Fejlmedicinering af børn på hospital - omfang og forebyggelse

Transkript

1 Fejlmedicinering af børn på hospital - omfang og forebyggelse Professor Anna Birna Almarsdóttir Institut for Farmaci Social and Clinical Pharmacy Group

2 2 CV Anna Birna Almarsdóttir, Professor, Ph.D., farmaceut Cand.pharm. University of Iceland 1988 Farmaceut på apotek i Island PhD UNC-Chapel Hill, USA 1994 Adjunkt/lektor DFU Forsker decode genetics Lektor/professor University of Iceland Professor SDU og OUH Professor i klinisk farmaci og samfundsfarmaci KU 2016-?

3 11/03/ Oversigt Definitioner af medicineringsfejl (MF / ME) Omfanget af MF i litteraturen og et dansk studie af hyppigheden af MF Hvor i medicineringsprocessen sker MF? Hvilke lægemidler? Hvordan kan MF forebygges?

4 Definition of Medication Errors (MEs) National Coordinating Council for Medication Errors Reporting and Prevention (NCC-MERP) 11/03/ any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use

5 11/03/ MF kan karakteriseres efter Hvad der sker f.eks. glemmer at give medicin, doserer forkert Konsekvenserne af fejlen dvs. graden af skade Potentielle årsager f.eks. forkert beregning af dosis, travlhed

6 11/03/ Definitioner og relationer mellem begreber Injuries not due to error Potentially harmful, but harm was not observed Injuries because of error

7 11/03/ Omfanget af MF hos børn litteraturen MEs: 5-27% (Miller et al. 2007, systematisk litteraturgennemgang) Harmful MEs: 1,2% ordinationer (Kunac et al. 2009) 0,05% (Kaushal et al. 2001) Potentially harmful MEs: 1,1% (Kaushal et al. 2001) 3 gange højere incidens end hos voksne (Ghaleb et al. 2006)

8 Rishøj RM. Medication Errors in Hospitalized Children. PhD thesis, SDU, 2017

9 11/03/2019 9

10 11/03/ Studie i Dansk Patientsikkerhedsdatabase (DPSD) Årene 2010 til 2014 MF på sygehuse børn 17 år og yngre Fandt 2071 MF

11 11/03/ Patient Age, y < Setting of medication error Pediatric General Care Unit Neonatal Unit Pediatric Unit (specialty unidentifiable) Pediatric Hematology/Oncology unit Pediatric Intensive Care Unit Missing Other locations Medication process Hospital Pharmacy Service Prescribing Dispensing Administration Missing 737 (35.6) 251 (12.1) 274 (13.2) 405 (19.6) 404 (19.5) 496 (23.9) 315 (15.2) 220 (10.6) 170 (8.2) 124 (6.0) 54 (2.6) 692 (33.4) 28 (1.4) 844 (40.8) 803 (38.8) 271 (13.1) 124 (6.0)

12 11/03/ ME types in relation to the medication process Total MEs, (n=2071) Prescribing, Dispensing Administration Missing, Wrong dose 981 (47.4) 465 (22.5) 371 (17.9) 74 (3.6) 71 (3.4) Dose omission 316 (15.3) 122 (5.9) 135 (6.5) 34 (1.6) 25 (1.2) Wrong medicine 228 (11.0) 78 (3.4) 114 (5.5) 25 (1.2) 11 (0.5) Wrong time 193 (9.3) 54 (2.6) 105 (5.1) 22 (1.1) 12 (0.6) Wrong rate 63 (3.0) 8 (0.4) 1 (0.1) 52 (2.5) 2 (0.1) Wrong patient 62 (3.0) 31 (1.5) 20 (1.0) 11 (0.5) N/A Other types of error 199 (11.6) 86 (4.8) 56 (3.1) 63 (3.5) 4 (0.2)

13 11/03/ Harm in relation to the medication process Total MEs (n=2071) Prescribing Dispensing Administration Missing, No harm 1551 (74.9) 668 (32.3) 580 (28.0) 193 (9.3) 83 (4.0) Mild harm 242 (11.7) 83 (4.0) 108 (5.2) 34 (1.6) 16 (0.8) Moderate harm 218 (10.5) 70 (3.4) 89 (4.3) 33 (1.6) 25 (1.2) Severe harm 27 (1.3) 9 (0.4) 14 (0.7) 4 (0.2) N/A Missing 33 (1.6) 14 (0.7) 12 (0.6) 7 (0.3) N/A

14 11/03/ Therapeutic Group Total MEs (N=2071) Harmful MEs (N=487) Antibacterials for systemic use 564 (27.2) 91 (18.7) Analgesics 269 (13.0) 88 (18.1) Plasma substitutes and perfusion solutions 124 (6.0) 43 (8.8) Antiinflammatory and antirheumatic products 114 (5.5) 24 (4.9) Cytostatics 95 (4.6) 24 (4.9)

15 11/03/ Medicines Total MEs (N=2071) Harmful MEs (N=487) Paracetamol 131 (6.3) 31 (6.4) Gentamicin 100 (4.8) 21 (4.3) Ampicillin 76 (3.7) 6 (1.2) Morphine 73 (3.5) 30 (6.2) Cefuroxime 66 (3.2) 6 (1.2) Diclofenac 44 (2.1) 7 (1.4) Ibuprofen 40 (1.9) 11 (2.3) Other 1303 (61.5) 293 (64.4) Missing 238 (11.5) 61 (12.5)

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17 11/03/ Field study observation in wards Direct observations by a pharmacist Large tertiary care hospital (>1000 beds) 4 wards (NICU, PICU, Infant, Newborn) Each ward observed for 7 non-consecutive days Followed 1 nurse or 1 doctor at the time

18 11/03/ Field study results 33 MEs Medication preparation and administration No harm observed 809 Potentially Unsafe Medication Practices (PUMPs) - practices or conditions with opportunities to cause medication errors No check of expiry, CPOE shows yesterday s prescriptions, no recalculation of dose, no double check, double check variations Only slight agreement between raters on seriousness (kappa = ) Not able to see patient information and underestimated prescribing errors

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20 11/03/ Focus group discussions Physicians and nurses separate groups at 3 NICUs Attitudes and experiences with preventing MEs Ideas for future prevention of MEs

21 11/03/ Focus group study results MEs still occur too frequently and action must be taken Nursing turnover CPOE Brand names Practices currently used to prevent MEs: Technology (CPOE, CDS) Procedures Education and skills Pharmacy services Future prevention strategies: Customize the CPOE system for pediatrics and ward Standardize double-check procedures Train calculation skills Improved communication

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23 11/03/ Survey of nurses and physicians 20 medication scenarios presented and asked about how likely they would be to report Different steps in the medication process, types of error, outcomes and medications All nurses and physicians working in pediatric or neonatal wards in Southern Denmark

24 11/03/ Survey results 42% response rate 61% of scenarios should be reported Nurses had OR 2.81 compared to physicians to selfreport Older participants had OR compared to younger (40 years or younger)

25 11/03/ Hvad kan der gøres? Ordinationsfejlene Hyppigst rapporterede i DPSD Spørgeskemaundersøgelsen viser Sygeplejersker er mere villige end læger til at rapportere hændelser Ældre læger og sygeplejersker mere villige Focusgrupper påpeger Ordinationssystemer Beregningsøvelser Dobbeltchecks på dispensering og administration Observation viser PUMPs kan bruges som udgangspunkt for at forbedre dispensering og administration (ordination?)

26 11/03/ Future of medication use in pediatric care Predicting the Future is a Dangerous Business! - Microencapsulation - Automatic compounding, 3D printing - Use of smartphones for drug information - Pediatric excipients have more attention - Global standards for pediatric compounding