Medicines safety in practice

Content of today’s session Feedback on voting and prescription-

writing

Identifying potential (preventable) harm from medicines

Case study with more prescribing and voting

Tips on preventing harm from prescribers

What did you vote for? Which drug to prescribe?

Diclofenac Fentanyl Morphine Paracetamol

Which option after allergy discovered? Diclofenac Give opioid Paracetamol Ask for help

Which system change? Post-op pain algorithm Clearer allergy record Training sessions for junior doctors Train nurses to prescribe & administer

How confident were you that your votes represented the best course of

action?

Not at all confident Not overly confident Quite confident Very confident

Votes from seminar 1

Options chosen

A. DiclofenacB. FentanylC. MorphineD. Paracetamol

Confidence in choice made

Votes from seminar 1Options chosen

A. DiclofenacB. Give opioidC. ParacetamolD. Ask for help

Confidence in choice made

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1 2 3 4Medics

Pharmacists

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A B C DMedics

Pharmacists

Votes from seminar 1

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Medics

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Options chosenA. Post-op pain

algorithmB. Clearer allergy recordC. Training sessions for

junior doctorsD. Train nurses to

prescribe & administer

Most students rated their confidence as 3 whichever option they voted for

Your prescriptions

Practical problems

Clinical problem

Note how errors are lapses rather than outright lack of knowledge

Identifying preventable harm from medicines

Worked example: lisinopril– ACE inhibitor, used in hypertension, post-MI, heart failure

and diabetic nephropathy

From BNF:Cautions: First doses can cause hypotension; severe

or symptomatic aortic stenosis (risk of hypotension); renal impairment

Contra-indications: hypersensitivity to ACE inhibitors (including angioedema); pregnancy

Side-effects: Hyperkalaemia, profound hypotension, renal impairment, persistent dry cough, angioedema.

Preventable harm from medicines

We know that lisinopril can cause:– Hyperkalaemia– Profound hypotension– Renal impairment

When prescribing or dispensing (or administering) lisinopril, consider the potential harm

Take action to minimise the harm:

– Compare with other treatment options (is there an alternative?)

– Put a monitoring plan into place – Provide the patient with information

What can individuals do to prevent harm caused by medicines?

Over to you……

Discuss this with your neighbour• Think about points from seminar 1 and today• Make a list of practical things YOU can do on a

daily basis as a doctor/pharmacist

Suggestions – we phoned some friends….

Doctors– Don’t “blag” it; ask if you are not sure– Make friends with a pharmacist

Pharmacists– Use more than one information source to check

unusual doses / adverse effects / indications etc.– Pre-empt error. Monitor for predictable adverse effects

and know your “problem drugs” All healthcare professionals

– Minimise distractions when accuracy is needed e.g. dispensing, administering IV drugs etc.

– Use each other! Talk to your seniors and other members of the healthcare team

Case study - infection Study the following case materials in groups

of three

- Identify the potential causes of harm to the patient from her medicines

-Discuss potential antibiotic treatment options based upon the diagnosis (use BNF handout)

Mrs Mary Cartwright

Mrs Mary Cartwright is admitted via A&E after her carer makes a 999 call

The paramedics hand over her medication pack

HOSPITAL UNIT NO 123456

HISTORY SHEET

SURNAME (BLOCK LETTERS)

Ca rtwr i ght

FIRST NAMES

Ma ry

DATE CLINICAL NOTES (Each entry must be signed)

1st Oct PC: Con fusi on . I n con ti n en t of u r i n e. Possi ble col la pse but n o hi story to corrobora te.

2009 HPC: Morn i n g ca rer ca l led to fi n d pt slumped i n cha i r , con fused & d i dn ’t kn ow

where she wa s. Ca l led 999

PMH: Hyperten si on – con trol led

Osteoa rthr i ti s

Been i n d i fferen t loca l hospi ta l a mon th a go ( from gra n dson ) ; fa l l due to d i zzi n ess.

Bru i si n g a n d sti tches to hea d . Wa s fi n e a n d i n good spi r i ts when d /c; on ly sta yed i n

2 da ys

Ca ta ra ct opera ti on 6 mon ths a go ( from gra n dson )

OE: Gen era l exa mi n a ti on : Alert a n d sa t up i n hospi ta l bed . Or i en ta ted i n person

( a ble to i den ti fy doctor) . Not or i en ta ted i n ti me ( i n correct da y, mon th a n d yea r) .

Wel l hydra ted wi th n orma l ca pi l la ry refi l l . Apyrexi a l ( Temp 36.5 tympa n i c)

CVS: BP 102/58 ( si tti n g) . Pu lse 70 regu la r a n d fu l l ( left ra d i a l ) . J VP n ot ra i sed .

Hea rt soun ds: 1 + 2 + 0 n o murmurs hea rd .

Per i phera l pu lses: n orma l volume a n d equa l

RS: Respi ra tory ra te 14. Good chest expa n si on wi th reson a n t percussi on throughou t.

Vesi cu la r brea th soun ds throughout wi th n o wheeze or cra ckles

Abdo: Abdomen soft, n on ten der . No ma sses/orga n omega ly/shi fti n g du l ln ess. Bowel

soun ds frequen t bu t n ot ti n kl i n g.

CNS: Appea rs mi ld ly con fused . GCS 15/15. Pupi ls equa l a n d rea cti ve. Abbrevi a ted

men ta l test score: 6/10. Cra n i a l n erves a l l i n ta ct.

Li mbs: Ton e, power , reflexes a n d sen sa ti on i n ta ct a n d equa l .

SH: Smoker i n her youth ( ga ve up ~ 20 yea rs a go a fter husba n d d i ed )

Husba n d d i ed 1990 – Ca lun g

Two chi ld ren – da ughter d i ed CVA 2002; son wel l , l i ves i n Ca n a da

Four gra n dchi ld ren – gra n dson NOK, l i ves i n Derby

Li ves a lon e; houseboun d. Ca rers twi ce da i l y.

Mrs Cartwight has been confused and incontinent of urine for the past couple of days. She may have collapsed but no-one can confirm this.

Her past medical history includes hypertension and trigeminal neuralgia. Her grandson mentions that she had a cataract operation 6 months ago and explains that she is not normally confused.

On examination

– Alert and sat up in hospital bed– Orientated in person (able to identify doctor); not orientated in time (incorrect day,month and year)– CVS: BP 102/58 (sitting) – Abdo: Abdomen soft, nontender– CNS: Appears mildly confused

Nil else of note Social history

– Lives alone; carers twice daily– Non-smoker, nil alcohol

The diagnosis and plan

Imp: UTI; need to rule out cardiac event

Plan: MSSU, Trop T

Results: Urine dipstick Trop T negative

Start antibiotic for uncomplicated UTI

Case study discussion In your groups of three

-Discuss potential antibiotic treatment options based upon the diagnosis

-Identify potential causes of harm to the patient from her medicines

Write a prescription

• Prescribe an antibiotic course for Mrs Cartwright on your hospital prescription chart.

Name Mary Cartwright

DOB 12/5/1916

Allergy status NKDA

Ward EAU

Consultant Smith

Mrs Cartwright’s progress

• Mrs Cartwright is now complaining of pain on passing urine; she is still confused.

 • Blood results are received.

  

Mrs Cartwright’s progress Her grandson brings in a repeat prescription

**CONFIDENTIAL**

Mrs Mary Cartwright 21/10/1924 11 Acacia Avenue, Salford M5 Poplars Medical Centre, Salford M6, Tel. 0161 123 4567 REPEAT PRESCRIPTION ORDER FORM --------------------------------------------- Tick items required and post in order box Phone orders 0161-256-****. PLEASE ALLOW TWO WORKING DAYS BEFORE COLLECTION. --------------------------------------------- Please note we are CLOSED Wednesdays 12:30 – 15:00 --------------------------------------------- There are 5 items on this re-order form 09/09/2009

1. LISINOPRIL tabs 20mg TAKE ONE DAILY mitte 1x28 Last ordered on 09/09/2009. You may order 3 more. --------------------------------------------------------------------------------------------- 2. BENDROFLUMETHIAZIDE tabs 2.5mg TAKE ONE DAILY mitte 1x28 Last ordered on 09/09/2009. You may order 3 more. --------------------------------------------------------------------------------------------- 3. CALCICHEW tabs 500mg TAKE TWO EACH DAY mitte 1x100 Last ordered on 22/06/2009. You may order 5 more. --------------------------------------------------------------------------------------------- 4. CARBAMAZEPINE tabs 100mg TAKE ONE EACH DAY mitte 1x84 Last ordered on 09/09/2009. You may order 3 more. --------------------------------------------------------------------------------------------- 5. LACRILUBE eye ointment AS DIRECTED mitte 1xOP Last ordered on 09/09/2009. You may order 3 more. ---------------------------------------------------------------------------------------------

The FY1 doctor follows the hospital antibiotic formulary and prescribes nitrofurantoin 50mg qds for 3 days for Mrs Cartwright’s UTI

Review Mrs Cartwright's treatmentConsider your original discussion: 

• Review the potential causes of harm to the patient from her medicines

• What action should you take (as a prescriber) to minimise the risks of harm to Mrs Cartwright from the nitrofurantoin she has been prescribed?

Over to you….Vote 1What will you do to minimise the potential harm from the treatment of Mrs Cartwright's infection?

A Change her antibiotic

B Reduce the dose of her antibiotic

C Increase the course length and monitor for adverse effects

D  Stop antibiotic and wait for sensitivity report from microbiology

Mrs Cartwight's progressMrs Cartwright was prescribed ciprofloxacin 250mg bd for 5 days by the registrar. • Day 3. Nurse reports profuse, watery and foul smelling diarrhoea.

Stool sample sent to microbiology dept for culture and sensitivity report.

 

4th October 2009 16:55 Microbiology report *** Cl. difficile toxin DETECTED *** * Please take enteric precautions *

REASON FOR REQUEST Antibiotic therapy; loose stools Requested by: Dr P Medic

The preventable medicines related incident?

 Mrs Cartwright eventually makes a full recovery after another antibiotic course for the hospital-aquired C difficile infection.

She ends up staying in hospital for a total of 14 days after becoming dehydrated secondary to the diarrhoea and developing acute renal failure.

QuestionDiscuss the potential cause of Mrs Cartwright's diarrhoea. Did you identify this as a risk?

Clostridium difficile Found in a small proportion of healthy

adults

Overgrowth can cause diarrhoea, from a mild disturbance to a very severe illness. It can be fatal.

Produces toxins that damage the cells lining the intestine.

A patient with C. difficile diarrhoea excretes large numbers of spores. These can be a source of hand-to-mouth infection for others.

What do you think?

Discuss in your groups 

This patient suffered significant harm to which the ciprofloxacin is likely to have contributed 

• Do you think this incident could have been prevented? How?

 

Over to you….Vote 2• What systems change would you implement first to prevent

antibiotic-related harm happening to other patients?

A Prevent hand-to-mouth spread of C difficile in the hospital through a hand-washing policy

B Restrict the prescribing of all broad spectrum antibiotics in the hospital

C Educate prescribers in the hospital on preventing antibiotic-related harm

D Minimise admissions to hospital by treating more patients in the community (working with GPs and district nurses)

Mitigating harm in decision making

Understand your options– Weigh up the benefits (efficacy, cost etc)– Against the risks (adverse-effects, likely

error, treatment failure) Be able to justify why your decision

minimises risk and maximises benefit– All treatments pose some risk– There are usually several acceptable options

Manage risks by recognising them early– Monitor treatment effectiveness and for

adverse effects– Prescribe and communicate your intentions

clearly

Next time…. In the final seminar we will…

Discuss what happens when things go wrong– How error and patient harm is reported and

investigated– How individuals and the NHS can prevent the

same mistakes happening again and again

Complete another case study (writing a prescription)

Provide information on the rest of the module for those who wish to sign up