Embed Size (px)
Citation preview
Dr David AlldredLecturer in PharmacyAcademic Unit of Medicines ManagementUniversity of [email protected]
BackgroundPatient safety initiatives of early 2000’s supplemented by DH policy research initiative:
Patient Safety Research Portfolio at:http://www.pcpoh.bham.ac.uk/publichealth/psrp
Commissioned research on medication errors in care homes.Care Homes’ Use of Medicines Study•Prof Nick Barber (University of London)•Prof Theo Raynor (University of Leeds) •Prof Peter Buckle (University of Surrey)
www.pharmacy.ac.uk
Care homes’ use of medicines study (CHUMS)Aims
1. To identify the frequency and causes of medication errors (prescribing, monitoring, dispensing, administration)
2. To determine the potential harm
3. To suggest solutions
(Alldred et al 2009; Barber et al 2009)
Methods256 randomly selected residents from 55 homes in W Yorks, Cambs and London (38 mixed care)
Visited homes:observed staff/records observed medicinesobserved administrations (2 drug rounds/resident) interviewed care home staff.
ResultsMean age 85, on mean of 8 meds
7 out of 10 residents were exposed to at least one medication error (mean of 1.9 errors/resident)
Prevalence of prescribing errors 8.3% of medicines (39% of residents)Monitoring errors 14.7% of medicines (18% of residents)Dispensing errors 9.8% of medicines (37% of residents)Administration errors 8.4% (22% of residents)
Administration errorsPrevalence of 8.4% (1 in 12)
Half were omissions, one-fifth wrong dose
Residential > Nursing? (adjusted OR 1.77 95% CI 0.96 to 3.25)
Types of administration errors
Omission Allergy error Extra dose(s) Wrong dose Unprescribed drug
Drug incorrect Formulation error Route errorDeteriorated drug Timing error
Omission: Fluoxetine 20mg capsules were prescribed “one daily” for depression and not administered for 6 days as drug not in stock.
Wrong dose: Casodex® (bicalutamide) 150mg tablets “one daily” were prescribed by the hospital for prostate cancer; the prescription was continued by the GP generically as bicalutamide and administered simultaneously.
Wrong dose: Glyceryl trinitrate patch prescribed generically “5mg/24 hours take HALF daily” for ischaemic heart disease. A patch was cut in half and applied to the resident’s chest despite the fact that the contents were leaking out.
Formulation and dispensing systemsCompared different formulations to see if any
difference in error ratesMonitored dosage systems versus
manufacturers’ packaging
(Alldred et al 2011)
Formulation and dispensing systems
When compared to tablets/capsules in MDS, error rates were:
Liquids – 4 times higher
OmissionsNot shaking bottleInaccurate
measurement
(Alldred et al 2011)
Formulation and dispensing systemsWhen compared to tablets/capsules in MDS, error rates were:
Topical/transdermal/injections – 19 times higher
OmissionsWrong dosesExpired
(Alldred et al 2011)
Formulation and dispensing systemsWhen compared to tablets/capsules in MDS, error rates were:
Inhalers – 30 times higher
Not shaking deviceResident not holding
breathSpacer not usedWrong number of puffs
(Alldred et al 2011)
Formulation and dispensing systems
When compared to tablets/capsules in MDS, error rates were:
Tablet/capsules not in MDS – twice as high
(Alldred et al 2011)
Drug sensitivitiesRecord review of 121 residents in 31 homes31 (26%) had ≥1 documented sensitivity48 sensitivities in totalNumber of sensitivities recorded by:
GP 35 (73%)Care home records 29 (60%)Medicines administration record 3 (6%)
Only 2 sensitivities documented on all three records
(Alldred et al 2010)
Recording of drug sensitivities
Causes of errors (CHUMS)Human error theorySystems approach59 interviews with staff who made errors
Multiple causes
Accident Causation Model
ManagementDecisions
and Organisational
Processes
IncidentErrors
Violations
Unsafe ActsWork/ Environment Factors
Team Factors
Individual (staff) Factors
Task Factors
Patient Factors
LATENT FAILURES
ERROR & VIOLATION PRODUCING CONDITIONS
ACTIVE FAILURES
ORGANIS-ATIONAL & CORPORATE CULTURE
CONTRIBUTORY FACTORS INFLUENCING PRACTICE
CARE MAN-AGEMENT PROBLEMS
DEFENCES/ BARRIERS
Causes of errors (CHUMS)
Lack of patient awareness of medicinesPhysical problems e.g. dysphagia, arthritisDispensing and ordering systemsLack of protocolsLack of knowledge and trainingTired, unwell, stressed etc.Verbal rather than written culture
Causes of errors (CHUMS)
Time pressureStaff turnoverDrug round interruptions (up to 12 per hour)Poor communication with pharmacy and GPLack of support from other healthcare
professionalsInaccurate medicines administration recordsPhysical environment –unpleasant smells,
poorly lit, noisy, shortage of space
SolutionsImprove/increase education and trainingDrug round breaksRedesign the drug trolleyReduce number of medicines/dosesPrescribe medicines more evenly over the dayImprove communication with, and support
from, other healthcare professionalsAdequate policiesTechnology e.g. barcoding, ordering systems
Summary
Prevalence of administration errors is high and needs reducing
Medicine-related and patient-related factors may increase the risk of error
Causes are multipleSolutions need to be developed to improve
systemsTechnology has a role
ReferencesAlldred et al 2011. The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. BMJ Qual Saf DOI: 10.1136/bmjqs.2010.046318
Alldred et al 2010. The recording of drug sensitivities for older people living in care homes. Br J Clin Pharmacol 69:553-557
Alldred DP et al 2009. Care home use of medicines study. Medication errors in nursing and residential care homes – prevalence, consequences, causes and solutions. Report to the Patient Safety Research Portfolio. Available at http://www.haps.bham.ac.uk/publichealth/psrp/PS025_Project_Summary.shtml
Barber ND et al 2009. The Care Homes’ Use of Medicines Study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual Saf Health Care 18, pp.341-6. Available at http://qshc.bmj.com/content/18/5/341.abstract
Dean B, Barber N. 2001. Validity and reliability of observational methods for studying medication administration errors. Am J Health System Pharm 58:54–9.
