e d i c a t i o n E r r o r

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2 e d i c a t i o n E r r o r s 2

3 Healt hcare Today.. I s a complex syst em Comprised of numerous int ricat e part s int eract ing wit h mult iple ot her part s in unexpect ed ways Has various levels of specialisat ion and int erdependencies and t hese places healt h care f acilit ies at high risk f or accident s (IOM 2000,Beyea 2002) 3

4 Mult idisciplinary Wide age and size range St at e of art equipment Highly advanced care t echnology New mode of drug delivery Evidence- based if not best pract ice Wide variet y of drugs Nurses of dif f erent grades 4

5 Common Causes of Medicat ion Errors in PI CU Dosage Error: Wrong Dilut ion Calculat ion Error Error in Pump Set t ings Prescript ion Error Ot hers: Wrong Drug Wrong Time Omission 5

6 Medicat ion Errors One t ype error most report ed in t he lit erat ure and is recognized as an import ant cause of iat rogenic inj ury in hospit al pat ient s. Occur anywhere on t he cont inuum, f rom prescribing, dispensing, administ ering.. Healt h care encompasses risks and complexit y, and administ ering medicat ion is probably t he highest - risk t asks Oh..! How do I go from here. 6

7 Medicat ion errors have been addressed by a problem- solving approach so t hat human cause of t he error is ident if ied and correct ed. Alt hough many medicat ion errors are due t o human error.. 7

8 Abundant evidence in t he human f act ors and cognit ive psychology lit erat ure recognizes t hat most human errors are sympt oms of underlying syst em f ailures. Human error t o adverse drug event s is a consequence rat her t han a cause (DoH, 2000). 8

9 Human Fallibilit y The I OM report (1999), f urt her caut ions t he f ocus of errors on individual responsibilit y while ignoring syst em f act or t hat made error possible. Human f act ors sciences emphasis met hods of improving human perf ormance in complex work syst em wit h designing of work syst ems t hat compensat e f or inevit able human f allibilit y. Work system 9

10 Leape et al (1995), recommended t hat a syst ems engineering approach be used t o make healt hcare delivery syst ems less error prone by int roducing root cause analysis. Error report s are valuable dat a which can be used t o analyse problem f rom mult iple angles and syst em. 10

11 I ncident Report s f or t he cause f act ors on opport unit ies f or t he development of prevent ive measures in minimising medicat ion errors. 11

12 Med Error Occurrences QPS.3.4 (B) - Medication Error per 1000 patient days % 26% Women Children % Neonate % Pharmacy Inpatient Ward 0 Year 2004 FY05 Jan-Mar Apr-Jun Jul-Sept Oct-Dec Jan-Mar (Yr06) Apr-Jun Jul-Sept Oct-Dec Jan-Mar (Yr 07) 52 74% 12

13 Who are t he people involved..? Staff Involved in Medication Errors 23% 4% 16% 11% Doctor Doctor & Nurse Nurse Pharm. Tech. 46% Pharmacist Physician order (39% t o 49%) - Up to 70% of are intercepted by pharmacists and nurses prior to administration During a nurse s administ rat ion of drug (26% t o 38%) Transcription (11% to 12%) Pharmacy dispensing (11% t o 14%) Leape et al,

14 Dat a Analysed Types of Medication Related Incidents, FY06 Wrong Preparation 1% Wrong Route 3% Others 14% Wrong drug 24% Omission 18% Wrong time 13% Contraindication 3% Wrong Patient 3% Wrong Dose 21% 14

15 Cause and Effect (Root Cause) Analysis Wrong Prescription Failure to check drug allergy status Given drug which patient allergic to Failure to check Medication orders not communicated Paste wrong sticker Did not verify with another staff Wrong Patient Change order No proper passing over procedure Omission Failure to follow-up IMR order Overlooked drug administration Parent request for medication Odd time dosing Misinterpret order interval Mum served medication Odd timing Wrong terminology on dose timing Appointment not properly instructed Patient turn up wrong time Prescription practice not communicated Wrong Time Lack standard practice in transcribing Wrong form, rate & dose Failure to verify correct order Pump error Dependent on pump Large dosage prescribed Overlook time of medication Failure to check Given repeated dose Dosage Error Misread order Wrong Wt Amended Wt Failure to give clear instruction Unable to read time No follow up with parent on time served Discontinue medication not properly write off Poor IMR design Wrong prescription Wrong filing of IMR Wrong drug drawn Wrong Drug Knowledge deficit Wrong calculation Misinterprets result Failure to communicate Patient self medicate Failure to check Identity of patient not verified Non compliance to practice standard Med. Errors 15

16 Wrong Prescription Failure to check drug allergy status Given drug which patient allergic to Failure to check Did not verify with another staff Wrong Patient Cause and Effect (Root Cause) Analysis Medication orders not communicated Paste wrong sticker Change order No proper passing over procedure Omission Failure to follow-up IMR order Overlooked drug administration Parent request for medication Odd time dosing Misinterpret order interval Mum served medication Odd timing Wrong terminology on dose timing Appointment not properly instructed Patient turn up wrong time Prescription practice not communicated Wrong Time Lack standard practice in transcribing Wrong form, rate & dose Failure to verify correct order Pump error Dependent on pump Large dosage prescribed Overlook time of medication Failure to check Given repeated dose Dosage Error Misread order Wrong Wt Amended Wt Failure to give clear instruction Unable to read time No follow up with parent on time served Discontinue medication not properly write off Poor IMR design Wrong prescription Wrong filing of IMR Wrong drug drawn Wrong Drug Knowledge deficit Wrong calculation Misinterprets result Failure to communicate Patient self medicate Failure to check Identity of patient not verified Non compliance to practice standard Med. Errors 16

17 1. Medicat ion order not properly communicat ed 2. Lack st andard pract ice in prescribing and t ranscribing I MR 3. Odd t ime dosing 4. Poor I MR design 5. Failure t o verif y order 6. Non compliance t o pract ice st andard 17

18 Verif icat ion of Root Causes 1. Using quest ionnaires and document at ion records t o det ermine how: I nf ormat ion are disseminat ed Medicat ion orders are verif ied 2. Review I MRs: I MR design Prescribing and Transcribing process Odd t ime dosing 3. Using observat ion t echnique t o: Adherence t o st andard pract ice in med. admin. 18

19 Review of I MR - Prescript ions I llegible handwrit ing Not sure of dosage f orm ordered in mls 19

20 Weight documented on wrong place 4 different dosages ordered at various point of time Discontinued and not signed off Oral medication ordered under Injection column 4hrly but interpreted as Hrly Legibility of hand writing and high dosage 20

21 Survey on Transcribing of I MR Verif icat ion of Orders Description Is there counterchecking of IMR after transcribing Who checks the IMR? RN checks. Is the name of countercheck RN recorded in IMR Yes 83% 100% 49% No 17% 0% 51% When is the transcribed IMR checked Immediately During medication serving During handover report % Immediate 1 day 2 days 3 days IMR sent for billing 36% 19% 36% 9% 21

22 Survey on Transcribing of I MR Verif icat ion of it ems on I MR Items on transcribed IMR checked Patient s name and ID number Medication orders Drug allergy Others e.g. date, weight, doctor signature Yes 97% 100% 93% 93% No 3% 0% 7% 7% 22

23 Survey on Transcribing of I MR Number of respondent s: 90 RNs Description Does the unit has a standard guideline for transcribing IMR Yes 17% No 83% Description If yes, where is the guideline filed P&P 78% IMR 22% P&P on t ranscribing of I MR is available in P&P f ile kept in all wards. 23

24 Survey f rom 90 RNs Communicat ion and verif icat ion of orders Description All the time Most of the time Some- times Not at all During the process of receiving a patient from another ward, are medication orders and time of last administration communicated to you 44% 39% 14% 3% 24

25 Observat ional St udy on Administ rat ion of Medicat ion On adherence t o med. administ rat ion pract ice Sample size: 90 Average pat ient s per shif t : 17 Average no. of RN/ s: 2 t o 3 Description Was there counterchecking of drug by 2 RNs Yes 100% No 0% RN carried IMR at bedside RN/s check and verify patient identity at bedside Was medication left unconsumed half hour later Signature of RN/s on IMR after serving 100% 78% 11% 99% 0% 22% 89% 1% 25

26 Descript ive st udy on Nurses Percept ion on Fact ors Cont ribut ing t o Medicat ion Errors Sample size: 530 nurses Respondent : 471 (89%) J ob Grade: NM, NC, SSN and SN Discipline: O&G, Peds and Neo (wards, I CUs and Emergency Dept ) Survey using scales t o: Rank t he level import ance Rank t he f requency of occurrence Score t he level of underst anding Priorit ize t he choice of pref erred measures 26

27 Nurses Percept ion on level of I mport ance t o Med. Admin. No Description Strict adherence to P&P of drug admin. Take personal responsibility in ensure safe drug administration Adequate staff level Minimize distraction Staff with at least 2 years in current specialty Have very clear and legible order Have user friendly IMR for clear documentation Rounding up medication dosage Have standardized way of writing prescription Use generic drug names Have good pharmacological knowledge of commonly use drugs Eliminate non critical stat orders Have periodic training and assessment of pharmaco.. knowledge Have clear assess to drug information Have clear P&P for counter-checking checking of medication Mean Score

28 Survey on Nurses Percept ion on Level of I mport ance in Administ rat ion of Medicat ion No Description Take personal responsibility in ensure safe drug administration to patients Have clear and legible order Strict adherence to drug administration P&P Minimize distraction Have adequate staff level Have user friendly IMR for clear documentation Have standardized way of writing prescription Mean Score Not Important Least Important Important Very 28 Important

29 Survey on Nurses Percept ion on Level of I mport ance in Med. Administ rat ion St rict Adherence t o P&P of drug administ rat ion Grade of staff NM/ NC SSNI SSNII SNI SNII Percentage rated as Very Important 95% 93% 82% 72% 58% Pearson Chi- Square: P value of.000 Take personal responsibilit y in ensuring safe drug administration to patients Grade of staff NM/ NC SSNI SSNII SNI SNII Percentage rated as Very Important 95% 97% 86% 79% 71% Pearson Chi- Square: P value of

30 Survey on Nurses Percept ion on Level of I mport ance in Med. Administ rat ion Have user f riendly I MR columns f or clear document at ion Years of experience Below 2 years 2 to 5 years Above 5 years Percentage rated as Very Important 68% 54% 59% Pearson Chi- Square: P value of

31 Nurses Percept ion on Fact ors Current ly Af f ect ing Their Effectiveness in Med. Admin No Description Inadequate staff level Inadequate skilled staff Having deployed staff Long working hours Distraction whilst preparing medication Unclear orders Illegible handwriting Complex Order (more than 5 prescriptions) Lack skill in calculation ( conceptual and measurement disabilities) ies) Knowledge deficit in medication ordered Too frequent change in medication order Change in medication packaging Medication not readily available Too many adhoc medication order Lack access to drug information Mean Score

32 Nurses Percept ion on Fact ors Current ly Af f ect ing Their Ef f ect iveness in Med. Admin No Description Illegible handwriting Distraction whilst preparing medication Unclear orders Inadequate staff level Inadequate skilled staff Complex Order Medication not available for serving Mean Score Not at all Sometimes Frequently 32 Most of the time

33 Nurses Percept ion on Fact ors Current ly Af f ect ing Their Ef f ect iveness in Administ rat ion of Medicat ion Illegible handwriting Discipline O&G Paeds Neo Percentage of respondents who rated Frequently and Most of the Time 54% 46% 30% Pearson Chi- Square: P value of

34 Nurses Percept ion on Fact ors Current ly Af f ect ing Their Effectiveness in Med. Admin Dist ract ion whilst preparing medicat ion Discipline Paeds O&G Neo Percentage of respondents who rated Frequently and Most of the Time 65% 38% 16% Pearson Chi- Square: P value of.000 Unclear orders Discipline O&G Paeds Neo Percentage of respondents who rated Frequently and Most of the Time 50% 39% 26% Pearson Chi- Square: P value of

35 Unclear Order Problem of interpretation Unclear Order Odd doses Rout e? 35

36 St andard Peds Medicat ion Dosage Syr Paracetomol 120mg/5mls Dosage Ordered 90 mg 100 mg 130 mg 140 mg 150 mg 160 mg 180mg 200 mg 210 mg 220 mg Amount to be given 3.75 mls 4.17 mls 5.42 mls 5.83 mls 6.25 mls 6.67 mls 7.5 mls 8.33 mls 8.75 mls 9.17 mls I/V Gentamycin 40mg/ml Dosage Ordered 20mg 24 mg 28 mg 30 mg 33 mg 40mg 42mg 45 mg 47 mg 50mg Amount to be given O.5mls 0.6mls 0.7mls 0.75mls 0.83mls 1mls 1.05mls 1.13mls 1.18mls 1.25mls This variat ion makes it dif f icult f or providers who work on unit s t o perf orm ef f icient ly and set s t hem up t o make errors. 36

37 Nurses Percept ion on Fact ors Current ly Af f ect ing Their Ef f ect iveness in Med. Admin Lack mat hemat ic skill in drug calculat ion Not at all Sometimes Frequently Most of the Time 45% 45% 5% 5% % of nurses who had no problem with drug calculation 37

38 Nurses Percept ion on Fact ors Current ly Af f ect ing Their Effectiveness in Med. Admin Inadequate staff level Discipline Paeds O&G Neo Percentage of respondents who rated Most of the Time 19% 13% 2% Pearson Chi- Square: P value of.000 Inadequate skilled staff Discipline Paeds O&G Neo Percentage of respondents who rated Most of the Time 9% 6% 4% Pearson Chi- Square: P value of

39 SUMMARY OF POST MED-ERROR REVIEW WITH STAFF & NM CASE NUMBER DATE 27/8/03 22/11/03 07/12/03 12/12/03 16/12/03 25/02/04 19/03/04 22/11/03 TIME 2000 HR 0130 HR 1500 HR 0300 HR 0700 HR 1240 HR 0815 HR 0020 HR TYPE OF MEDICATION ERROR Wrong drug Wrong drug Wrong dose Omission Wrong route Wrong dose Wrong drug Wrong dose DEMOGRAPHIC OF STAFF INVOLVED JOB GRADE SNI/SN SN1/SNI SSN/SNI SSN/- SNII/SNI SSN/SNII SN/- SNI/SNI YEARS OF EXPERIENCE 5 / 4 ½ 1 ½ / 3 20 / ** 23 1 ½ / 4 12 / 1 6/12 3 / 1 ½ IV TRAINED YES (Y) / NO (N) Y / N N / Y Y / Y Y Y / Y Y / N N Y / N WARD DEMOGRAPHIC NO. OF STAFF ON DUTY 4RN 2RN + 2J 4RN + 1J 2RN +1J 3RN + 1J 5RN + 2J 3RN + 2J 2RN + 2J TOTAL PATIENT DURING EVENT WHAT WAS THE ROOT CAUSE? 50% 54% 35% 65% 88% 81% 81% 53% Assumption that drug was available.? Did not know how to use reference (DIMS) Failure to: - Check drug Check dose Countercheck with another RN Failure to: - Check drug Check dose bedside was not evident? Unclear prescription order. RN misinterprets order as discontinued Incomplete prescription. Failure to: - Check route Countercheck bedside Knowledge deficit of Dr + RN. Failure to: - Comply with guideline on 1 st IV dose administrat n?disruption. Failure to: - Check drug Countercheck Failure to: - Check type of infusion. Check dose Countercheck 39

40 Nurses Percept ion on Fact ors Current ly Af f ect ing Their Effectiveness in Med. Admin Too many adhoc medication orders (odd time order) Discipline Paeds O&G Neo Percentage of respondents who rated Frequently and Most of the Time 21% 12% 8% Pearson Chi- Square: P value of.001 Medicat ion not available on t ime of serving Discipline Paeds O&G Neo Percentage of respondents who rated Frequently and Most of the Time 21% 18% 2% Pearson Chi- Square: P value of

41 Suggest ed Measures t hat maybe helpf ul in prevent ing medicat ion error occurrence No Description Explore root cause and dwell on problem identified Instill awareness on the need of taking personal accountability in med. administration Improve staff competency in med. administration Improve staff competency in drug knowledge Devise staff-directive learning program and perform yearly assessment on staff competency Use case scenario to educate staff Devise performance improvement plan Compartmentalize medication trolley Punitive action to those not adhering to standard Punitive action to all committed error Rank of Preference

42 Top 5 Measures t hat Nurses Rat ed Helpf ul in Prevent ing Medicat ion Error Occurrence No Description Priority Explore root cause and dwell on problem identified Instill awareness on the need of taking personal accountability in med. administration Improve staff competency in med. administration Improve staff competency in drug knowledge Devise self-directive learning program and perform yearly assessment on staff competency

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44 St andardisat ion and simplif icat ion in processes which could reduce variat ion e. g. in prescribing, have legible handwrit ing, dosing, t iming Review I MR and modif y design t hat best suit t he st af f. Develop and review procedures t o obt ain unif orm pract ices across all areas and most import ant ly make known t o all levels of st af f. 44

45 Recognise weakness of st af f and invest in t raining, f ost ering mult idisciplinary and t eamwork approach in dwelling down t o problem ident if ied. Recognising adverse work condit ions such as dist ract ion, inadequat e st af f level and poor communicat ion t hat could be a consequence f or error commission. Have qualit y init iat ives such as creat ing a f orum of sharing, raising awareness and f acilit at ing t he implement at ion of pract ices t hat improve pat ient saf et y.. 45

46 I t imperat ive f or us t o: Creat e a cult ure in which t he exist ence of risk is acknowledged and injury prevent ion is recognised as everyone s responsibilit y. Provide collaborat ive and support ive environment f or st af f members t o report near misses and errors. Recognise human errors are sympt oms of underlying syst em f ailures and be willing t o dwell on syst em f act ors Syst emat ically t rack and evaluat e report s as analysing dat a set has great pot ent ial f or developing prevent ive st rat egies t o reduce f ut ure errors 46

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