The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

OBJECTIVE: To use the electronic prescribing system to identify how prescribers have responded to the duplicate 'Anticoagulant Alert' and the extent to which the system has prevented unintentional prescription of Low Molecular Weight Heparins (LMWHs) to patients prescribed Direct Acting Anticoagulants (DOACs). To determine the clinical appropriateness of the actions taken by the prescriber following the alert override and the impact this has on patient safety. MATERIAL AND METHODS: A retrospective service evaluation was conducted to determine the impact of a duplicate 'Anticoagulant Alert' on the prevention of prescription of LMWHs to patients already prescribed DOACs at a 950-bed acute teaching hospital in the UK. The number of alert overrides, actions taken by the prescriber following the alert override, and the clinical appropriateness of prescribers' actions over the 15-month period 26th June 2017 - 8th October 2018 were evaluated. RESULTS: Of the 894 alerts that triggered over the study period 111 were in response to attempts to prescribe a LMWH to a patient prescribed a DOAC. The alert was overridden in 65 (58.6%) cases but accepted, preventing co-prescription of duplicate anticoagulants, in 46 (41.4%) cases. Overrides were appropriate and justified in 44/65 cases. In 6 cases duplicate anticoagulants were prescribed and administered but without patient harm. CONCLUSION: The anticoagulant alert prevented duplicate anticoagulant prescribing for 46 patients reducing the risk of patient harm from duplicate-anticoagulation. The 58.6% of alerts that were overridden were appropriate and justified in the majority of cases. Where duplicate doses were administered, no harm was observed. The electronic alert has improved the safe use of anticoagulants within our organisation.

Magnitude of error: a review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system.

OBJECTIVES: Our aim was to review medication-related incidents reported to a hospital voluntary incident reporting system to identify and quantify the magnitude of wrong dose errors. METHODS: The study was a retrospective review of medication-related incidents reported over a 7-year period at a large acute teaching hospital in the UK, providing secondary and tertiary care for a range of clinical specialties. Medication-related incident reports submitted from all clinical settings were reviewed. Incidents submitted under the categories 'wrong dose', 'wrong dose preparation', 'wrong rate' or 'wrong quantity' and describing situations where incorrect doses were prescribed, dispensed or administered were analysed. Magnitudes of medication overdoses and underdoses reported from adult and paediatric settings were calculated. Stage of the medicines process and drug classes most commonly involved in wrong dose errors were described. RESULTS: Of 12 006 reported medication incidents, 1568 described 'wrong-dose' errors: 702 (44.8%) were prescribing errors, 223 (14.2%) were dispensing errors and 643 (41%) were administration errors. Overdoses were reported more frequently than underdoses. 926 (59%) of reported wrong dose errors were overdoses, 464 (29.6%) were underdoses; the magnitude could not be determined in 178 (11.4%) of reports. Twofold and 10-fold overdoses and underdoses were the most commonly reported error magnitude, although dosing errors across a wide range of magnitudes were reported. Incidents were reported from paediatric wards (491, 31.3%), non-paediatric wards and clinical settings (880, 56.1%) and pharmacy (197, 12.6%). Prescribing errors (702, 45.9%) were reported more commonly than administration (643, 41%) and dispensing errors (223, 14.2%). Drugs acting on the central nervous system, cardiovascular drugs and anti-infectives were the drug classes most commonly involved. CONCLUSIONS: Wrong dose errors occur across all inpatient settings. Wrong dose errors of all magnitudes are possible, but twofold and 10-fold errors occur most frequently. Drug classes involved in wrong dose incidents reported to a voluntary reporting system in a large acute hospital are similar to those identified using other methodologies. Harms and potential harms associated with specific drugs and error magnitudes need to be identified to inform quality improvement work to reduce the risk of patient harm.

The Problem with Amphotericin.

Patient harm from inadvertent administration of amphotericin B (Fungizone™) instead of liposomal amphotericin (AmBisome®) has been described in the literature and has been the subject of patient safety alerts in the UK. Safe use of intravenous amphotericin depends on the knowledge and awareness of practitioners of the availability and differences between the different presentations of intravenous amphotericin. Knowledge is a weak barrier to error. Recommendations to reduce the risk of error following adverse drug events in the UK, USA and The Netherlands have largely focused on actions to be taken at an organisational level, such as drug supply, storage, dose checking and specifying brand and generic names on prescriptions. None have considered or addressed the contributory factors relating to the products themselves, namely the similarity between the presentations of AmBisome and Fungizone, both of which are manufactured as 50 mg vials despite their different dose recommendations. The need to use multiple vials of Ambisome to prepare infusions for adult patients is contrary to the usual practice of using only one or two vials to prepare doses of injectable medicines for adult patients, increasing the risk of error not only with injectable amphotericin formulations but potentially also with the preparation of other injectable medicines. Whilst the development of robust local risk reduction strategies are important, external factors, such as the design of medicines, should also be identified and highlighted to manufacturers and regulatory authorities as potential contributors to error and harm.

Evaluation of the practice of dose-rounding in paediatrics.

OBJECTIVES: To investigate the rounding of prescribed drug doses for paediatric administration. METHODS: A cross-sectional medication chart review was conducted at a UK paediatric hospital. Proposed administration dose volumes were calculated for prescribed doses using available manufactured liquids measured with oral and intravenous syringes. Resulting percentage deviations in doses administered were calculated. RESULTS: Of 2031 doses observed, 524 (25.8%) required rounding. The majority of which were for children aged 1-12 months. Twenty-seven rounded doses deviated from the prescribed dose by more than 10%. CONCLUSION: This study highlights the impact of dose-rounding in paediatrics and the need for standardisation.

Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients.

Hypoglycemia is a serious complication following treatment of hyperkalemia with intravenous insulin. The aims of this study were to determine the incidence of hypoglycemia (≤3.9 mmol/l, 70 mg/dL) and severe hypoglycemia (<3.0 mmol/l, 54 mg/dL) in noncritical care inpatients following treatment of hyperkalemia and to establish the risk factors predisposing to this complication. This was a single-center observational study reviewing the Electronic Patient Records of hyperkalemia treatment with intravenous insulin on the general wards of a large UK teaching hospital. A total of 662 episodes of hyperkalemia treated with insulin/dextrose were included. Among these episodes, 116 treatments (17.5%) resulted in hypoglycemia and 47 (7.1%) resulted in severe hypoglycemia. Lower pretreatment capillary blood glucose level, older age, and lower bodyweight were associated with a higher risk of posttreatment hypoglycemia. The incidence of hypoglycemia following hyperkalemia treatment in hospitalized patients is unacceptably high. Identifying individuals at high risk of hypoglycemia and adjusting prescriptions may reduce the incidence.

Iatrogenic magnesium toxicity following intravenous infusion of magnesium sulfate: risks and strategies for prevention.

A 65-year-old man being treated with radiotherapy and chemotherapy for recurrent colonic adenocarcinoma was admitted for management of hypokalaemia and hypomagnesaemia secondary to diarrhoea. He was treated with intravenous infusions of potassium chloride and magnesium sulfate. Following an infusion of magnesium sulfate, he experienced a sudden neurological deterioration. A CT of the head revealed no haemorrhage or evidence of acute ischaemic injury. Results of serum biochemistry later that day revealed an elevated magnesium level. Iatrogenic magnesium toxicity was suspected. Further discussions between the pharmacist and ward staff confirmed that a medication error had been made in the preparation of the infusion resulting in an overdose of intravenous magnesium.

A pre-postintervention study to evaluate the impact of dose calculators on the accuracy of gentamicin and vancomycin initial doses.

OBJECTIVES: Gentamicin and vancomycin are narrow-therapeutic-index antibiotics with potential for high toxicity requiring dose individualisation and continuous monitoring. Clinical decision support (CDS) tools have been effective in reducing gentamicin and vancomycin dosing errors. Online dose calculators for these drugs were implemented in a London National Health Service hospital. This study aimed to evaluate the impact of these calculators on the accuracy of gentamicin and vancomycin initial doses. METHODS: The study used a pre-postintervention design. Data were collected using electronic patient records and paper notes. Random samples of gentamicin and vancomycin initial doses administered during the 8 months before implementation of the calculators were assessed retrospectively against hospital guidelines. Following implementation of the calculators, doses were assessed prospectively. Any gentamicin dose not within ± 10% and any vancomycin dose not within ± 20% of the guideline-recommended dose were considered incorrect. RESULTS: The intranet calculator pages were visited 721 times (gentamicin=333; vancomycin=388) during the 2-month period following the calculators' implementation. Gentamicin dose errors fell from 61.5% (120/195) to 44.2% (95/215), p<0.001. Incorrect vancomycin loading doses fell from 58.1% (90/155) to 32.4% (46/142), p<0.001. Incorrect vancomycin first maintenance doses fell from 55.5% (86/155) to 33.1% (47/142), p<0.001. Loading and first maintenance vancomycin doses were both incorrect in 37.4% (58/155) of patients before and 13.4% (19/142) after calculator implementation, p<0.001. CONCLUSIONS: This study suggests that gentamicin and vancomycin dose calculators significantly improved the prescribing of initial doses of these agents. Therefore, healthcare organisations should consider using such CDS tools to support the prescribing of these high-risk drugs.

Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.

BACKGROUND: Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these. METHODS: We used a mixed methods, controlled before and after design. At baseline, wards were audited on medication safety indicators; during the 'feedback' phase scorecard results were presented to intervention wards on a weekly basis over 7 weeks. We interviewed 49 staff, including clinicians and managers, about scorecard implementation. RESULTS: At baseline, 18.7% of patients (total n=630) had incomplete allergy documentation; 53.4% of patients (n=574) experienced a drug omission in the preceding 24 h; 22.5% of omitted doses were classified as 'critical'; 22.1% of patients (n=482) either had ID wristbands not reflecting their allergy status or no ID wristband; and 45.3% of patients (n=237) had drugs that were either unlabelled or labelled for another patient in their drug lockers. The quantitative analysis found no significant improvement in intervention wards following scorecard feedback. Interviews suggested staff were interested in scorecard feedback and described process and culture changes. Factors influencing scorecard implementation included 'normalisation' of errors, study duration, ward leadership, capacity to engage and learning preferences. DISCUSSION: Presenting evidence-based performance indicators may potentially influence staff behaviour. Several practical and cultural factors may limit feedback effectiveness and should be considered when developing improvement interventions. Quality scorecards should be designed with care, attending to evidence of indicators' effectiveness and how indicators and overall scorecard composition fit the intended audience.

Risk of medication safety incidents with antibiotic use measured by defined daily doses.

BACKGROUND: Medication incidents (MIs) account for 11.3 % of all reported patient-safety incidents in England and Wales. Approximately one-third of inpatients are prescribed an antibiotic at some point during their hospital stay. The WHO has identified incident reporting as one solution to reduce the recurrence of adverse incidents. OBJECTIVES: The aim of this study was to determine the number and nature of reported antibiotic-associated MIs occurring in inpatients and to use defined daily doses (DDDs) to calculate the incident rate for the antibiotics most commonly associated with MIs at each hospital. SETTING: Two UK acute NHS teaching hospitals. METHODS: Retrospective quantitative analysis was performed on antibiotic-associated MIs reported to the risk management system over a 2-year period. Quality-assurance measures were undertaken before analysis. The study was approved by the clinical audit departments at both hospitals. Drug consumption data from each hospital were used to calculate the DDD for each antibiotic. MAIN OUTCOME MEASURES: The number of antibiotic-related MIs reported and the incident rate for the 10 antibiotics most commonly associated with MIs at each hospital. RESULTS: Healthcare staff submitted 6,756 reports, of which 885 (13.1 %) included antibiotics. This resulted in a total of 959 MIs. Most MIs occurred during prescribing (42.4 %, n = 407) and administration (40.0 %, n = 384) stages. Most common types of MIs were omission/delay (26.3 %, n = 252), and dose/frequency (17.9 %, n = 172). Penicillins (34.5 %, n = 331) and aminoglycosides (16.6 %, n = 159) were the most frequently reported groups with co-amoxiclav (16.8 %, n = 161) and gentamicin (14.1 %, n = 135) the most frequently reported drugs. Using DDDs to assess the incident rate showed that cefotaxime (105.4/10,000 DDDs), gentamicin (25.7/10,000 DDDs) and vancomycin (23.7/10,000 DDDs) had the highest rates. CONCLUSIONS: This study highlights that detailed analysis of data from reports is essential in understanding MIs and developing strategies to prevent their recurrence. Using DDDs in the analysis of MIs allowed determination of an incident rate providing more useful information than the absolute numbers alone. It also highlighted the disproportionate risk associated with less commonly prescribed antibiotics not identified using MI reporting rates alone.