noleen nath - redcliffe hospital

Medication Safety within the Hospital and Strategies to Improve and Prevent

Medication Related Patient Harm SAFE AND SECURE HOSPITALS CONFERENCE 2014

NOLEEN NATH

CLINICAL PHARMACIST

REDCLIFFE HOSPITAL, BRISBANE

Overview• Investigate implications of medication misadventure in hospitals• Explore contributing factors

• Explore common medication pitfalls of hospital practice which maycontribute to preventable patient harm

•Identify the role of medications in triggering violence, aggressionand agitations• Safety considerations when using antipsychotics

•Investigate hospital initiatives to improve medication safety andprevent patient harm

Drug Vs Poison

DIFFERENCE =

DOSE/ MONITORING/ APPROPRIATENESS OF THERAPY/ PATIENT

Medication Misadventure within Australian Hospitals

•Medication-related hospital admissions are a significant issue• Approximately 190,000 medication-related hospital admissions occur per

year in Australia

• Estimated $660 million per year cost to the healthcare system

•Medication misadventure within hospitals are the second mostcommon type of incident reported in Australian hospitals

•Reasons for medication misadventure are complex• Human error, system failures and patient factors can catalyse a chain of

events which cause morbidity and mortality

Common Medication Pitfalls in Hospitals

RECOGNISING HOW MEDICINES CAN CAUSE PATIENT HARM AND CONTRIBUTE TO COMPLICATIONS OR EXTENDED

HOSPITAL ADMISSION

Common Medication Pitfalls•Commence medication therapy to mange a health condition• Therapy may be inappropriate for the patient (dose, frequency, monitoring)• Medication therapy in hospital• Discharge - increases risk of readmission to hospital

• Patients may develop a adverse effect from the medication• Polypharmacy• Increased falls risk• Increased risk of delirium – Agitation and Aggression

•Commence medication therapy to mange a side effect of a medication therapy • Intentional or unintentional

Ensure Safe and Quality Use of Medicines

• Recognise the importance of non-pharmacological interventions and employ where appropriate

• If medication is essential always consider: The place of therapy – why and what is the

therapeutic goal Dosage and length of proposed

treatment

Clinical condition Monitoring considerations

Risk and benefits The Individual Patient

Co-existing conditions and therapies Cost

Polypharmacy •Polypharmacy: The use of 5 or more medications

◦ Includes prescribed, over-the-counter, and complementary medicines

•Associated with increase risk of hospitalisation, functional and cognitive impairment, geriatric syndromes (delirium, falls or frailty) and mortality.

•Demonstrated to be linked with reduced health outcomes, declining nutritional status, and non-adherence

Suggestions for AvoidingPolypharmacy

1. Avoid prescribing for minor, non-specific or self-limiting complaints. Onlyprescribe when their is good evidence

2. Regular medication review

3. Utilise Non-pharmacological approaches were possible and trialcombination with pharmacotherapy to lessen the medication burden

4. Clarify patient concerns, expectation and any difficulties in using themedication or with the regime. Discuss changes to the medication regimenwith the patient’s other health care providers

5. Simplify medication regime to only include essential medicines

ViolenceAgitation Aggression

Meet Beryl 73 year old

Married and living independently at home with her 75 year old husband.

Medical History: Hypertension, Diabetes and Glaucoma,

April 2014

•Fall and sustained a fracture of her Right Radius which required surgery

•Post surgery developed constipation and urinary tract infection.

•Day 3: developed urosepsis, hyperglycemia and confusion

•Day 5: nursing staff stated quite confused and staff noted increasing agitation

Meet Beryl• Day 6: Moved to Delirium and Falls Unit as persistently

confused and behaviour becoming more aggressive• Commenced on regular Haloperidol

• Day 9: Sustained a fall – diagnosed with fractured Neck of Femur

• Day 11: Post surgery for the fractured Neck of Femur diagnosed with postoperative wound infection.• This exacerbated her delirium which persisted for a further 4 days.

• Day 18 Discharged from hospital

Falls: Medications which increase the risk

•Medicines which can cause sedation, altered gait or postural hypotension, increase falls risk.

•Common culprits are:• Antidepressants• Sedatives • Antipsychotics• Opioid Analgesics

Remember the elderly are more susceptible to dizziness, light headedness and fainting. Slight changes in medications can

significantly increase falls risk

Identifying Links between Delirium, Agitation and Aggression with Medicines

• Delirium is psychological state where agitation and aggressive behaviour can be more prominent. Medicines can be implicated in the development of delirium directly and indirectly• Factors such as Infection, Hyponatermia and Dehydration can be implicated in

agitation and aggression and medications can facilitate the development of these physiological processes.

• Medicines with high risk of causing or complicating delirium:

- Anticholinergics - Benzodiazepines

- Non Steroidal Anti-Inflammatory Drugs - Opioids

- Dopaminergic drugs - Corticosteroids


- Constipation - Post Operative Phase- Confusion - Urinary Tract Infection - Delirium - Pain

FALLS

MEDICATION

MEDICATION

Hospital Initiatives to Prevent Medication Misadventure During

Admission

Identify High Risk Medications•Medicines with a low therapeutic index

•Medicines that present a high risk when administered by the wrong route or when other system errors occur.

A Anti-infectives

P Potassium and other electrolytes

I Insulin

N Narcotics and other sedatives

C Chemotherapeutic agents

H Heparin and other anticoagulants

S Systems

Drug Safety Working Group(DSWG)

• Multidisciplinary group which aims to promote a culture of prescribingand medication administration that is prudent and cautious to minimisethe risk of harm to patients.◦ Conducts regular audits of prescription and monitoring prescribing practices.

◦ Results and improvement suggestions communicated to Resident MedicalOfficers, nursing staff, pharmacists and hospital executives

• Membership:

-Patient Safety Officer - Assistant Director of Nursing - Clinical Auditor

-Consultant Physician - Level 2 Nurse - Pharmacists

-Junior House Officer - Directors of Pharmacy

Drug Safety Working Group Monthly meeting to identify and review high risk areas and processes relating to medication safety

Major Tasks:◦ To monitor hospital prescribing performance and administration of

medications.

◦ To disseminate and enhance relevant knowledge within the group, usually through the medical literature, with all members bringing appropriate articles to group meetings.

◦ To feed back results and recommendations to the hospital staff as a quality, safety and improvement activity.

Drug Safety Working Group Review Process:◦ Each month the use of one specific drug or process is audited.

◦ Twenty charts of patients prescribed the nominated drug in the previous months are reviewed by appropriate committee members according to experience with the specific drug.

Drug Safety Working Group: Accomplishments

• The group was requested to review and comment on a fatalityfrom inappropriate paracetamol prescribing and administration• A patient was prescribed and administered 12g of paracetamol for 3.5 days.

• The patient developed liver failure and the case was fatal.

• On investigation it was discovered maximum doses of paracetamol were prescribed as anindividual order, as a combination product and in the as required (PRN) section of themedication chart.

• The group recommended a hospital wide policy where:

◦ paracetamol combination products are not stocked on any wards

◦ paracetamol cannot be prescribed as a combination product

◦ A zero tolerance for combination and duplicate paracetamol prescribing


◦ Following patient harm from not receiving a prescribed medication foran extended period of time as it was not available on the standardformulary list, a audit of N for “Not Available” document on medicationcharts conducted.◦ DSWG derived a 3 point plan action plan for all major disciplines

1. Prescribers are encouraged to become familiar with the Queensland PublicHospitals’ List of Approved Medications

2. Nursing staff encouraged to contact physicians to prescribe an appropriatealternative medication, or ask patients to arrange their own supply ofprescribed medication unavailable from the hospital pharmacy

3. Pharmacy provides a list of commonly used medications that are unavailableto wards, as a prompt to prescribers


◦ An audit of Medical Emergency Team calls detected that 2% of all calls were to attend to narcotised patients. ◦ The DSWG was asked to review and comment and make recommendations

◦ The DSWG, emphasised the importance of documenting drug frequency and maximum dose per 24-hour period on PRN order especially that of analgesics

Medication Safety Nursing Group (MSNG)

Medication management requires a multidisciplinary approach and interdisciplinary communication is essential to reduce medication errors

The nursing profession has been identified as essential to the promotion of patient safety and reducing medication errors

The MSNG is a monthly meeting to raise awareness of medication safety concerns detected in daily practice


• Nursing Lead Forum

• Protected one hour monthly meeting attended by a nurse representative fromeach ward and specialist area, pharmacist and patient safety officer

• Nursing staff raise medication safety issues they detect in daily practice withthere colleagues in a safe, secure and supportive environment

• Opportunity for insight into medication safety issues and solutions within thehospital

• Multidisciplinary initiative to addressing medication safety within the hospital

** Keeps Medication Safety on the Brain **


•Objectives• Identify medication safety issues and escalate concerns or proposed solutions

to hospital executive committees

• Dissemination Information and education pertaining to medication safety

• Participate in procedure development and review

• Review medication safety incidents reported and share lessons learnt andmake recommendations to hospital executive committee on possibleavoidance measures for noting and further discussion


Accomplishments◦ Noted an medication incident occurred regarding cessation of a epidural

pump ◦ The epidural pump cessation procedure was recirculated to all wards and staff requested to

discuss/ clarify any concerns with the Acute Pain CNC

◦ Noted a new procedure for Ketoacidosis management is in operation◦ Staff alerted to the procedure and implications for nursing staff noted

◦ Identified different protocols for iron infusion are in operation at different hospitals within the same district. As medical staff often are often required to rotate within the district, non-standardisation can result in prescribing and administration confusion and error. ◦ Issue identified and escalated


• Accomplishments

• Raised awareness and provided education regarding novel anticoagulationagents entering clinical practice

• Safety concerns and implications to daily practice discussed

• Assisted in the development of safety alert signage and presentations to assist staff inidentifying these new medications and safety implications

• Raised awareness of a change in practice from the anaesthetics departmentin the management of postoperative pain with the use of buprenorphinepatch applied in theatre.

• Awareness raised and implication for nursing staff discussed.

Concluding Comments• Appropriate use of medications is central to maintaining hospital safety forpatients and staff.

• Inappropriate medicine use can result in unnecessary patient harm which cancomplicate and extend hospital admissions or even result in prematuremorbidity and mortality

• Employing the principles of quality use of medicines, can assist in avoiding/minimising medication misadventure

• Medications can be a trigger point for violence, aggression and agitation.Understanding of this link can assist in preventing and managing thesebehaviours

Concluding Comments• Committees in which staff are supported to strive for medication safety isessential in creating healthy culture of risk awareness

“It can be argued that medication safety committees are more essential in ensuring the safe journey of patients through hospital,

rather than availability of the most modern therapeutic and diagnostic modalities”

“The greatest opportunity to improve outcomes for patients over the next quarter century will probably come not from discovering new

treatments, but from learning how to deliver existing effective therapies safely”


- Constipation - Post Operative Phase- Confusion - Urinary Tract Infection - Delirium - Pain

FALLS

MEDICATION

MEDICATION

References • Runciman WB,Roughead E, Semple SJ, Adams RJ. Adverse drug events and medication errors in Australia. Int J Qual Health Care 2003; 15-(Suppl. 1): i49–i59

• Roughhead L, Semple S, Rosenfeld E, Literature Review: Medication Safety in Australia (2013). Australian Commission on Safety and Quality in Health Care, Sydney.

•Roughhead L, Semple S, Rosenfeld E, Literature Review: Medication Safety in acute care in Australia (2008). Quality Use of Medicines and Pharmacy Research Centre Sansom Institute , Adelaide

•Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now?. Part 1: a review of the extent and causes of medication problems 2002–2008 ANZ Health Policy 2009, 6:18.

•Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 4: Medication Safety (October 2012). Sydney. ACSQHC, 2012.

References•Semple SJ ,Roughead EE : Medication safety in acute care in Australia: where are we now? Part

2: a review of strategies and activities for improving medication safety 2002-2008. Aust New Zealand Health Policy 2009, 6:24

•Liu GG, Christensen DB. The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc (Wash) 2002;42:847–57.

•Roughead EE, Anderson B, Gilbert AL. Potentially inappropriate prescribing among Australian veterans and war widows/widowers. Intern Med J 2007;37:402–5.

•Hilmer SN, Gnjidic D. The effects of polypharmacy in older adults. Clin Pharmacol Ther 2009;85:86–8.

•National Prescribing Service. Anticipating the risks of polypharmacy. NPS. 2013; August

References•Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;(9):CD007146.

•Australian Council on Safety and Quality in Health Care. Achieving safety and quality improvements in health care. Sixth report to the Australian Health Ministers’ Conference. Commonwealth of Australia, 2005.

•Australian Nursing Federation. Anf position statement: Quality Use of Medicines. 2012

•Nath N, Jones E, Stride P, Premaratne M, Thaker D, Lim I. The nuts and bolts of pills and potions: the functions of a drug safety working group. Australian Health Review 35(4) 395-398

Strid P, Seleem M, Nath N, Horne A, Kapitsalas C. Integration of patient safety systems in a suburban hospital. Australian Health Review 36(4) 359-362

noleen nath - redcliffe hospital

Healthcare