Safety Snippets Safety Resource of the Month Leeds North Clinical Commissioning Group Leeds South &...

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• Safety Resource of the Month

Leeds North Clinical Commissioning GroupLeeds South & East Clinical Commissioning GroupLeeds West Clinical Commissioning Group

Two weeks too longAn epileptic patient has been left with severely compromised speech and mobility when they were left without medication for 2 weeks.

The post-discharge review appointment was not scheduled to take place before the patient ran out of medication.

May

2015

NICE NG5 Medicines Optimisation Guidance on transitions.

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Concentration is CriticalPrescribing Insulin is complex, error prone and high risk.

D – Drug Name. Prescribe by Brand. Check for errors with similar named products.

D – Device. Check changes are intended and agreed with the patient.

D – Dose. If the dose is included on the prescription make sure it is reviewed and updated.

D – Duration. Check for short and longer acting insulin mix-ups

D – Deadly. Ensure high-strength insulins are intended before prescribing

May

2015

MHRA guide to prescribing insulins:www.gov.uk/drug-safety-update/high-strength-fixed-combination-and-biosimilar-insulin-products-minimising-the-risk-of-medication-error

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Prednisolone PerilsPrescribing oral steroids is error prone. Our Datix system has 34 incidents relating to prednisolone or hydrocortisone. Errors include;Dose errors in short courses.

Course duration errors.

Failure to discontinue and

Failure to prescribe protective polypharmacy

April

2015

MHRA e-learning tool to manage risks of prescribing steroidswww.gov.uk/drug-safety-update/corticosteroids-e-learning-module-launched

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Former Formulary Foul

When trying to prescribe atorvastatin the practice formulary offered simvastatin as an alternative. This was a throwback to before the most recent guideline.

Check you practice formulary and remove simvastatin as a synonym of atorvastatin.

March

2015

Check how safe your prescribing is with the PINCER audit toolhttp://www.nottingham.ac.uk/primis/tools/audits/pincer.aspx

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Five Alive

Remove warfarin 5mg tablets from the repeat list of any patient who does not take a dose of ≥5mg.

Don’t add 5mg tablets to repeat unless the dose is ≥5mg.

At least annually, advise patients who take white 0.5mg tablets to “watch out” for the red/pink 5mg tablets to avoid errors.

Feb

2015 Page 7 Patient Information Book for warfarin

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Kidney Conundrum

12 reports on Datix highlight the difficulty of prescribing drugs for CKD Patients. Clinicians should set up CKD warnings to appear for patients with CKD stage 3,4 & 5.

When prescribing for patients with CKD stage 3,4 & 5 read the on-screen prescribing information for suitability of the selected drug.

Feb

2015MHRA Safety update on Nitrofurantoin www.gov.uk/drug-safety-update

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All they want is Radio GABA

11 incident reports this year involve Pregabalin or Gabapentin.

6 were dose errors at transitions of care.

•Reconcile dose 48 hrs after hosp’ appt .

1 incident included death involving abuse of gabapentin

Jan

2015PHE-NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf

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I said ‘4T’ not ‘40’!

The words used to tell people about dose changes of methotrexate can mislead.

•Never assume 2.5mg tablets are in use.

•Check if the patient has 10mg tablets.

•Always give written instructions stating dose in mg and number of tablets.

Jan

2015Improving the safety of telephone of verbal orders

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Mortality METHOd • TriMETHOprim increases METHOtrexate toxicity.• The interaction has been fatal.• Degree of harm is not dose dependent.

There have been 2 reported incidents of co-prescribing this combination this year in Leeds.

Never prescribe trimethoprim to patients on methotrexate (not even a short course or low dose)

Educate patients to watch out for this interaction.

Dec

2014Methotrexate info for patients & Arthritis Research UK

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Thrush Rush Reaction

• Oral Miconazole gel interacts with Warfarin, increasing INR.

• 1 patient with INR of 22 required blood transfusion as result.

• Computer alerts are easily overridden.Nystatin & warfarin are safer. Miconazole and Dabigatran is safe.

Dec

2014Pharmaceutical Journal Article on this interaction .

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In Datix We TrustLess than 7% of medicines related incidents on Datix are reported to have occurred in Acute Trusts.

Use Datix to report hospital incidents relating to DANs, TANs and medicines at admission & discharge .

Nov

2014

Hospitals

#SaferNHS

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Beware the BlaggersPatient’s who attempt to manipulate health systems and prescribers to obtain psychoactive drugs need a whole team approach to their management.

Vulnerabilities in the system can include:

•Targeting time pressured urgent appointments.

•Targeting GP registrar’s or “push over” GPs

•Requesting drugs less known for abuse (pregabalin, gabapentin, promethazine etc)

Sept

2014SMAH Addiction to medicines factsheets www.rcgp.org.uk/smah

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The Other Trouble

Putting ‘Red’ drugs and drugs prescribed elsewhere on the repeat list presents the risk that these drugs will be inadvertently prescribed by the GP.

There is a “How to” guide to avoiding this risk.

Sept

2014

SystmOne & EmisWeb Guide to managing “other drugs” in Medicines Management sections of:http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

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Always Ask About Allergy13 drug allergy incidents reported since April’14

Prescribing when not in the GP surgery is a common contributing factor.NICE says: Check a person's drug allergy status and confirm it with them (or their family or carers) before prescribing any drug.

Make a @signuptosafety pledge:

“I will Always Ask About Allergy”

Sept

2014www.england.nhs.uk/signuptosafety @SignUpToSafety

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“One” to be watched

The SystmOne pre-set dose for warfarin is

“One to be taken as directed”. This might be misleading.

Change the warfarin dose to

“Dose dependent on INR test results”

On new prescriptions and repeat templates.

June

2014

Health And Social Care Information Centre - Patient Safety Incident Reporting: National Service Desk Telephone – 0845 366 0066 [email protected]

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Allergy Alert

2 out of every 5 care home patients have inaccurate allergy status.

Inform Care Homes and their supplying pharmacies of your patients allergy status.

SystmOne & EmisWeb Guide to managing allergy status in Medicines Management sections of:http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

June

2014

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Motivation for Monitoring• Medication monitoring shows when drug changes are

needed before Adverse Drug Reactions lead to hospitalisation

• In 384 care home patients 676 monitoring tests were needed to carry out annual medication reviews, inc.– U&Es for those prescribed ACEi, ARBs, diuretics– TFTs, FBCs, HbA1c– Shared care monitoring for amber drugs inc. antipsychotics

Guide to monitoring for safer use of medicines:http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Drug%20monitoring%20document%20Feb%202014.pdf

June

2014

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Transition Trouble

Transitions of care such as hospital discharge are error prone

All medicines changes need accurate reconciliation on GP systems (and MAR charts). The changes should be authorised by a prescriber and made by a clinician.

http://www.nice.org.uk/nicemedia/pdf/PSG001Guidance.pdfJune

2014

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Dorment Drugs pose Danger

There have been a number of cases of high risk drugs remaining on the repeat list after they were discontinued. eg•Methotrexates tabs on repeat when changed to S/C•Warfarin left on repeat after end of 6/12 course.•Dabigatran left on repeat when changed to warfarin•Aspirin continued when clopidogrel started instead

May

2014

Community Pharmacy New Medicines Service: Improves adherence and highlights errors.

http://www.cpwy.org/pharmacy-contracts-services/advanced-services.shtml

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Don’t Forget Dementia

Two cases reported on Datix of patients on Alzheimer's drugs not receiving a memory clinic review every 6 months.

Dementia friends could help support your patients with dementia.

May

2014www.dementiafriends.org.uk

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Picking-List Pitfalls

Three errors picking the wrong drug have occurred because of the way the GP system presents the drug list:Buprenorphine presented 2mg but not 0.2mg tabs

“B12” presented cyanocobalamin not hydroxycobalamin.

‘Polyvinyl alcohol’ presents FML drops as well as liquifilm

MAY

2014

Incident report all such incidents:

http://nww.incidentreportform.nhsleeds.nhs.uk/index.php

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I don’t need rescuing!

A parent with an epileptic child ordered buccal midazolam every month. But the child was never admitted with a seizure.

Over-ordering of repeats with PRN doses are not highlighted by GP systems.

May

2014

Thinking of making a change? Experiment first using Plan, Do, Study, Act cycles.www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html

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Clozapine Communication

77% of GPs had been correctly informed of their patient(s) being prescribed clozapine ,but only 41% reported the that the information on clozapine would be available at consultation.

Recording of Clozapine and other “red drugs” can be improved using the new guides for SystmOne and Emis Web. (See link below)

Dec

2013http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

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Sensitive issue

Sensitivities to medication have been missed if not entered on the GP system correctly.

•Use the guidance documents below to Record ADRs and Allergies.

Dec

2013http://n3appscsu.bradford.nhs.uk/DQResources/Shared%20Documents/Forms/AllItems.aspx

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Stop at home

Set a short review date when discontinuing drugs that affect heart rhythm.

Provide written advice to staff in care homes on monitoring the patient when stopping drugs

Sept

2013“Deprescribing” in www.australianprescriber.com/magazine/34/6/182/5

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Missed the red spot

• All DANs and Hospital Letters must be screened by a clinician before changes are made to a patient’s medication.

• The Leeds Formulary should be checked if hospital letters include drugs that the GP is not familiar with.

Oct 2013 The Leeds Formulary www.leedsformulary.nhs.uk/

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Yellow Card Reporting

• MHRA must now monitor ADRs from medication errors and drug abuse.

• Consider ADRs from errors and drug abuse to be reportable.

• Use Datix or MHRA Yellow Card to report ADRs

August

2013Yellow card reporting on MHRA website https://yellowcard.mhra.gov.uk/

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Noxious NSAIDS

• Make repeat prescribing of NSAIDs the exception rather than the rule.

• Always ask the patient about OTC use of NSAIDs at review.

• Review NSAIDs regularly with an intention of discontinuing if possible.

August

2013Reminder: MHRA alert on Diclofenac on www.mhra.gov.uk

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Lithium levels

• Lithium levels are affected by fluid intake.

• Risk of dehydration may require additional monitoring for lithium toxicity

• Remind care homes to monitor the hydration of patients on Lithium.

July

2013NPSA alert on Lithium www.nrls.npsa.nhs.uk/alerts/?entryid45=65426

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Action Allergy

• Capture allergy status from letters/DANs.

• Record allergy “cause and consequence”

• Present allergy status prominently.

• Habitually ask about allergies.

• Test your systems for barriers.

July

2013www.worldallergy.org/professional/allergic_diseases_center/drugallergy/

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Warfarin Wary

In May 2013, 617 patients had been prescribed warfarin when they did not have an INR result recorded on the GP system in the preceding 13 weeks.

One had not had an INR in the last 14 months. One had not had an INR in years!

July 2013 New Warfarin Amber Drug guidelines on Leeds Health Pathways

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Cutting corners

A GP squeezed in one more job before surgery started. They didn’t look at all the information presented to them which led to them missing the changes on the DAN.

•Give yourself time to concentrate on medication changes.

Easy time- Management tips on www.nhs.uk June 2013

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NOACs & Renal Function

There is a clear link between renal function and the safe use of the New Oral Anticoagulants (NOACs), Rivaroxaban, Apixaban and Dabigatran.

•Follow the new shared care guidelines when monitoring NOACs

NOAC Amber Drug guidelines on Leeds Health PathwaysJune 2013

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Symptom or Side Effect

3 patient stories on Datix show how easy it is to miss Adverse Drug Reactions caused by drug errors.

•Suspect a Side-effect when new symptoms cannot be explained by the existing morbidities.

Drug Analysis Prints on www.mhra.gov.uk June 2013

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Equine ColicPethidine has an established place in therapy for

treating horses with colic.However, Pethidine is no longer advocated for

pain relief for home births.Any requests for pethidine for home births should

be reported on Datix and referred back to the midwife.

Jan 2013

Home Births – Appendix A of “Care of Women in Labour” nww.lhp.leedsth.nhs.uk

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Abuse potential

Pregabalin and Gabapentin abuse is on the increase. They enhance the effects of opiates and have euphoric effects. They can be injected, snorted or taken orally.

• Caution in substance using patients.

• Tighten control on repeat requests.

Jan 2013

Useful look into abuse potential of drugs from RCGP based on prescribing prisons:

www.rcgp.org.uk/news/2011/november/~/media/Files/News/Safer_Prescribing_in_Prison.ashx

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Drug using patients and SSRIs

Methadone & (es)citalopram – QT intervalCrack & SSRIs – Serotonin syndrome• Review need to antidepressant• Change to Mirtazipine/sertraline if

necessary• Seek advice from CDT clinical lead

Jan 2013

Substance Misuse Management in General Practice www.smmgp.org.uk

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Red letter days

• GPs still receive requests to prescribe red (and black-light) list drugs

• Requests from patients can be difficult to refuse.

• The reasons for red and black-light classifications are available to patients

Dec 2012 Traffic Light lists on www.leeds.nhs.uk/medicines

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Weighty decisionsEven simple calculations are worth a second

look.Errors in calculating the dose based on a child’s

weight may not be necessary – Check the children’s BNF for age related doses

Include the patient’s weight and the calculations in the script notes

Nov 2012

Children’s BNF available for smart phones:

http://www.nice.org.uk/aboutnice/nicewebsitedevelopment/NICEApps.jsp

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Book’em Danno

A review of methotrexate books in one GP practice highlighted inconsistent use.

Methotrexate books may not be effective unless incorporated into repeat prescribing systems.

• Check for dose and blood results before prescribing.

Oct 2012 Methotrexate shared care guideline on nww.lhp.leedsth.nhs.uk

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Altered Image

Alterations made to prescriptions can lead to dispensing errors

• Never make hand written changes to bar-coded prescriptions.

• Cross out and clearly re-write the whole change. Initial all changes.

Oct 2012 Ciprofloxacin story on www.leeds.nhs.uk/medicines

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Focus on opioid errors

• Watch out for mg and ml errors

• Get the actual opioid history

• Be cautious when increasing the dose

• Know your patches

• Know your s/r from your m/r

Sept 2012 Opioids on www.leeds.nhs.uk/medicines

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Prescribing the wrong dose or strength was the most commonly reported GP medication error in Leeds in 2011/12.

Top Tip: Always review the medication screen after starting, stopping or making changes to a patient’s medication.

Dose Errors Top the Chart

Review of Leeds Medication Incidents on www.leeds.nhs.uk/medicines August 2012

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A GP restarted warfarin for a patient with AF after it had been stopped by a colleague for compliance issues.

• Record the reasons for stopping medication in consultations

• Use protected time to review the records before restarting medication

Start – Stop – Restart Error

Receptionist input into Quality and Safety on www.bmj.com August 2012

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A third of patients with INR>8 have been prescribed an interacting drug.

Check INRs within 5-7 days of starting warfarin patients on antibiotics marking the blood form “dINR for warfarin clinic”

Interactions Increase INRs

Anticoagulant therapy: Information for GPs on www.nrls.npsa.nhs.uk/ July 2012

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A GMC report shows the frequency and severity of GP prescribing errors.

Reduce the risk by:• Optimising the support from your computer system• Focus on safety in education, training and peer review• Build a co-operative relationship with pharmacists

1 in 20 scripts includes error

July 2012 Evidence Scan: Reducing Prescribing Errors on www.health.org.uk

Safety Snippets Safety Resource of the Month Leeds North Clinical Commissioning Group Leeds South &...

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