noleen nath - redcliffe hospital qld - preventing medication errors within the busy hospital: a...
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Beyond 2015:
A Novel Nursing and
Pharmacy Collaboration
Keeping Patients Safe
from Medicines in the
Busy Hospital
Safe and Secure Hospitals 2015
Noleen Nath: Pharmacist
Redcliffe Hospital QLD
Overview
• Explore Current Demands for Hospital Care
• Review how medicines effect patient outcomes
– Positive and Negative
• Review safety concerns with medicines
– Stories from Redcliffe Hospital
• Unravel the intricacies of a novel Nursing and Pharmacy
collaboration
• Looking Beyond 2015 to minimise misadventure with
medicines in hospitals
Australian Hospitals Today
• The number of hospital admissions is
rising ~ 3% each year
o 9.7 million hospital admissions in Australia (2013-2014)
o Largely driven by the aging population
o Complex admissions and more frequent admissions with
high care demands
o Elderly patients are at higher risk of declining health
High Workload Demands and Pressure on all Hospital
Staff
Redcliffe Hospital
• 250 Bed general hospital in Queensland serving a
catchment of 200,000 people
• Rapid growth in unplanned medical admissions
– Predicted growth ~ 6% per year
– Some of the shortest average length of stay in Qld
• Above average population of elderly people
• 5th Busiest Paediatric Emergency presentations/service
in Qld
Use of Medicines
within Hospitals
•Medicines: The commonest treatment used in healthcare
•Due to there common use and narrow therapeutic index,
medicines are associated with more errors and adverse
events than any other aspect of healthcare.
•Patients in hospitals are unwell and thus have reduced
capacity to overcome medication misadventure
–A large portion of medication errors are preventable
“We need to improve the safety and quality use of
medicines within hospitals at the level of both individual
practice and within organisational systems.”Professor Lloyd Sansom
Medication Errors within Hospitals
The Difference Between a Drug and a Poison?
• The Dose
• How it is given:
• Route
• Rate
• Time
• Reconstitution fluid
• Patient Factors (age, renal/ hepatic function,
allergies, weight)
The Medication Use Pathway
PATIENT
Prescribing
error rate
2.5 – 5.4%
0.08 – 0.8%
error rate
5 - 20%
error rate
Australian Council for Safety & Quality in Health Care
2nd Report on Patient Safety, June 2002
DOCTORS
NURSES
PHARMACY
Error rate
on discharge
5-17%Decision to
prescribe
Order entry
Review order
Supply
medicineSupply
information
Distribute
Administer
Monitor response
Transfer
information
Why Medication Errors Happen?
• Nurse
checking
• Pharmacists
• Senior Staff
• Organisation
/Workplace
• Lack of
Safety
Culture
• High risk
task
• Lack of
knowledge
• Lack of
information
• Distractions
• Team work?
• Slips
• Lapses
• Rule
violation
Vincent et al, (1998), BMJ 316: p 1154-1157
Underlying
(latent)
conditions
Error
making
conditions
Active
failuresBarrier
defencesACCIDENT
REPORT!
Improve
systems
and
practices
“Swiss Cheese Model” – sometimes the errors get through gaps in processes
Tales of Medication
Misadventure
• Adverse reaction to medicines
• Paracetamol overdose
• Medications doses missed
• Too much medication
Redcliffe Hospital:
Initiatives to Prevent Medication
Misadventure During Admission
Medication Safety
Initiatives
• Monthly Nursing Orientation Workshop
• Nursing Medication Safety Group
– Education Session
• Provides nurses with troubleshooting advice/
resources/ plan to maintain medication safety
• Improvements in formal Nursing/ Pharmacy collaboration
within the wards
– beyond our daily duties
Nursing Orientation
Workshop
• Medication Risk Awareness Outline the complexity of the medication use
process
Identify some of the factors involved with adverse
medication events
Identify the role of the nurse in preventing adverse
medication events
Describe a simple action plan of what to do when
faced with a potentially hazardous medication order
Medication Safety
Nursing Group (MSNG)
• Medication management requires a multidisciplinary
approach and interdisciplinary communication is
essential to reduce medication errors
• The nursing profession has been identified as essential
to the promotion of patient safety and reducing
medication errors
• The MSNG is a monthly meeting to raise awareness of
medication safety concerns detected in daily practice
MSNG
• One hour monthly meeting attended by nursing
representatives from wards and specialist areas,
pharmacist and patient safety officer
• Nursing staff raise medication safety issues
encountered in daily practice.
• Opportunity to discuss concerns colleagues in a
safe, secure and supportive environment
• Opportunity for insight into medication safety issues
and solutions within the hospital
** Promoting a culture which strives for excellence
with Medication Safety **
MSNG
• Objectives
• Identify medication safety issues and escalate
concerns or proposed solutions to hospital executive
committees
• Dissemination information and education pertaining to
medication safety
• Participate in procedure development and review
• Review medication safety incidents reported and
share lessons learnt
• Make recommendations to hospital executive committee on
possible avoidance measures for noting and further
discussion
MSNG
• Accomplishments
– Noted an medication incident occurred regarding cessation of a
epidural pump prematurely
• The epidural pump cessation procedure recirculated to all
wards
– Acute Pain CNC supported further education to wards
and staff
– Noted a new procedure for Ketoacidosis management is in
operation
• Staff alerted to the procedure and implications for nursing
staff noted
– Identified different protocols for iron infusion are in operation at
various hospitals within the district.
• Issue identified and escalated. Decision for only use of the
Redcliffe Protocol within Redcliffe Hospital
MSNG:
Education Sessions• Case based learning
• Review fundamentals of medicine safety in
each presentation, each time with a different
clinical scenario
• Review management options/ troubleshooting
ideas to maintain medication safety
– Review implications for medication error in
each scenario
• Promotes a culture which strives for safety with
medicines
Formal Nursing/Pharmacy
Collaboration within Wards• Encourages regular collaboration specific to medication
safety to ward clinical nursing staff
• Each presentation focuses a specific clinical topic
• Acknowledge the demands of their role as nurses are
very high – however medication safety cannot be
compromised
• Discuss the medications involved in each clinical topic
and the implication of medication error
• Discuss options for prevention and management
which are practicable within a busy working
environment
Medication Safety
Beyond 2015
• Promote regular formal Nursing and Pharmacy
collaboration
– Opportunity to provide information regarding current
medication safety concerns
• Gest speakers attending MSNG
– Nursing staff
– Representative from the medical profession
– Representative from pharmacy management
• Develop an electronic medication safety toolkit for the
hospital
Concluding Comments
• Appropriate use of medications is central to maintaining
hospital safety for patients and staff.
• Inappropriate medicine use fosters unnecessary patient
harm, complicates and extend hospital admissions and
increases risk of premature morbidity and mortality
• Employing the principles of quality use of medicines, can
assist in avoiding/ minimising medication misadventure
• Hospitals are becoming busier – organisations need to
develop and maintain avenues which support staff
achieving medication safety
Concluding Comments
• Committees which support staff to strive for medication
safety is essential in creating a healthy culture of risk
awareness
“It can be argued that medication safety committees are
more essential in ensuring the safe journey of patients
through hospital, rather than availability of the most modern
therapeutic and diagnostic modalities”
“The greatest opportunity to improve outcomes for patients
over the next quarter century will probably come not from
discovering new treatments, but from learning how to
deliver existing effective therapies safely”
References
• Australian Bureau of Statistics 2002, Social Trends in
Australia:2002, 2002, cat. no. 4102.0, ABS, Canberra.
• Semple SJ ,Roughead EE : Medication safety in acute care in
Australia: where are we now? Part
• 2: a review of strategies and activities for improving medication
safety 2002-2008. Aust New Zealand Health Policy 2009, 6:24
• Liu GG, Christensen DB. The continuing challenge of inappropriate
prescribing in the elderly: an update of the evidence. J Am Pharm
Assoc (Wash) 2002;42:847–57.
• Roughead EE, Anderson B, Gilbert AL. Potentially inappropriate
prescribing among Australian veterans and war widows/widowers.
Intern Med J 2007;37:402–5.
References
• Hilmer SN, Gnjidic D. The effects of polypharmacy in older adults.
Clin Pharmacol Ther 2009;85:86–8.
• National Prescribing Service. Anticipating the risks of polypharmacy.
NPS. 2013; August
• Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S,
Clemson LM, et al. Interventions for preventing falls in older people
living in the community. Cochrane Database Syst Rev
2012;(9):CD007146.
• Australian Council on Safety and Quality in Health Care. Achieving
safety and quality improvements in health care. Sixth report to the
Australian Health Ministers’ Conference. Commonwealth of
Australia, 2005.
• Australian Nursing Federation. Anf position statement: Quality Use
of Medicines. 2012
• Nath N, Jones E, Stride P, Premaratne M, Thaker D, Lim I. The nuts
and bolts of pills and potions: the functions of a drug safety working
group. Australian Health Review 35(4) 395-398
• Strid P, Seleem M, Nath N, Horne A, Kapitsalas C. Integration of
patient safety systems in a suburban hospital. Australian Health
Review 36(4) 359-362
References
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