20

interventions
Interventions
  • Increased input from clinical pharmacists
    • Prospective review of 10778 medication orders in two children’s hospitals
    • Analysed 10 error prevention strategies
    • 3 interventions had the greatest potential impact
      • clinical pharmacists might have prevented 81.3%
      • computerised prescribing might have prevented 72.7%
      • improved communication between staff might have prevented 47.7%
      • In combination 98.5% could potentially have been prevented.

Fortescue et al, Pediatrics. 2003;111:722-9

slide36
Simpson et al (Arch Dis Child 2004) Glasgow
    • Pharmacist led education programme
    • Errors fell from 24/1000 to 5/1000
    • Change in staff increased rate to 12/1000
    • Still lower than before intervention
ways to avoid
Ways to avoid?
  • Education for prescribers (& testing?)
  • Rules regarding zeroes/decimal points
  • Ready access to paediatric drug dosing texts
  • Avoid calculations by use of standard doses/dose charts etc
  • Provide drug monographs of high risk drugs
  • Individualised emergency drug dose chart
other ways to avoid
Other ways to avoid?
  • Check weight is appropriate for age
  • Ensure dose is not > adult dose
  • Do not accept poor/ambiguous prescriptions
  • Accurate patient history taking
    • involve families
    • maintain patient profiles for regular patients
other ways to avoid39
Other ways to avoid?
  • Avoiding interruptions
    • tabards
    • quiet room
    • medication nurse/technician
  • Double checking
  • Root-cause analysis of all major errors
purchasing for safety
Handwritten drug name

Verbal drug name

Dose overlap

Presentation

Directions & frequency

Purchasing for safety

Assess all new products before introducing:

  • Indication
  • Alphabetical location
  • Packaging & labelling
  • Information
storage for safety
Storage for safety

Numerous commercially available parenteral medications indicated for neonates were being stored on shelves in the central pharmacy adjacent to similar-sounding and similar-appearing medications for adults.

  • Resolution

Neonatal medications were segregated into a “neonates only” portion of clearly marked shelving. Purchasing personnel created this new segregated shelving space and allocated purchased medications to this space when deliveries arrived from the distributor

summary
Summary
  • Acknowledge the problem
  • Quantify it’s extent and causes
  • Cease finger pointing
  • Analyse all errors via quality assurance
  • Evaluate proposed solutions
summary of learning points
Summary of learning points
  • Establishment of a medication error review scheme is essential
  • A ‘no blame’ system of reporting should be established
  • Suitable paediatric reference sources should be readily available
  • Users should be aware of problems relating to unlicensed or off label drug use
  • Patients / carers should have suitable information
slide45
Any system that helps prevent medical mistakes, by helping doctors come forward without the fear of being blamed, would hold real benefits for the NHSMichael Wilks, chairman of the British Medical Association's Medico-Legal Committee