1. Medication Error Safe(er) Prescribing Gentamicin in Neonates Anil Tuladhar C Harikumar Debbie Bryan

2. Plan Introduction Medicines Policy Education Standards of Practice Recording incidents

3. The Medication Error Iceberg

4. Medication incident types

6. Top 10 incidents at NTHFT

7. Gentamicin & Vancomycin Commonly used Highly active Narrow therapeutic window Significant toxicity Need blood level monitoring Errors common 

8. Fish Bone Diagram People Nurses – checking Doctors – prescribing Babies – all look alike Place Busy unit High turn over  Patient: Nurse ratio Process Training Supervision Counterchecking Communication Dosage timing Policy Not explicit Not adhered to Different guidelines

11. What does the alert say? A local gentamicin protocol must be available Local protocol Use the four elements of the care bundle Use care bundle Use small cycles of change with a sample of patients PDSA cycle Measure care bundle compliance daily Measurement All relevant staff should be provided with applicable training Training

12. Double checking prompt Local protocol Use care bundle PDSA cycle Measurement Training

13. PDSA cycle applied to gentamicin Local protocolUse care bundlePDSA cycleMeasurementTraining Ensure compliance charts, audit charts and double- checking prompts are all available Collect data Analyse the data at monthly data review meetings What elements of the care bundle need addressing? Do we understand the measures we are using? Who will analyse the data? How often will data be analysed? Share your results with your staff and senior leaders Implement identified actions arising from your data analysis ActPlan DoStudy

14. Local protocolUse care bundlePDSA cycleMeasurementTraining Three steps to measurement Fill out compliance chart (appendix A) after each administration of gentamicin Use above compliance charts to populate audit charts (appendix B) Use above weekly audit charts to populate extranet on a monthly basis

16. Local protocolUse care bundlePDSA cycleMeasurementTraining Complete the compliance chart Care bundle compliance chart Care bundle daily audit chart Extranet / run chart 243 128 4627 01/01/201016.07

17. Local protocolUse care bundlePDSA cycleMeasurementTraining Complete the compliance chart Care bundle compliance chart Care bundle daily audit chart Extranet / run chart

18. Local protocolUse care bundlePDSA cycleMeasurementTraining Fill out the audit chart and totals Care bundle compliance chart Care bundle daily audit chart Extranet / run chart

21. Audit (Nov’10 – Jan’11) November – 47% December – 69.5% January – 86.5% Common reasons for non-compliance 1.Dose not given within 1 hr of prescription (8) 2.Check list not recorded as being used (7) 3.Time of administration not recorded (6) 4.Only 1 signature on documentation for administration (4) 5.Wrong Prescription – time incorrect (2) One ‘NO’ on a chart is a failure!

22. Audit (Nov’11 – Jan’12) Prescribing and administering error

23. Audit (Nov’11 – Jan’12)

24. Prescribing and administering timing error

25. Audit (Nov’11 – Jan’12) Recommendations Regular training to trainees in ‘how to prescribe in paediatric/neonate’ maybe useful Regular update to nurse to spot common prescribing errors in paediatrics and neonatal units. Prescribers will also need to think about their dose calculations and if the dose prescribed is measurable for administration. Improved communication between prescribers and staff nurses regarding results of blood levels. Another audit to look at the general prescribing habit in NNU.

27. Human Error