Post on 09-Jun-2015
description
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
0
10
20
30
40
50
60
1 2 3 4Medics
Pharmacists
0
10
20
30
40
50
60
70
80
A B C DMedics
Pharmacists
Votes from seminar 1
0
10
20
30
40
50
60
70
A B C D
Medics
Pharmacists
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