nanime medication incidents and safe prescribing fy2 [part 2] 2016
TRANSCRIPT
Case ONE: Mr Green
Mr Green (1111222) 72 year old male, Admitted to MFE ward with SOB and a productive cough.
PMHx High cholesterol, OA, Parkinson’s disease
DHx: see next slide, NoK has a bag of drugs
Allergies: Penicillin, Doxycycline• O2 sats: 82% OA
• Scattered wheezes heard on auscultation.
• Temp: 38.2.
• WBC 17.2, CRP 113.
• U+E N (Urea 5mmol/l)
• RR: 18
• BP: 121/71
∆ ?CA-LRTI In the mean time write up Mr Greens drug chart
• NO Metoclopramide
• Parkinsonspatient
Regular Prescriptions 2
Date
Circle times or enter other times
26/9
4. Drug (approved name)
Rotigotine Start Date
26/9/14
06 08
Dose
6mg/24hrs
Route
Top(Patch)
Frequency
Once daily
12
14 Reason for starting / stopping
Parkinsons Disease
Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
5. Drug (approved name)
Simvastatin
Start Date
26/9/14
06 08
Dose
40mg
Route
po
Frequency
Once Daily
12
14 Reason for starting / stopping
High cholesterol
Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18 22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
6. Drug (approved name) Start Date 06 As Required Prescriptions 1
1. Drug (approved name)
Sodium Chloride 0.9% Start Date
On admission Date/
Time
Dose
5 mL Route
IV Pharm:
STOCK Route
Maximum Frequency
See Trust Protocol To flush peripheral cannula, flushes for
other types of IV line must be prescribed. Dose
Prescriber’s Signature
As per Trust Drug Protocol 1.2
Given By
2. Drug (approved name)
Co-dydramol 10/500
Start Date
26/9/14
Date/
Time
Dose
Ii
Route
po
Pharm: cc: DH New
STOCK/ POD / TTO / IP / CD Route
Maximum Frequency
qds
Indication / Other Instructions
pain Dose
Prescriber’s Signature
Hbassi Bleep No
1287
Given By
3. Drug (approved name)
Start Date Date/
Time
As Required Prescriptions 1
1. Drug (approved name)
Sodium Chloride 0.9% Start Date
On admission Date/
Time
Dose
5 mL Route
IV Pharm:
STOCK Route
Maximum Frequency
See Trust Protocol To flush peripheral cannula, flushes for
other types of IV line must be prescribed. Dose
Prescriber’s Signature
As per Trust Drug Protocol 1.2
Given By
2. Drug (approved name)
Co-dydramol 10/500
Start Date
26/9/14
Date/
Time
Dose
Ii
Route
po
Pharm: cc: DH New
STOCK/ POD / TTO / IP / CD Route
Maximum Frequency
qds
Indication / Other Instructions
pain Dose
Prescriber’s Signature
Hbassi Bleep No
1287
Given By
3. Drug (approved name)
Start Date Date/
Time
Community Acquired Pneumonia
Mod severity
Antibiotic policy recommends
Amoxicillin 500mg tds po
plus
clarithromycin 500mg bd po 7 days
Penicillin allergy:
Doxycycline 200mg po stat then 100mg-200mg od 7 days
Antibiotics Only Review IV route daily
Antibiotics Only Review IV route daily
Antibiotic Prescriptions 1 Indication and stop or review date MUST be completed by prescriber
On review consider if IV route necessary refer to Trust policy for further guidance
Date Circle times or enter other times
1. Antibiotic (approved name)
Clarithromycin Start Date
26/9/14
06 08
Dose
500mg
Route
po
12
14 Frequency/Other Instructions
Twice daily
Supply
POD ( ) TTO /IP/Stock/Fridge
Sign: Date:
18
22 Indication(s)
LRTI
cc Date
DHx New
24
Prescriber’s Signature
HBassi Bleep No
1287
Initial Stop /Review Date
5/7
Revised Stop/Review Date Revised Stop/Review Date Revised Stop/Review Date
4. Drug (approved name)
Simvastatin
Start Date
26/9/14
06 08
Dose
40mg
Route
po
Frequency
Once Daily
12
14 Reason for starting / stopping
High cholesterol
Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18 22 X X X X X
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
Hold while co-prescribed Macrolide (clarithromycin) 5. Drug (approved name) Start Date 06
Regular Prescriptions 2
7/7
Xx/xx/xx
Xx/xx/xx
Case Two: Mrs Brown
Mrs Brown (55667789) admitted to A&E with confusion 2° to UTI, now successfully being treated with Trimethoprim 200mg BD 5/7. Her vitals are currently stable
PMHx: CCF, High cholesterol, OA (will not take Bisposponates)
DHx: see bag of drugs
Allergies: NKDA
The cases is handed over to you, as the FY2 to write up her drug chart.
Regular Prescriptions 2
Date Circle times or enter other times
26/9
4. Drug (approved name)
Adcal D3 Start Date
26/9/14
06 08
Dose
One
Route
po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
5. Drug (approved name)
Digoxin
Start Date
26/9/14
06 08
Dose
250micrograms
Route
po
Frequency
Once Daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
6. Drug (approved name)
Simvastatin
Start Date
26/9/14
06 08
Dose
40mg
Route
Po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
7. Drug (approved name) Start Date 06
Xx/xx/xx
Xx/xx/xx
Duplication
• Simvastatin and Bezafibrate both given for hypercholerstolaemia
• High risk drug? No
• Acute indication? No
• Confirm with a second source (Medicines reconciliation)
Medicines reconciliation
• Pharmacist confirms that Bezafibrate was stopped and replaced with Statin.
• All of the other tablets are correct however Mrs Brown was started on the following by her GP last month Amlodipine 10mg OD
Regular Prescriptions 2
Date Circle times or enter other times
26/9
4. Drug (approved name)
Adcal D3 Start Date
26/9/14
06 08
Dose
One
Route
po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
5. Drug (approved name)
Digoxin
Start Date
26/9/14
06 08
Dose
250micrograms
Route
po
Frequency
Once Daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
6. Drug (approved name)
Simvastatin
Start Date
26/9/14
06 08
Dose
40mg
Route
Po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
7. Drug (approved name)
Simvastatin
Start Date
26/9/14
06 08
Dose
20mg
Route
Po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New 24
8. Drug (approved name)
Amlodipine
Start Date
26/9/14
06 08
Dose
10mg
Route
Po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
9. Drug (approved name) Start Date 06
STOP dose reduced due to interaction with amlodipine. HBassi #1287
26/9/14
Xx/xx
Xx/xx
Xx/xx
Xx/xx
Xx/xx
MHRA guidance Drug interactions associated with increased risk of myopathy/rhabdomyolysis
Interacting agents Prescribing recommendationsItraconazoleKetoconazolePosaconazoleErythromycinClarithromycinTelithromycinHIV protease inhibitors (eg, nelfinavir)NefazodoneCiclosporinDanazolGemfibrozil
Contraindicated with simvastatin
Other fibrates (except fenofibrate) Do not exceed 10 mg simvastatin dailyAmiodaroneAmlodipineVerapamilDiltiazem
Do not exceed 20 mg simvastatin daily
Fusidic acidPatients should be closely monitored. Temporary suspension of simvastatin treatment may be considered.
Grapefruit juice Avoid grapefruit juice when taking simvastatin
Case Three: Mrs Pink
You are on-call and asked to see Mrs Pink (22335544).
She was admitted to EAUS for a planned TKR however unsuitable for surgery, her BP has been dropping since admission. Currently 87/58mmHg
Unable to access her EMPA drug chart
Nurse informs
you patient is
currently
prescribed One
of each…..
-Amiodarone
100mg od
-Amlodipine
10mg od
-Atenolol 75mg
od
-as per her bag
of drugs
Don’t assume.• Confirm atenolol dose.
– 25mg
– 50mg
– 75mg?
• Amiodarone and atenolol interaction (negative chronotropic ) thus confirm the dose!
• Even with electronic prescribing we INPUT into the system. Errors are two fold now:
– System errors (EMPA/drug charts/ICE)
– User errors (us lot)
Regular Prescriptions 2
Date Circle times or enter other times
26/9
4. Drug (approved name)
Atenolol Start Date
26/9/14
06 08
Dose
25mg Route
po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
5. Drug (approved name)
Amiodarone Start Date
26/9/14
06 08
Dose
100mg
Route
po
Frequency
Once Daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
6. Drug (approved name)
amlodipine Start Date
26/9/14
06 08
Dose
10mg
Route
Po
Frequency
Once daily
12
14 Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx New
24
7. Drug (approved name)
Simvastatin
Start Date
26/9/14
06
Xx/xx/xx
Xx/xx/xx
Xx/xx/xx
Can you see a
potential error here?
Electronic systems –
alphabetised – reading
in a rush
Case Four: Mrs Blue
• Admitted to AMU-L via ambulance.
• See clinical notes
• You are asked to write up the drug chart for this lady
• Mr Blue has documented Mrs Blue’s acute past medical history and Drug history in a letter
Drug Husbands List TTO GP list
Buprenorphine - - Yes
Candesartan Yes Yes Yes
Lercandipine 20mg od Yes Yes Yes
Simvastatin Yes Yes Yes
Adcal d3 Yes Yes Yes
Aspirin Yes Yes Yes
Atenolol Yes Yes Yes
Bendro Yes Yes Yes
Moxonidine - Yes -
Alendronic acid - Yes -
Drug Husbands List Old TTO 2012 GP list
Buprenorphine Check patient - Yes
Candesartan Yes Yes Yes
Lercandipine 20mg od Yes Yes Yes
Simvastatin Yes Yes Yes
Adcal d3 Yes Yes Yes
Aspirin Yes Yes Yes
Atenolol Yes Yes Yes
Bendro Yes Yes Yes
Moxonidine STOP - Yes -
Alendronic acid STOP - Yes -
Case Five: Mrs Yellow
You are a GP and one of your regular patients, Mrs Yellow (2/8/1962, 13 mountain way, any town, NM90KL) comes to see you for a regular prescription.
PHx: Chronic back pain, depression
DHx: Morphine Sulphate MR 20mg BD, Citalopram 10mg OD
Allergies: NKDA
You are keen to control her pain but monitor her progress regularly so write a 2/52 repeat prescription
BNFZomorph® (Archimedes)
Capsules , m/r, morphine sulfate10 mg (yellow/clear enclosing pale yellow pellets),
net price 60-cap pack = £3.47; 30 mg (pink/clear enclosing pale yellow pellets),
60-cap pack = £8.30; 60 mg (orange/clear enclosing pale yellow pellets),
60-cap pack = £16.20; 100 mg (white/clear enclosing pale yellow pellets),
60-cap pack = £21.80; 200 mg (clear enclosing pale yellow pellets), 60-cap
pack = £43.60. Label: 2, counselling, see belowDose every 12 hours, dose adjusted according to
daily morphine requirements; for further advice on determining doses, see Prescribing in Palliative
Care; dosage requirements should be reviewed if the brand is altered
2/8/1962 Mrs Yellow
13 mountain way,
Any town, NM90KL
Please supply
Citalopram 10mg OD x 1op
Morphine Sulphate
Modified release Capsules
20mg Twice daily,
total supply of (Fifty six) 56 x 10mg capsules
/////
Hbassi x/y/zz
Not an error – but
slows down patients
receiving drugs
Checking in the BNF
Easier – call the
pharmacy and check
stock/strengths
available
Revision of common Pall care
agents and doses
• Nausea & Vomiting – Haloperidol 2.5-10mg/24hrs
– Cyclizine 150mg/24hrs
– Metoclopramide 30-120mg/24hrs
– Levomepromazine 6.25-25mg/24hrs
• Anxiety/aggitation– Midazolam 10-60mg/24hrs
– Haloperidol 10-30mg/24hrs
– Levomepromazine 25-200mg/24hrs
• Pain – Diamorphine patient specific doses
– Morphine – patient specific doses
– Alfentanyl – patient specific doses
• Respiratory secretions– Hyoscine hydrobromide 600mcg-2.4mg/24hrs
What are the two common causes for prescribing errors?
• Time pressure• Prescribing in isolation
Resilience• Recognise triggers
• Rushed
• New drugs• Someone breathing down your neck• High risk drugs• Time sensitive drugs Slow down & double check
High risk drugs
• Methotrexate
• Anticoagulants
• Injectable medicines
• Epidurals
• Oral chemotherapy
• Oral opiates
• Medical gases
• Insulin
• Parkinsons
Drugs with time-sensitivity
• Anticoagulants, antiplatelets, thrombolytics
• Antiepileptics
• Anti-parkinsonians
• Anti-diabetics (insulin & oral hypoglycaemics)
• Antimicrobials (systemic routes only)
• Steroids
• Immunosuppressants
• Chemotherapy & associated adjunctive therapy
• Electrolyte correcting agents
• Anti-arrhythmics
• Anti-anginal agents