Helen Hotchkiss Level 5
Causes of Medication Errors
Upon the identification of the chosen subject it is a fundamental to further compress the chosen area of research into a defined avenue of investigation. By pinpointing key hypothesis, I will be able to detail my research in a much more structured way. The potential functions of a research project can be to identify, compare, develop, analyze and evaluate information and detail a clear pathway of investigation leading to finite, evidence-based conclusions. In this research project I intend to discuss medication errors within the Care Home/Nursing Home environment. The research will define what a medication error is, the causation of an error, what lessons have been learnt and the strategies that are implemented to prevent errors. I will discuss the implications of a medications error and at what point in the chain of events the error has taken place. This will be done by looking at weekly audits, cases studies and a survey. I will inform the staff that the survey is confidential and anonymous, and what the information is to be used for and respect their honest opinions. I will also review policies and documentation to ascertain the short falls in systems. To produce a varied account, I will produce case studies of administration, prescribing and dispensing errors. I will also conduct internet research looking at websites of NICE, SCIE and NHS England to find out the prevalence of medication errors and other research re the same problems. Look at the CQC website for statistics and information pertaining to medications. The European federation of Pharmaceutical industries association determined that “Medication errors, broadly defined as any error in the prescribing, dispensing, or administration of a drug, irrespective of whether such errors lead to adverse consequences or not” and that they are the single most preventable cause of patient harm. (http://www.ema.europa.eu/docs/en_GB/document_library/Presentation/2013/03/WC500139864.pdf )
What is a medication error?
A medication error is an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicine advice, regardless of whether any harm occurred. Care homes/Nursing Homes are required to have “arrangements for reporting adverse events, adverse drug reactions, incidents, errors and near misses.
The National Reporting and Learning Systems (NRLS) defines a ‘patient safety incident’ (PSI) as, ‘any unintended or unexpected incident, which could have or did lead to harm for one or more patients receiving NHS care.’ (www.england.nhs.uk)
Types of Error
Omissions – any prescribed dose not given when prescribed, for any reason.
Wrong dose administered, too much or too little, or an extra dose given.
Un-prescribed medicine – the administration to a resident of any medicine not authorised for them.
Wrong dose interval, either too soon or too far apart to be effective.
Wrong administration route – administration of a medicine by a different route or in a different form from that prescribed
Administration of a drug to which the resident has a known allergy
Administration of a drug past its expiry date
Medication not signed for following administration.
Wrong dose, or wrong medication administered.
Incorrect instructions on dispensing label
Incorrect amount of medication
Medication prescribed that the patient is known to have adverse reactions to documented in medical notes
Prescribing errors are defined as errors in the prescribing decision or in prescription writing that significantly reduced the likelihood of the treatment being given at the appropriate time and of being effective or increased the risk of harm.
Possible causes for errors with regard to Administration
Distraction: A nurse who is distracted may read “diazepam” as “diltiazem.” The outcome is not insignificant-if diazepam is accidentally administered, it could sedate the patient, or worse (e.g., if the patient has an allergy to the drug).
Environment: A nurse who is chronically overworked can make medication errors out of exhaustion. Additionally, lack of proper lighting, heat/cold, and other environmental factors can cause distractions that lead to errors.
Lack of knowledge/understanding: Nurses who lack complete knowledge about how a drug works, its various names (generic and brand), its side effects, its contraindications, etc. can make errors.
Incomplete patient information: Lacking information about which medications a patient is allergic to, other medications the patient is taking, previous diagnoses, or current lab results can all lead to errors. Nurses who aren’t sure should always ask the physician or cross-check with another nurse.
Memory lapses: A nurse may know that a patient is allergic, but forget. This is often caused by distractions. Forgetting to specify a maximum daily dose for an “as required” drug is another example of a memory-based error.
Systemic problems: Medications that aren’t properly labelled, medications with similar names placed in close proximity to one another, lack of bar code scanning system, and other issues can lead to medical errors.
Example of fundamental administrational errors
type of error Example Outcome
Knowledge based Being unaware of the interaction between warfarin and erythromycin Warfarin toxicity
Rule based Prescribing oral treatment in a patient with dysphagia Lung aspiration or ?failure to treat
Action based Being distracted, writing diazepam for diltiazem Sedation
Technical Writing illegibly, so that ‘Panadol’ (paracetamol) is dispensed instead ?of ‘Priadel’ (lithium)a Loss of effect
Memory based Forgetting to specify a maximum daily dose for an ‘as required’ drug Poisoning or ?unnecessary treatment
This stresses the importance of prescribing by generic name whenever possible, since more errors are made by confusing brand names than generic names; however, in this case ‘Priadel’ had to be prescribed—modified-release formulations of lithium must be prescribed by brand name because of differences in bioavailability from brand to brand.
There are many possible causes for medication errors. My research will focus on a 12 month period in a 30 bedded Nursing home in which I manage. I will cross reference weekly and monthly medication audits and give senior staff who administer medication anonymous questionnaire to evaluate the reason for medication errors in a nursing home environment. I will also look at case studies.
The main methods include:
• Focus group interviews.
I will collect date using Primary and Secondary data collection techniques, Primary data collection using a questionnaire. Secondary data collection electronically stored weekly audits and case studies. A questionnaire will allow anonymity and give the individual time to think about their answer. I personally believe that staff will be able to answer questions without prejudice using a questionnaire. It is also less time consuming and prevents staff from opting out. Other types of data collections such as one to one interviews can put staff under undue pressure and as it is not compulsory I am relying on good will staff. For this reason, I have decided not to use one to one interviews or group interviews as this could be intrusive in my work area and not productive. The other source I have used is weekly audits. These are also anonymous and look at the whole aspect of errors rather than the individual. Conducting research in a busy nursing home environment can be time consuming, so case studies, questionnaires and audits are less intrusive for staff. In order to get accurate data, I spoke to staff and reassured that all the information provided was totally confidential it is important that staff feel comfortable about the process.
The data I collect will be annualized and recorded using graphs and pie charts to display the data in a practical pragmatic way. It will only be used as evidence in this research project.
Please complete you answers are totally anonymous and will not reflect on you capabilities
Question Answer What would you change/improve?
1.How long have you been qualified to administer Medication
2.What area of administration do you find most challenging
3.How Many drugs rounds do you do per shift
4.What in your opinion is the most common drugs error
5.Are you aware of the policy and procedures with regard to reporting a drugs error
6. Would you like more training
7.How many staff are involved in a drugs round
9. Do you feel more confident if two members of staff do a drugs round together
The questionnaire results highlighted strongly one of the major causes of error was not lack of training or appropriate training. 30% of staff found that they were more likely to make errors if they were short staffed and under pressure to complete a drug round quickly in order to deal with other duties. 40% said if there felt tired and had worked long hours. 5% stated if they were not familiar with the setting. 20% distraction and the inability to concentrate due to interruptions. Minor errors such as missed signatures where highlighted by the 5% of the staff this was an issue with MARS sheets as the signature boxes which required initials are extremely small and staff found that they were easily misinterpreted. 0% requested more training. All staff agreed that they were less likely to make an error if two staff were administering together. This was evidenced by the controlled drug register where two members of staff administer and count all medication prior to administration and after administration. They also cross check the drug with the MARs and both sign the controlled drugs register after administration. 100% of staff felt comfortable with policy and procedures. The questionnaire showed that staff were well trained and competent however were able to identify areas of concern.
Audits over the twelve-month period showed a surprisingly increase in pharmacy errors these ranged from drugs not being delivered on time and mid-month changes in scrips not being changed. These errors were all amended prior to administration due to the signing in process which is the policy of the home. The most common error by nursing staff was missed signatures and also medication not ordered in time to administer as prescribed. On one occasion a Methotrexate injection which is ordered weekly did not arrive on time due to a bank holiday. This was difficult to attach blame as although staff were able to fax the request on the Monday as directed the pharmacy didn’t pick it up until the Tuesday and were unable to process the request in time.
In a busy nursing home environment these figures are disturbing but unfortunately not unique. In a report by ND Barber for the British Medical Journal it is reported that in a study conducted two thirds of residents in care homes were exposed to one or more medication errors. Older people living in care homes are potentially at greater risk of medication error than most other groups. They are prescribed multiple medicines and this, coupled with age-related changes in pharmacokinetics and pharmacodynamics, makes them particularly susceptible to adverse drug events. Many have some degree of cognitive impairment that prevents them from being actors in the detection of errors. In addition, the medicines management system in care homes is complex—for example, many residents receive clinical interventions from multiple sources; medicines may be dispensed from multiple sites; and medicines may be dispensed in, and administered from, one of several different types of packaging systems known as “monitored dosage systems” (MDS).
http://qualitysafety.bmj.com/ by ND Barber – ?2009
Case Study 1
Patient A is a 62-year-old woman with a diagnosis of schizophrenia. She is under the care of the Adult Mental Health team and resides in a care home as she is unable to look after herself independently. Over a six-month period, her mental health deteriorated, and she was referred by her Community Psychiatric Nurse (CPN) to be seen by a consultant psychiatrist. It was decided at the consultation that her anti psychotics would be increased over a four-week period. The psychiatrist would write to her GP who would manage the titration of medication. When the prescription arrived at the nursing home from the pharmacy the dose had been doubled not titrated over a four-week period as discussed at the consultation. The care staff cross referenced this with the notes recorded in the patients care plan from the consultation. The error had occurred with the GP increasing the dose but not titrating. The senior nurse made a telephone call to pharmacy who confirmed that the script had been written by a locum GP who was unaware of the case. The medication was not administered until the GP had confirmed the actual titration regime in writing.
Case Study 2
A Nursing home holds a contract with the local pharmacy, they provide medication monthly for all services users. They also conduct medication audits once a year and will provide basic training for staff. All service users’ medication is produced monthly by the pharmacy in individual blister packs. The nursing home has the responsibility to inform the pharmacy of any changes to medication that have been made by the prescriber midmonth.
This is then cross referenced with prescriber and a prescription will be produced. All medication is dispensed in blister packs unless the manufactures instructions dictate special storage. These packs contain 28 days’ supply of medication. It was noted on two occasions when staff were signing in medication that one blister pack had two tablets in one pod instead of one in each. This was highlighted to pharmacy and the full blister pack returned and amended by the pharmacist. On another occasion the last pod was sealed but not tablet present. This was also reported to pharmacy. When investigated by the pharmacy it became clear that this was a mechanical error due to the machine that dispensed the medication into the pod jamming. However, during the cross referencing process this should have been picked up by a pharmacy technician prior to being released from the pharmacy
Case Study 3
In a Nursing Home drugs rounds are conducted four times a day. These a done by trained staff. It has been observed that patient A has excessive amounts of fluoxetine remaining at the end of the month. When the medication administration sheet (MARS) is check all medication has been signed for but the 10mgs dose has been increased to 20mgs which means two tablets instead of one. Staff have continued to administer previous dose. There reason for this error is that although the medication was sent from pharmacy the MARs had not been updated. Although this has not caused a detrimental effect to health it has potentially caused omission of a prescribed drug. This was safe guarding issues and was reported to the local authority safe guard team and CQC.
These case studies all show medication error happen not just with administration. The general coconscious from medical professionals is that error happen when a nurse/care assistant administer medication during a drugs round. This in theory is one of the areas that is more apparent as the administrated is the last link in the chain of events and obviously causes the most damage to the patient. My research has shown that medication errors can happen at any time from prescribing to administration. The three case studies highlight this. The information for these studies was gain by reviewing medication audits over a twelve-month period.
When focusing on the administration of medication in a care home environment the legal aspects need to be addressed. Qualified Nurses are registered with the Nursing and Midwifery Council (NMC) and must follow the code of conduct www.nmc.org.uk/standards/code/ If they breach the code of conduct they can lose their Pin number and be taken off the register to practice. In extreme cases medication errors can be fatal and result in criminal charges.
There are several pieces of legislation that relate to the prescribing, supply, storage and administration of medicines. It is essential that staff comply with these.
The human Medicine Regulations 2012 health-ni.gov.uk/articles/legislation-covering-medicines Set out a comprehensive regime for the authorisation of products; for the manufacture, import, distribution, sale and supply of those products; for their labelling and advertising; and for pharmacovigilance.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: CQC Regulation 12. All care homes are legally bound to register with CQC and comply with all standards set out.
Litigation about care homes is over seen and managed by Care Quality Commission (CQC)
CQC can prosecute for a breach of this regulation or a breach of part of the regulation if a failure to meet the regulation results in avoidable harm to a person using the service or if a person using the service is exposed to significant risk of harm. We do not have to serve a Warning Notice before prosecution. Additionally, CQC may also take further action.
In conclusion my research has shown that Drugs errors happen at each stage of the process. But one thing that has been highlighted is that due to robust policies and audits many errors are obverted. It also gives the overview of that simple errors can be prevented by common sense approaches. Research I have conducted actually concludes that the main cause of medication errors in hospitals and care homes is human error. Staff shortages and inappropriate working conditions. The research concluded that in many cases staff needed to be open and honest about mistakes so changes could be implemented to prevent errors in the future “part of the change needs also to be cultural: moving from a blame culture to a learning culture so doctors and nurses are supported to be open about mistakes rather than cover them up for fear of losing their job”. Jeremy Hunt minister for Health https://www.ft.com/content/
Statistically the NHS has seen an increase in the reporting of errors and this is seen as a good thing so that lessons can be learnt and the causes of errors looked at and training used to overcome these. Research has shown that higher reporting rates correlate with a better safety culture and risk management ratings; regular reporting of incidents from organisations is therefore something to be encouraged. Incidents are reported may be at greater risk of harming a patient with a medicine as there is less opportunity to learn and improve their medication systems. (Safety in Doses: Improving the use of medicines in the NHS 2007)
However although the data I have collected in the area I work supports this theory that staff being over worked and understaffed this is not the main reason for errors. In my own
research missed signatures were found to be the highest errors. Also it was apparent that errors were less likely to happen during the administration of a controlled drug. This is due to two member of staff conducting the administration reducing the trend for errors. We also we must ask the question due to the restrictions and legislation regarding the administration of a controlled drug are staff more diligent? After discussions with staff it has been decided to look at a weekly MARs chart rather than a monthly. This will allow the signature boxes to be larger and more visible. The other highlighted issues were controlled drugs. Very few administration errors occurred here and the general consensus was two members of staff being present during administrations. We intend to look at staffing and where possible have to members of staff conductus a drugs round.
On evaluating the data collected my only criticism is the questionnaire although it gives staff the ability to evaluate their own practice it is opinion based and not factual. This was apparent when the data was collected.
Financial Times https://www.ft.com/content/
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: CQC Regulation 12. (www.cqcregulation12)
Safety in Doses: Improving the use of medicines in the NHS 2007
The human Medicine Regulations 2012 health-ni.gov.uk/articles/legislation-covering-medicines
The National Reporting and Learning Systems www.england.nhs.uk
http://qualitysafety.bmj.com/ by ND Barber – ?2009