Medication Related Incidents on PICU Sharon Coulson, Senior Sister, PICU Bev Robinson, Clinical Educator, PICU December 2017

Total of 398 Datix reports submitted

Drivers for a change in practice… Growing concern from senior staff and Matron about the number of MRI’s being reported. Safe reporting culture or indication of a problem?? Recognition at Sister’s meetings that quality of prescription writing was deteriorating Feeling that nurses were being penalised for poor medical practice Acknowledgement that ‘extraneous’ factors contributed to this problem – lack of resources / distractions /conflicting information

3 weeks in October 2016…. 12 charts reviewed 107 prescriptions None conformed fully with LTHT prescription standards Patient details recorded but Consultant and Ward were not Weight was recorded but age was not Prescriptions were legible but not printed Other charts in use were not recorded Cancelled prescriptions were signed but not dated Prescribers did not print their name and contact details ‘Saline’ and ‘hepsal’ were used which are not recognised abbreviations

PICU Medication Related Incidents Jan – Dec 2016

PICU RISK EVALUATION MATRIX FOR MEDICATION RELATED INCIDENTS /EVENTS A Datix must be completed for every event, regardless of score   CONSEQUENCE LIKELIHOOD Insignificant 1 Minor 2 Moderate 3 Major 4 Catastrophic 5 Almost certain Low 10 15 20 High 25 Likely 8 12 16 Possible Very Low 6 9 Unlikely Rare Adapted from Sentinel Incident Reporting System. Worcester Health Authority 2015  

Development of PICU RISK Matrix and Proforma progression Score 1 – 3 Low risk and triggers an informal conversation Score 4 – 6 Triggers proforma’s A, B, C Score 8 and above Triggers Level 2 investigation Records kept of all nurses involved in datix reports Reviewed at least monthly for trends, patterns and accuracy

For scores 4 – 6…

Scores 4 – 6 continued…

Strategies to decrease the likelihood of medication errors Avoid reliance on memory – use protocols and evidence-based resources Make resources highly visible Promote a culture which encourages the use of these Use checklists and separate double checking for IV’s Conscious mindfulness – not routine automaticity Monitor risks and empower staff to question practice Increasing the individual’s awareness of fallibility IMSAFE – illness, medication, stress, alcohol, fatigue, emotion A note about interruptions…..

80% of these events were interrupted at least once to a maximum of 10 times

Culture Change Separate prescribing desk for Drs with all necessary resources attached to it. Zero tolerance for non-essential interruptions during prescribing or making up of drugs Education for parents on admission and staff both on Mandatory Training days and on PICU STOP notices which are displayed prior to drawing up medications Moves to make staff visible – trollies, yellow trays, red tabards PC’s in side rooms so information more readily available START DATE!

1st December 2017 PC’s / i Pads have been set up in side rooms Parents notified Nursing staff spoken to and e-mailed Consultants / MDT on board Review of previous years Datix reports made available

References Gluyas H, Morrison P (2014) Human factors and medication errors: a case study. Nursing Standard. 29, 15, 37-42 Sawyer D (2014) Do it by desigh: An Introduction to Human Factors in Medical Design. www.fda.gov/MedicalDevices Carayon P (2012_ Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety. CRC Press., Boca Raton FL Fryer L (2012) Human Factors in Nursing:the time is now. Australian Journal of Advanced Nursing. 30, 2, 56-65. LTHT Risk Matrix for Incident Grading. Approved July 2016 Sentinel Incident Reporting System. Worcester Health Authority 2015