Medication ErrorSafe(er) Prescribing

Gentamicin in Neonates

Anil Tuladhar C HarikumarDebbie Bryan

The Medication Error Iceberg

Top 10 incidents at NTHFT

Gentamicin & Vancomycin

• Commonly used• Highly active• Narrow therapeutic window• Significant toxicity• Need blood level monitoring• Errors common

Fish Bone DiagramPeople

• Nurses – checking• Doctors – prescribing• Babies – all look alike

Place • Busy unit• High turn over• Patient: Nurse

ratio

Process

• Training• Supervision• Counterchecking• Communication• Dosage timing

Policy

• Not explicit• Not adhered to• Different guidelines

What does the alert say?

• A local gentamicin protocol must be availableLocal protocol

• Use the four elements of the care bundleUse care bundle

• Use small cycles of change with a sample of patientsPDSA cycle

• Measure care bundle compliance dailyMeasurement

• All relevant staff should be provided with applicable trainingTraining

Double checking prompt

Local protocol

Use care bundle

PDSA cycle

Measurement

Training

PDSA cycle applied to gentamicin

Local protocol

Use care bundle

PDSA cycle

Measurement

Training•Ensure compliance charts, audit charts and double-checking prompts are all available

•Collect data

•Analyse the data at monthly data review meetings

•What elements of the care bundle need addressing?

•Do we understand the measures we are using?

•Who will analyse the data?•How often will data be analysed?

•Share your results with your staff and senior leaders

• Implement identified actions arising from your data analysis

Act Plan

DoStudy

Local protocol

Use care bundle

PDSA cycle

Measurement

Training

Three steps to measurement

Fill out compliance chart (appendix A) after each administration of gentamicin

Use above compliance charts to populate audit charts (appendix B)

Use above weekly audit charts to populate extranet on a monthly basis

Local protocol

Use care bundle

PDSA cycle

Measurement

Training

Complete the compliance chart

Care bundle compliance

chart

Care bundle daily audit

chart

Extranet / run chart

243 128 462701/01/2010 16.07

Local protocol

Use care bundle

PDSA cycle

Measurement

Training

Complete the compliance chart

Care bundle compliance

chart

Care bundle daily audit

chart

Extranet / run chart

Local protocol

Use care bundle

PDSA cycle

Measurement

Training

Fill out the audit chart and totals

Care bundle compliance

chart

Care bundle daily audit

chart

Extranet / run chart

Audit (Nov’10 – Jan’11)November – 47%

December – 69.5%January – 86.5%

Common reasons for non-compliance1. Dose not given within 1 hr of prescription (8)2. Check list not recorded as being used (7)3. Time of administration not recorded (6)4. Only 1 signature on documentation for administration

(4)5. Wrong Prescription – time incorrect (2)

One ‘NO’ on a chart is a failure!

Audit (Nov’11 – Jan’12)Prescribing and administering errorError Prescribing Administration Comment

Level

monitoring 0 0

Frequency 45 0

Timing 9 5

Signature 2 0

Not

signed

NPSA Alert 2 0

wrong

date

Total 53 5

Audit (Nov’11 – Jan’12)

Audit (Nov’11 – Jan’12)Prescribing and administering timing error

Timing

error Prescribing Administration Comment

Late

Timing 8 4(2) 1.5 - 2.5 hours late

Too Early 1 1 2 hours early

total 9 5

Audit (Nov’11 – Jan’12) Recommendations

• Regular training to trainees in ‘how to prescribe in paediatric/neonate’ maybe useful

• Regular update to nurse to spot common prescribing errors in paediatrics and neonatal units.

• Prescribers will also need to think about their dose calculations and if the dose prescribed is measurable for administration.

• Improved communication between prescribers and staff nurses regarding results of blood levels.

• Another audit to look at the general prescribing habit in NNU.

Human Error