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RAISING AWARENESS OF RISKS
Allergy and Adverse Drug Reaction (ADR) Status
- The hospital drug chart has a section dedicated to allergy/ADR status which should be completed, signed and dated before prescribing, ordering or administering any medication
- If a patient has had an ADR or allergic reaction to a medicine/food/substance, the name of this and type of reaction should be clearly documented
- If the patient states they have not had an ADR or are not allergic to a medicine/food/substance that they are aware of, then this should also be documented on the drug chart
- Do not assume if the allergy/ADR section is incomplete that the patient’s allergy status has been confirmed
- One of the main groups patient’s report an allergy to are the penicillins
- It is important to be aware of which antimicrobials are contra-indicated or cautioned in penicillin allergic patients to prevent harm
- You must familiarise yourself with your local Trust policy in relation to the above
Reporting Medication Errors
- All medication errors or near misses (prevented patient safety incidents) must be dealt with and reported according to your local Trust policy
- Incident reporting helps identify trends, potential risks and opportunities to improve patient care
- They also provide an opportunity to learn from mistakes
Patient Safety Alerts
- Incidents reported at Trust level feed into the National Reporting and Learning System (NRLS) which analyses and manages incident reports
- If a patient safety issue requiring national action is identified, a National Patient Safety Alert will be issued by NHS Improvement, which set out actions for healthcare organisations to undertake to reduce risk
Now watch this short video on The NHS National Patient Safety Alerting System and the importance of reporting incidents:
The NHS NPSA System
Never Events
Never Events are serious and preventable incidents that should never happen because guidance or safety recommendations have been implemented by the Trust. NHS Improvement produce a Never Events Policy and Framework with a list of never events, some of which are related to medicines.
- All never events have had a patient safety alert issued
- You should be aware of never events and follow your local Trust policy to prevent these from occurring
- The latest never events related to medicines are:
- Mis-selection of a strong potassium solution
- Administration of medication by the wrong route
- Overdose of insulin due to abbreviations or incorrect device
- Overdose of methotrexate for non-cancer treatment
- Mis-selection of high strength midazolam during conscious sedation
To keep up to date with the latest never events list, follow this link:
Never events
Reducing Administration Risks
The medicines or areas listed below are those where a national patient safety alert was issued and/or are high risk. Read this section in conjunction with both the relevant section of the latest BNF and your local Trust policy (please note this is not an exhaustive list):
- All adults must be assessed for VTE and bleeding risk on admission, discharge and whenever their clinical situation changes (be familiar with your local Trust policy)
- Medicine doses may be frequently omitted or delayed, and this may lead to harm
- A list of critical medicines, where timely administration is crucial, should have been identified by the Trust e.g. antimicrobials, anticoagulants, insulin, resuscitation medicines, medicines for Parkinson’s disease – refer to your local Trust policy for a full list
- Ensure you are aware of how to obtain medicines both within and out-of-hours to minimise risk
- Omission or delay of critical medicines, for inpatients or on discharge from the hospital, are patient safety incidents and should be reported
- Loading doses are used when rapid clinical response is required, however they can be complex and lead to errors
- Medicines such as aminophylline, warfarin, amiodarone, digoxin, phenytoin and others identified locally, should be checked by medical, nursing and pharmacy staff to ensure loading and maintenance doses are prescribed correctly – refer to the BNF and/or your local Trust policy
- Loading doses are usually prescribed on the once only section of the drug chart but can be prescribed on other designated sections of the chart – refer to your local Trust policy
Patients must receive appropriate verbal and written information, especially on initiation of anticoagulation and at hospital discharge:
- Patients on warfarin (or other coumarins) must be counselled and given an Anticoagulant Patient information Booklet and Alert Card plus a yellow Oral Anticoagulant Book detailing indication, target INR, duration of treatment, monitoring clinic details and the dose to be taken
- Patients on Direct Oral Anticoagulants (DOACs) must be counselled and provided with an anticoagulant alert card and any other required information
- Examples of DOACs include rivaroxaban, edoxaban, apixaban and dabigatran
- When clinically significant interacting medicines are prescribed with oral anticoagulants, the appropriate action should be taken (refer to BNF or ask your pharmacist)
- Ask patients for their insulin passport detailing their treatment (not all patients will have one)
- Insulins are usually prescribed by their brand name e.g. Humulin M3®, NovoRapid®, NovoMix 30®
- Ensure the word ‘units’ is written in full for the dose of insulin and not ‘U’ or ‘IU’ to prevent a 10-fold or greater overdose
- For example, if a dose is written as 10U it can be misinterpreted as ‘100’ and as a consequence can result in an overdose
- Always use an insulin syringe or insulin pen device to measure the dose of insulin
- Do not withdraw insulin from an insulin pen or pen refill and then administer this using a syringe and needle
- Refer to medication never event related to insulin
- Potassium solutions for intravenous administration should be prescribed in those concentrations which are available as commercially prepared ready to use diluted solutions
- IV fluid infusions containing therapeutic levels of potassium are labelled in red
- Potassium chloride concentrate solutions (which are higher in concentration) are restricted to pharmacy departments and to critical care areas where the concentrated solutions are needed for urgent use e.g. ITU
- Potassium chloride concentrate solutions are stored in a separate locked cupboard away from common diluting solutions such as sodium chloride 0.9 % (normal saline) solution to prevent selecting the wrong medicine
- Refer to your local Trust policy and local injectable medicines administration guide (or IV Policy) for details on safe administration of intravenous potassium
- Refer to medication never event related to potassium
- Patient must be counselled on lithium and given a patient information booklet, lithium alert card and record book for tracking blood levels on initiation and throughout treatment
- Lithium should be prescribed using the brand name as there is a clinically significant difference in bioavailability between preparations - refer to BNF or ask your pharmacist
- When clinically significant interacting medicines are prescribed with lithium, the appropriate action should be taken (refer to BNF or ask your pharmacist)
- Midazolam comes as 1 mg/mL (low strength) and 2 mg/mL and 5 mg/mL (high strength) to cover its various indications
- There is a risk of selecting one of the high strength midazolam preparations instead of the low strength which is used for conscious sedation
- Stock of high strength midazolam (5 mg/mL and 2 mg/mL) is restricted to general anaesthesia, intensive care, palliative medicine and clinical areas/situations where its use has been formally risk assessed
- Other clinical areas should stock and use low strength midazolam (1 mg/mL ampoules) and not the higher strengths
- Flumazenil injection must be available to reverse over sedation and staff should be aware of where it is kept on the ward
- Refer to medication never event related to midazolam
- This applies to anyone who prescribes, dispenses or administers opioids
- Other than in an acute emergency, recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient should be confirmed
- If opioid dose is increased, check the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone, not normally more than 50% higher than the previous dose)
- Be familiar with the usual starting dose, frequency of administration, standard dosing increments, symptoms of an overdose and common side-effects
- Naloxone injection must be available to reverse opioid overdosage and staff should be aware of where it is kept on the ward
- Patients taking oral methotrexate should be given a patient information leaflet and a methotrexate monitoring booklet to record details of their blood tests and dose
- For non-cancer treatment the dose of methotrexate is ONCE weekly
- Refer to medication never event related to methotrexate
- Underdosing with LMWH is associated with an increased risk of a thromboembolic event, while overdosing can increase risk of bleeding
- The patient’s weight must be accurately recorded, as it is used for calculating the required dose of LMWH
- Renal function should also be taken into consideration when prescribing the dose – refer to your local Trust policy
- Follow your local Trust’s antimicrobial guide
- Intravenous antimicrobials should be reviewed 24-48 hours after starting and daily thereafter
- Patients on intravenous antimicrobials should be switched to the oral route when clinically appropriate
- The duration of treatment of antimicrobials should be recorded on the drug chart and in the notes
- Be aware of antimicrobials which are not safe to be administered in penicillin allergic patients
- Vancomycin, gentamicin and amikacin are examples of antimicrobials which require therapeutic drug monitoring – refer to your local Trust policy
- Intravenous amphotericin is available as lipid and non-lipid formulations and dosage recommendations can vary between the preparations.
- This can be confusing and lead to:
- Overdosing or underdosing, due to the different dose recommendations
- Patients experiencing potentially lethal side-effects or sub-therapeutic doses
- Healthcare professionals are advised:
- Prescriptions for amphotericin must state both the brand and generic brand name
- The amphotericin dose must be verified, prior to administration, to ensure it is correct for the preparation prescribed on the drug chart
- Always refer to your Trust’s intravenous medicines administration guide or IV policy on how to safely administer parenteral medicines