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Medication Error Safe ( er ) Prescribing Gentamicin in Neonates. Anil Tuladhar C Harikumar Debbie Bryan. The Medication Error Iceberg. Top 10 incidents at NTHFT. Gentamicin & Vancomycin. Commonly used Highly active Narrow therapeutic window Significant toxicity - PowerPoint PPT Presentation
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Medication ErrorSafe(er) Prescribing
Gentamicin in Neonates
Anil Tuladhar C HarikumarDebbie Bryan
The Medication Error Iceberg
Top 10 incidents at NTHFT
Gentamicin & Vancomycin
• Commonly used• Highly active• Narrow therapeutic window• Significant toxicity• Need blood level monitoring• Errors common
Fish Bone DiagramPeople
• Nurses – checking• Doctors – prescribing• Babies – all look alike
Place • Busy unit• High turn over• Patient: Nurse
ratio
Process
• Training• Supervision• Counterchecking• Communication• Dosage timing
Policy
• Not explicit• Not adhered to• Different guidelines
What does the alert say?
• A local gentamicin protocol must be availableLocal protocol
• Use the four elements of the care bundleUse care bundle
• Use small cycles of change with a sample of patientsPDSA cycle
• Measure care bundle compliance dailyMeasurement
• All relevant staff should be provided with applicable trainingTraining
Double checking prompt
Local protocol
Use care bundle
PDSA cycle
Measurement
Training
PDSA cycle applied to gentamicin
Local protocol
Use care bundle
PDSA cycle
Measurement
Training•Ensure compliance charts, audit charts and double-checking prompts are all available
•Collect data
•Analyse the data at monthly data review meetings
•What elements of the care bundle need addressing?
•Do we understand the measures we are using?
•Who will analyse the data?•How often will data be analysed?
•Share your results with your staff and senior leaders
• Implement identified actions arising from your data analysis
Act Plan
DoStudy
Local protocol
Use care bundle
PDSA cycle
Measurement
Training
Three steps to measurement
Fill out compliance chart (appendix A) after each administration of gentamicin
Use above compliance charts to populate audit charts (appendix B)
Use above weekly audit charts to populate extranet on a monthly basis
Local protocol
Use care bundle
PDSA cycle
Measurement
Training
Complete the compliance chart
Care bundle compliance
chart
Care bundle daily audit
chart
Extranet / run chart
243 128 462701/01/2010 16.07
Local protocol
Use care bundle
PDSA cycle
Measurement
Training
Complete the compliance chart
Care bundle compliance
chart
Care bundle daily audit
chart
Extranet / run chart
Local protocol
Use care bundle
PDSA cycle
Measurement
Training
Fill out the audit chart and totals
Care bundle compliance
chart
Care bundle daily audit
chart
Extranet / run chart
Audit (Nov’10 – Jan’11)November – 47%
December – 69.5%January – 86.5%
Common reasons for non-compliance1. Dose not given within 1 hr of prescription (8)2. Check list not recorded as being used (7)3. Time of administration not recorded (6)4. Only 1 signature on documentation for administration
(4)5. Wrong Prescription – time incorrect (2)
One ‘NO’ on a chart is a failure!
Audit (Nov’11 – Jan’12)Prescribing and administering errorError Prescribing Administration Comment
Level
monitoring 0 0
Frequency 45 0
Timing 9 5
Signature 2 0
Not
signed
NPSA Alert 2 0
wrong
date
Total 53 5
Audit (Nov’11 – Jan’12)
Audit (Nov’11 – Jan’12)Prescribing and administering timing error
Timing
error Prescribing Administration Comment
Late
Timing 8 4(2) 1.5 - 2.5 hours late
Too Early 1 1 2 hours early
total 9 5
Audit (Nov’11 – Jan’12) Recommendations
• Regular training to trainees in ‘how to prescribe in paediatric/neonate’ maybe useful
• Regular update to nurse to spot common prescribing errors in paediatrics and neonatal units.
• Prescribers will also need to think about their dose calculations and if the dose prescribed is measurable for administration.
• Improved communication between prescribers and staff nurses regarding results of blood levels.
• Another audit to look at the general prescribing habit in NNU.
Human Error