DART - on target for safe prescribing

Karin Purshouse

Judith Bailey

Jane Hough

Triss Clark

Today

Prescribing errors

What is DART?

Group work

Prescribing errors

Nationally 1 in 10 patients = adverse event 15% of these are medication related

Case

75 year old lady with advanced cancer, brain and bone metastasis

Admitted with general malaise, vague neurological symptoms

Attended with sister and bag of medications

Stated she had forgotten her morphine, but normally took 100mg MST.

Case continued

SHO prescribed 100mg MST and asked sister to check medication at home.

Next day… Medicine reconciliation by pharmacist, found patient

actually took 20mg MST BD. Sister had called the ward and message hadn’t been

handed on. Patient was completely well, slightly drowsy.

Case learning points

Near miss

Prompted this Quality Improvement Project on prescribing.

Prescribing errors can happen to everyone

Any examples?

Evaluation of prescribing in EAU and medical wards – Dec/Jan 2013/14

1 in 5 prescriptions had an error

Nearly HALF were due to drug omissions on admission

Nearly a THIRD were dose-related (mostly over-dosing)

10% were due to incorrect/absent drug timings

Of high-risk drugs, antibiotic and insulin prescribing was least accurate

You are agents for change!

FY1 FY2 Reg Unknown0

5

10

15

20

25

30

35

40

45

Total number of errors per grade of prescriber in medicine

n=59 patientsTotal number of errors per grade of prescriber

http://www.clipshrine.com/edit/edit.xhtml?imgid=3676

http://www.clipshrine.com/edit/edit.xhtml?imgid=3676

D• DOCUMENTATION - Complete the prescription

CLEARLY in full so it can BE GIVEN SAFELY. Clearly document changes to medicines in the medical notes.

A• ALLERGIES - Is the patient allergic to the drug? Have I

checked and documented this?

R• REGULAR MEDICATIONS - Do I know the patients'

regular medications? - Find out via OxCS. Check the pharmacy box in the drug chart.

T• TIME CRITICAL MEDICINES- Does this medication

need to be given STAT? Tell the nursing staff!

Oxfordshire Care Summary

1) Search ‘Oxfordshire Care Summary’

2) Complete training

3)Use when clerking!

For those in AGM/Medicine: Prescribing simulation sessions Multidisciplinary (Nurses, doctors, pharmacists)

Dates: Friday 11th April 2-3pm, 3.30-4.30pm AGM seminar room Wednesday 16th April 2-3pm, 3.30-4.30pm GPEC seminar

room 2B

One hour, coffee+cake and certificate for your e-portfolio

Consultants will be looking for your participation.

Groups

Cases from actual scenarios found in the study

Discuss the cases and amend the prescriptions

Take a DART card for your badge holders