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DART - on target for safe prescribing
Karin Purshouse
Judith Bailey
Jane Hough
Triss Clark
Today
Prescribing errors
What is DART?
Group work
Prescribing errors
Nationally 1 in 10 patients = adverse event 15% of these are medication related
Case
75 year old lady with advanced cancer, brain and bone metastasis
Admitted with general malaise, vague neurological symptoms
Attended with sister and bag of medications
Stated she had forgotten her morphine, but normally took 100mg MST.
Case continued
SHO prescribed 100mg MST and asked sister to check medication at home.
Next day… Medicine reconciliation by pharmacist, found patient
actually took 20mg MST BD. Sister had called the ward and message hadn’t been
handed on. Patient was completely well, slightly drowsy.
Case learning points
Near miss
Prompted this Quality Improvement Project on prescribing.
Prescribing errors can happen to everyone
Any examples?
Evaluation of prescribing in EAU and medical wards – Dec/Jan 2013/14
1 in 5 prescriptions had an error
Nearly HALF were due to drug omissions on admission
Nearly a THIRD were dose-related (mostly over-dosing)
10% were due to incorrect/absent drug timings
Of high-risk drugs, antibiotic and insulin prescribing was least accurate
You are agents for change!
FY1 FY2 Reg Unknown0
5
10
15
20
25
30
35
40
45
Total number of errors per grade of prescriber in medicine
n=59 patientsTotal number of errors per grade of prescriber
D• DOCUMENTATION - Complete the prescription
CLEARLY in full so it can BE GIVEN SAFELY. Clearly document changes to medicines in the medical notes.
A• ALLERGIES - Is the patient allergic to the drug? Have I
checked and documented this?
R• REGULAR MEDICATIONS - Do I know the patients'
regular medications? - Find out via OxCS. Check the pharmacy box in the drug chart.
T• TIME CRITICAL MEDICINES- Does this medication
need to be given STAT? Tell the nursing staff!
Oxfordshire Care Summary
1) Search ‘Oxfordshire Care Summary’
2) Complete training
3)Use when clerking!
For those in AGM/Medicine: Prescribing simulation sessions Multidisciplinary (Nurses, doctors, pharmacists)
Dates: Friday 11th April 2-3pm, 3.30-4.30pm AGM seminar room Wednesday 16th April 2-3pm, 3.30-4.30pm GPEC seminar
room 2B
One hour, coffee+cake and certificate for your e-portfolio
Consultants will be looking for your participation.
Groups
Cases from actual scenarios found in the study
Discuss the cases and amend the prescriptions
Take a DART card for your badge holders