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

2. Total of 398 Datix reports submitted

5. 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

6. 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

8. PICU Medication Related Incidents Jan – Dec 2016

9. 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

10. 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

11. For scores 4 – 6…

12. Scores 4 – 6 continued…

13. 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…..

14. 80% of these events were interrupted at least once to a maximum of 10 times

15. 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!

19. 1st December 2017
PC’s / i Pads have been set up in side rooms Parents notified Nursing staff spoken to and ed Consultants / MDT on board Review of previous years Datix reports made available

21. 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.
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,
LTHT Risk Matrix for Incident Grading. Approved July 2016
Sentinel Incident Reporting System. Worcester Health Authority 2015