Case 23- Error

Question 1

Prescribing errors- Choosing a medicine

Answer 1

• Irrational, inappropriate or ineffective
• Under-prescribing= not prescribing a medication when you should have i.e. not prescribing an antibiotic when a patient clearly has an infection
• Over-prescribing= i.e. prescribing an antibiotic when a patient has no sign of infection.

Question 2

Prescribing errors- Prescription writing

Answer 2

• Omission of information
• Selection error- accidently selecting the wrong medication or forgetting what medication is prescribed for the condition.
• Dispensing or administration error- giving a medication which was not prescribed
• Monitoring error- Includes baseline and others, not doing the blood tests and imaging which is required before you start a medication. Not doing following up tests

Question 3

Effect of prescribing errors

Answer 3

Death, morbidity and nuisance. Significant cost for the NHS, may need other medications to be prescribed to avoid the adverse effects of the medication.

Question 4

Common prescribing errors

Answer 4

• Opioids- cause respiratory depression
• Anticoagulants linked to mortality and haemorrhages
• Antimicrobial and PPI linked to c.difficile in patients who get toxic enterocolitis
• Infections in immunocompromised patients (gluccorticosteroids, chemotherapy and antineoplastics)

Question 5

How do medication errors cause harm to patients in the NHS

Answer 5

• Most commonly linked to wrong doses (using wrong units, often the errors are in factors of ten) or illegible prescriptions
• 1 in 20 hospital admissions are due to medication errors
• 1.5% secondary care, 11% primary care- wrong prescription. Tends to be because pharmacists have a much greater role in secondary care

Question 6

How can prescribers reduce error- different types of competency

Answer 6

• Unconsciously incompetent- tends to be about something you don’t know a lot about
• Consciously incompetent- something you don’t know a lot about, but you are aware of your lack of knowledge-
• Consciously competent- know how to do something
• Unconsciously competent- know how to do something without having to check how its done

Question 7

Where on the competency scale should you be when prexcribing

Answer 7

• Difficult to know where you are on that scale, helped with reflection and peer discussion. For example, a doctor may be competent enough to prescribe some drugs without checking but not others. Or you can prescribe the drug to some patients but not others who may have contraindications
• When prescribing best to stay in the consciously incompetent and consciously competent range. If you are consciously incompetent you know that you should not be prescribing that medication. If you are consciously competent you know to double check the prescription before you send it out
• When you are unconsciously competent you may not be aware of changes that are occurring such as new medications or changes in the patient group

Question 8

Prescribing medication- control

Answer 8

• Systems focused: supply medication uses many systems that have checks built in to ensure accuracy
• Over the last ten years this has developed from focusing on supply, to clinical checking
• Ensuring that prescribers have up-to-date information e.g. BNF Online, MedicinesComplete, SCR

Question 9

Prescribing medication- culture

Answer 9

• Prescribing not a significant part of undergraduate medical education
• Important to talk about prescribing errors and discuss it as a MDT
• Having a culture of openness and honesty
• Social stigma around certain medication such as antidepressants so wont discuss it openly
• Communication is often limited to drug names and sometimes even those are abbreviated i.e. Fluclox

Question 10

Identifying prescribing errors- different types of error

Answer 10

• Wrong drug- may sound similar, look similar or have similar packaging
• Wrong dose- may have given an adults or child dose. Patients who weigh less may need less medications. LFT function may affect dose
• Wrong time- don’t give medication which makes the patient drowsy or dizzy first thing in the morning
• Wrong way
• Wrong patient

Question 11

Reducing prescribing error- regular review of medication at every oppurtunity

Answer 11

The Green bag scheme- the patient takes all their medications in for the hospital appointment so that it can be fully reviewed. By taking the medication in you can see if the patient is actually taking them

Question 12

Correcting prescription errors

Answer 12

• Typically identified by pharmacists and discussed with the prescribers individually
• Encourage broader discussion with the team to prevent reoccurrence
• Root cause analysis- what events lead to the error
• Be open and honest about mistakes- let people involved know
• Careful when remedying- may be more complicated then stopping or switching to the right treatment. The treatment you gave which is wrong may still provide some symptomatic relief so stopping it completely may not help.
• Communication about any changes to the patients regimen i.e. notes, letters, the patient. You may think there is an error but its intentional i.e. using smaller doses for amputee’s. The patient should be aware of error
• If before the prescription has been processed, make sure the changes are clear

Question 13

Approaches to reducing prescribing errors

Answer 13

• Expanding professional roles
• Education roles
• Using computerised tools

Question 14

Expanding roles- reducing prescription errors

Answer 14

• Typically pharmacists involved in supplying medication at the request of the medical prescriber
• Demand controlled by physicians and supply controlled by pharmacists
• Extremely profitable for both professional groups that enabled expertise and specialisation to be developed in diagnosing illnesses and creating treatment regimens, respectively.
• However, generated culture we have today that still has many prescribing errors

Question 15

Reducing prescription error- educational strategies

Answer 15

• Prescribing safety assessment introduced to ensure that MBBS graduates can prescribe safely
• Postgraduate supervision by consultants, speciality and core trainees as well as pharmacists in practise
• Can include group session, individual sessions, audits and error reporting requirements
• Increasingly involved in postgraduate certification i.e. RCP, RCGP

Question 16

Role of e-prescribing in reducing errors

Answer 16

• Most literature identifies improvements to patient safety. Some identifies unintended consequences
• Although UK primary care is the most computerised in the world in we still sit at the median of prescribing errors, indicating that some errors may be unavoidable or new errors are being created.
• For example= Pop ups can be ignored or provide inaccurate information, Resilience when computers not available, Human factors E.g. workflow, tool design and context
• NHS to be paperless by 2020
• Integrated into patients medical records
• ePrescribing systems in place for some specialities i.e. chemocare
• Purpose built software which may differ between each organisation, will have to learn about each new interface especially when rotating from one trust to another
• Generally improves workflow by speeding up prescribing

Question 17

Medication error definition

Answer 17

Medication errors are any incident where there has been an error in the process of: prescribing, dispensing, preparing, administering, monitoring or providing medicines advice regardless of whether any harm occurred or was possible.

Question 18

How can you minimise the chance of making a prescribing error

Answer 18

• If possible avoid distractions
• Take your time
• Check!
• Clear communication
• BNF, prescribing protocols etc.
• Ask your seniors for help
• Input from Pharmacists…
• E-prescribing…
• If an error occurs, find out why. Learn from it

Question 19

Professional duty of candour

Answer 19

• Tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong
• Apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
• Offer an appropriate remedy or support to put matters right (if possible)
• Explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

Question 20

Healthcare professionals must (prescription errors)

Answer 20

• Take part in reviews and investigations when requested
• Raise concerns where appropriate
• Support others to be open and honest and not stop them from raising complaints

Question 21

The role of community pharamcists

Answer 21

• Drug preparation
• Health promotion
• Drug monitoring
• Accessible to the public
• Supply medication prescribed
• Collect and clarify patient information i.e. drug history
• Provide advice to public and health professional

Question 22

The role of hospital pharmacists

Answer 22

• Monitor patient response to drugs
• Promote rational prescribing
• Involvement in policy-making committees
• Some pharmacists can prescribe
• Recognise and report adverse drug reactions
• Education of other health care professional
• Monitor patterns of drug usage

Question 23

Collaborating with pharmacists

Answer 23

• Provide information about new medications to prescribers.
• Education of formulary, guidelines, and protocols.
• Monitor patient medications.
• Prevent errors and adverse effects.
• Rationalise patient’s drug list (reduce interactions and improve patient compliance).
• Can prescribe (reducing burden).
• Are a huge fountain of knowledge about drugs

Question 24

Compliance, Adherence, Concordnace

Answer 24

Compliance- the extent to which the patients behaviour matches the prescribers recommendation.
Adherence- the extent to which the patients action or behaviour matches the agreed recommendations from the prescriber.
Concordance- the relationship between the patient and the prescriber and the degree to which they agree about the treatment

Question 25

Why dont patients take their medication

Answer 25

• Lack of agreement that a prescription medicine is the best treatment for an illness.
• Concern about the effectiveness of a treatment or about possible adverse effects.
• Outside influences e.g. advice from family/friends/own beliefs.
• Failure to appreciate the reasons for therapy.
• Inability to use the medicine.
• Forgetfulness.
• Financial issues.

Question 26

Why is patient non-concordance an issue

Answer 26

• Limit the benefits of medicines
• Lack of improvement of condition
• Deterioration, in health
• Wasted medicines
• Increased cost for healthcare if health deteriorates
• Affects patient, doctor relationship and trust

Question 27

Types of non-adherence

Answer 27

Unintentional non-adherence= patient wants to follow the treatment plan advised but is unable to because of circumstances beyond their control. I.e. forgetting, unable to use devices, financial difficulties.
Intentional non-adherence= the patient decides that they do not want to follow the treatment recommendations. Need to consider the patients beliefs, perceptions, motivations, side-effects, practical barriers

Question 28

How can you improve adherence

Answer 28

• Reduce the frequency of administration
• Reduce the number of drugs for administration
• Large print instructions
• Medications
• Medication aides
• Concordance and shared decision making

Question 29

How can you improve concordance

Answer 29

• Listen to your patient
• Communicate to your patient appropriately, explain the benefits and adverse effects of a drug/treatment
• Answer their questions
• Clear instructions
• Involve family or carers in the discussion (with the patients permission)- team effort in some cases
• Non-blame approach

Question 30

Providing the right amount of information

Answer 30

• Ask the patient how much information they want
• Chunking and checking
• Check patient understanding before proceeding
• Leave space for the patient to contribute
• Use your patients response as a guide

Question 31

The key principles for the statutory duty of candour

Answer 31

• Care organisations have a general duty be open and transparent in relation to care.
• The duty, like the contractual one, applies to organisations rather than individuals, but staff should cooperate to make sure the organisational obligation is met.
• Patients should be told of a ‘notifiable safety incident’ as soon as is practical.
• A notifiable safety incident has two statutory definitions, depending on whether the healthcare organisation is an NHS body or not.
• The organisation has to explain to the patient what’s known at the time, what further enquiries will be made, offer an apology and keep a written record of the notification to the patient. Failure to do so could be a criminal offence.
• The patient should be given reasonable support. This could be practical (eg, an interpreter) or emotional (eg, counselling).
• The patient must get written notes of the initial discussion and of the notification, including details of further enquiries, their results and an apology. The organisation needs to keep copies of all correspondence.

Question 32

Medical error

Answer 32

Preventable adverse effect of medical care which may or may not cause harm to the patient e.g. incorrect/missed diagnosis, incorrect prescribing, misinterpretation of investigation results.

Question 33

Near muss

Answer 33

Any event due to error that could of had an adverse patient consequence but did not

Question 34

Patient safety issues

Answer 34

Issues in the health care system which result in patient safety being compromised:
• These can occur as result of medical error
• If the clinical environment/system has played a role in that error occurring and the issues have not been addressed then it is possible for the error to occur again and affect other patients
• Therefore it is important that we can understand sources of error and how to respond to them, to improve patient safety

Question 35

Why is the epidemiology of medical error difficult to claculate

Answer 35

• Individuals may not have immediately realised they have made an error or they may not feel comfortable admitting it
• Organisations may not have adequate systems in place for recording and dealing with error

Question 36

Medical error- Previous BLAME culture

Answer 36

• Focussed more on blaming individuals for error
• Led to people not wanting to admit mistakes or covering up their mistakes
• This also ignored the fact that medical error often occurs due to a several factors and can involve wider organisational/workplace issues – when ignored could lead to the same error being made again by a different person

Question 37

The ‘LEARN NOT BLAME’ culture

Answer 37

• Focusing on learning from mistakes instead of looking to place blame on one individual
• This allows staff to feel more able to admit mistakes which can then be learnt from
• By trying to learn from mistakes any wider systemic issues can be identified and changes can be made to prevent the same error happening again, therefore leading to improved patient safety

Question 38

Human error can be split into two main types

Answer 38

• Human error- unintentional action or decision

* Violation- intentional failures (deliberately doing the wrong thing)

Question 39

Human error- skill and mistake

Answer 39

• Skill- based errors- slips of action, lapses of memory.

* Mistakes- Rule based mistakes, knowledge based mistakes

Question 40

More information on human error

Answer 40

• Slips of action- not doing what you are meant to do. Occurs in familiar tasks when our attention is diverted
• Lapses of memory- forgetting to do something or losing your place in a task i.e. failing to check if the patient is allergic to penicillin before giving Flucloxacillin
• Mistakes- rule based mistake: a rule or procedure is remembered or applied incorrectly. Knowledge based mistakes: a new situation is encountered for which the usual rules or procedures may not apply i.e. prescribing a drug without knowing its contraindications, resulting in patient harm.

Question 41

Swiss cheese effect

Answer 41

Patient harm usually occurs when lots of small errors are combined to result in harm

1. Many layers of defence
2. Each level of defence has little ‘holes’ in it- these represent errors
3. If the holes (errors) become aligned over successive levels of defence then a window for a patient safety incident is created

Question 42

Factors leading to error (IM SAFE)

Answer 42

• Illness- the practitioner may be ill and this is affecting their ability to make decisions
• Medication- may cause poor sleep or fatigue
• Stress- may be overwhelmed
• Alcohol- if the practitioner is drunk
• Fatigue- long shifts
• Emotion

Question 43

System factors for medical errors

Answer 43

• Organisational i.e. not invested in training/staff development
• Environment i.e. chaotic, understaffed. Not enough time to talk to patients and fully explore what’s going on
• Teams i.e. junior doctor supervision arrangements
• Technology i.e. portable x-ray availability
• Difficult tasks i.e. taking blood from neonate. Task may not be done as often as it should be
• Patient i.e. challenging behaviour

Question 44

Impact of medical error on the patient

Answer 44

• Death
• Disability
• Increased length of hospital stay
• Delayed/missed diagnosis
• Financial impact if unable to work
• Social isolation
• Reduced confidence in medical professionals
• Reduced confidence in medical systems/organisations

Question 45

Impact of medical errors on families

Answer 45

• Loss of trust in medical profession
• Concern for loved one
• Bereavement
• Stress/anxiety
• Breakdown of family relationships

Question 46

Impact of medical errors on doctors

Answer 46

• Increased tendency to practice defensively to avoid further mistakes (particularly if felt ‘blamed’ for error). For example, having people check their work when they don’t need to
• Stress/anxiety/ may avoid similar situations where error could occur
• Feelings of guilt towards patient
• Loss of confidence in own abilities

Question 47

Responding to medical errors

Answer 47

Should be followed for all types of medical errors even if it was a near miss:
• Recognise the error – be open and honest, don’t try to cover it up
•mCorrect the error where possible – offer an appropriate remedy or support to put matters right if possible
• Alert the medical team/your supervisor
• Duty of candour – inform the patient (and family if appropriate) about the error, apologise to them, and explain fully any short/long term effects of what has happened
• Document what has happened in the notes, and any discussions with the patient/their family
• Datix (recording the error on hospital system) – not for blame reasons but so the error can be discussed and learnt from for future practise
• Reflect on the error in your eportfolio/discuss it with your clinical and educational supervisors

Question 48

The 6 key elements of a meaningful apology

Answer 48

• Acknowledgement of the wrong done.
• Accepting responsibility for the offence and the harm done.
• A clear explanation as to why the offence happened.
• Expressing sincere regret.
• An assurance that the offence will not be repeated.
• Making amends- improving the patients confidence in your practise and the healthcare system

Question 49

Serious untoward events/ Serious incidents

Answer 49

These are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified.

Question 50

Root cause analysis

Answer 50

This is a problem solving methodology for discovering the real cause of problems or difficulties, including adverse incident management. It aims to identify all contributing factors to a problem or event

Question 51

Principles of root cause analysis

Answer 51

• Focusing on corrective measures of root causes is more effective than simply treating the symptoms of a problem or event.
• There is usually more than one root cause for a problem or event.
• The focus of investigation and analysis through problem identification is WHY the event occurred, and not who made the error (links to learn not blame culture)

Question 52

Basic method for carrying out root cause analysis

Answer 52

• Define the problem.
• Gather information, data and evidence.
• Identify all issues and events that contributed to the problem.
• Determine root causes.
• Identify recommendations for eliminating or mitigating the reoccurrence of problems or events.
• Implement the identified solutions.

Question 53

Clinical iatrogenesis

Answer 53

Any injury or illness which occurs from medical care, it is not a medical error.
Doubles the risk in >65’s because they are more frail, increased co-morbidity and polypharmacy

Question 54

Examples of clinical iatrogenesis

Answer 54

Drug or Vaccine side effects
Hospital Acquired Infection
Intervention related infection e.g. catheter
Complications after surgery e.g. incisional hernia