National Medication Safety Network. Observatory Erskine David UKMI, Guy s and St Thomas NHS Foundation Trust

Transcription

1 National Medication Safety Network Observatory Erskine David UKMI, Guy s and St Thomas NHS Foundation Trust Slide 1 MSO Web Event 28 th January

2 Slide 2 MSO Web Event 28 th January 2015 National Medication Safety Network 28 th January 2015 Observatory of recent safe medication bulletins, practice research, reports, and publications Presented by David Erskine, david.erskine@gstt.nhs.uk

3 Recent regulator and statutory body activity NHS England- Harm from using Low Molecular Weight Heparins when contraindicated (Stage 1 warning) Need to stop giving them when contra-indicated NHS England - Risk of death or serious harm from accidental ingestion of potassium permanganate preparations (Stage 1 warning) Need to stop people swallowing the tablets Slide 3 MSO Web Event 28 th January 2015

4 Slide 4 MSO Web Event 28 th January 2015 Recent regulator and statutory body activity MHRA - Medicines related to valproate: risk of abnormal pregnancy outcomes. Tighter control in females of child-bearing age with supporting information for healthcare professionals and patients MHRA - Diclofenac tablets now only available as a prescription medicine Supply now only via prescription or PGD, topical products not affected

5 Slide 5 MSO Web Event 28 th January 2015 Recent regulator and statutory body activity MHRA - Isotretinoin (Roaccutane): reminder of possible risk of psychiatric disorders warn patients and family; monitor patients for signs of depression Reinforcement of previous warnings- increased need to counsel patients/carers MHRA - Ivabradine (Procoralan) in the symptomatic treatment of angina: risk of cardiac side effects new advice to minimise risk Not to be used if resting heart rate < 70bpm or in conjunction with other drugs that cause bradycardia

6 Recent regulator and statutory body activity MHRA - Hydrogen peroxide: reminder of risk of gas embolism when used in surgery do not use in surgery, in closed body cavities or on deep or large wounds MHRA - Autopen insulin pen injection devices. Manufacturer: Owen Mumford A mechanical fault in specific batches caused reversion to no dose being administered Slide 6 MSO Web Event 28 th January 2015

7 Slide 7 MSO Web Event 28 th January 2015 Recent regulator and statutory body activity MHRA - All Accu-Chek Spirit Combo insulin infusion pumps. Manufactured by Roche Diagnostics Ltd. shifts in basal rates possible after break in power supply MHRA - Veletri (epoprostenol) powder for solution for infusion: incompatibilities with some models of administration devices need to check appropriateness of extension sets and pumps if using this drug

8 Slide 8 MSO Web Event 28 th January 2015 Recent regulator and statutory body activity PHE - Advice for GPs on pregnant women who are inadvertently vaccinated against measles, mumps, rubella, chicken pox (varicella) or human papilloma virus. Details of a post-exposure monitoring scheme MHRA New single reporting site for adverse effects to medicines, adverse incidents with devices, defective medicines or devices, concerns about fake medicine or device. Simpler method of reporting issues to MHRA

9 Slide 9 MSO Web Event 28 th January 2015 Some more useful stuff to know Specialist Pharmacy Service/NPA - Community pharmacy NSAID safety audit 2014 National data from PharmOutcomes ~3000 out of 16,366 patients taking regular NSAIDs not on gastroprotection PSNC Changes to way community pharmacists report to NRLS not to be introduced until decriminalisation of dispensing errors FDA - Dietary Supplements Containing Live Bacteria or Yeast in Immunocompromised Persons: Warning - Risk of Invasive Fungal Disease UKMI producing a Q&A to support implementation of naloxone alert

10 Slide 10 MSO Web Event 28 th January 2015 This months papers Dabigatran and Rivaroxaban Use in Atrial Fibrillation Patients on Hemodialysis E-publication in Circulation 2015 ( abstract ) Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. BMJ Quality and Safety 2015;doi: /bmjqs (published early online 16 Jan 2015) Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications. International Journal for Quality in Health Care 2014;doi: /intqhc/mzu099 act

11 Slide 11 MSO Web Event 28 th January 2015 This months papers Complexities of medicines safety: communicating about managing medicines at transition points of care across emergency departments and medical wards Journal of Clinical Nursing Jan 2015;24(1-2): Factors associated with medication warning acceptance for hospitalized adults. Journal of Hospital Medicine Jan 2015;10(1): Clinical coding of prospectively identified paediatric adverse drug reactions - a retrospective review of patient records BMC Pharmacology and Toxicology 17 Dec 2014;15:72 Medication safety strategies in hospitals - A systematic review. International Journal of Risk and Safety in Medicine, 2014, 26: ( )

12 Slide 12 MSO Web Event 28 th January 2015 This months papers Medication safety strategies in hospitals - A systematic review. International Journal of Risk and Safety in Medicine, 2014, 26: ( ) Benefits and Risks of Using Smart Pumps to Reduce Medication Error Rates: A Systematic Review. Drug Safety 2014; 12: ( ) An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events. Journal of Pediatrics 2014, 165: ( ) Medication administration errors in an urban mental health hospital: a direct observational study. Int J Mental Health Nursing 2014; 24: ( )

13 Slide 13 MSO Web Event 28 th January 2015 The effect of early in-hospital pharmacy-led medication review on health outcomes: a systematic review Published in British Journal of Clinical Pharmacology 2015;doi: /bcp /abstract Methodology comprehensive literature search, quality assessment, appropriate methods to combine data Results - included 7 controlled studies (one from N. Ireland) involving 3292 patients

14 The effect of early in-hospital pharmacy-led medication review on health outcomes: a systematic review Results No significant effect on length of hospital admission [WMD (-) 0.04 days (-1.63 to +1.55)] No significant effect on mortality [OR 1.09 (0.69 to 1.72)] No significant effect on re-admissions [OR 1.15 (0.81 to 1.63)] No significant effect on emergency department revisits [OR 0.6 (0.27 to 1.32)] Slide 14 MSO Web Event 28 th January 2015

15 Slide 15 MSO Web Event 28 th January 2015 The effect of early in-hospital pharmacy-led medication review on health outcomes: a systematic review Potential Limitations Small number trials of limited size and quality Practicalities of testing value using controlled design methodologies No assessment of impact on process outcomes eg prescribing errors, numbers of medicines, costs of medicines Most studies involved frail elderly where potentially many confounding factors 6/7 studies involved pharmacists who were not able to enact their recommendations

16 What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Published in Int J Quality Health Care 2015: 1-9 Findings comparing evidence of prescribing errors from an audit of 3291 patient records, direct observation of 180 nurses administering 7451 medicines and reported medication incident reports Slide 16 MSO Web Event 28 th January 2015

17 Slide 17 MSO Web Event 28 th January 2015 What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. 12,567 prescribing errors identified at audit, of which clinical errors accounted for 31.1% and 539 (4.3%) were rated clinically important During this timeframe 15 incidents were reported to incident systems all had also been picked up in audit This equates to a ratio of 1.2 incident reports per 1000 identified errors (increases to 13 reports per 1000 errors for clinically important errors) 21.9% of clinically important errors were detected by staff but only 6% of those detected were reported to incident systems

18 Slide 18 MSO Web Event 28 th January 2015 What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Direct observation of 7451 drug administrations yielded 10,955 administration errors One or more clinical errors occurred in 27.4% of drugs administered 10.2% of all drug administrations involved errors rated as clinically important None of these were reported to the hospital incident system.