1. EPMA- Learning from Serious Incidents STAT dosing Iain Davidson Chief Pharmacist Feb 16

2. Aim of the Session 1.Discuss two serious incidents where EPMA was implicated 2.Our learning & actions from those SIs 3.Other reflections

4. A Quick EPMA Introduction….. Implemented JAC EPMA across all IP beds Dec 2012- Dec 2013. Live in ED since Feb 2014 Live across Outpatients June 2015

5. Both SIs Related to Stat Dosing of Medicines

6. First some background…...

7. Default dosing

8. SI 1- delayed dose of IV antibiotic Patient admitted to hospital Required IV antibiotics Stat dose correctly prescribed Nurse couldn’t get IV access Recorded missed dose under reason ‘no IV access’ Clinical team didn’t realise dose had not been given. Delayed first dose of IV antibiotic Patient died. Picked up on mortality review EPMA was listed as a root cause in the investigation report

9. The Stat Function Add in screenshot of how to prescribe a stat

13. Contributory factors Nurse not following the missed dose procedure. Drs not correctly checking EPMA to check that the dose had been given. Design of the system Training on the system

14. SI 2- missed first dose of LMWH Patient admitted with ?pneumonia Differential and correct diagnosis made by the on-take consultant of PE Prescribed treatment dose LMWH for PE Initially prescribed correctly with ‘associated stat’ dose Dose changed after weighing the pt. ‘Associated stat’ dose not prescribed with the altered dose. Clinical team didn’t realise First dose delayed by 10hrs Patient died.

15. Contributory Factors Human lapse Working under pressure Design of the system Training on stat dosing

16. What have we done?

17. Company Actions Improved design of EPMA system For prescribing- A process that incorporates stat and default dosing An alert to flag when a first dose will be delayed For administration- Improved visibility of administered and non-administered stat (and other ) doses Configurable alerts if missed dose entered against a dose. One view of prescription and admin chart to support quick review

18. JAC v2014 Will go someway of mitigating risk but: Wouldn’t have stopped the LMWH SI It comes up for every drug It’s not configurable e.g. antibiotics will always trigger, an antihypertensive if next dose > X hours away etc. No discussion with ourselves regards this ‘fix’.

19. Local Actions

20. Reviewed our Default Dosing For critical medicines: No longer default to specific times (e.g. At Night 22pm) Now default just to frequency (e.g. Every 24 hours) This means the time when prescribed is the time for the first administration Can create problems further down the line but nurses then ask the prescriber to alter the times of the subsequent doses.

22. Trust Pharmacy Alert:

23. First Dose Check Report

24. Pharmacist Friend:

25. Reflections STAT dosing is an area of risk for us….. Two main themes 1.Alert at the time of prescribing/ administering for critical medicines 2.Improved visibility of the drug chart 1.Prescribed 2.Administered 3.Current 4.Discontinued Challenge of delivering this without making the chart too complex to view

26. Reflections: SI 1 A procedural error. Same could/ would have happened on paper Visibility of chart to prescribers an issue. SI 2 was a human lapse Visibility of chart an issue Intelligent, informed system design could eradicate both of these risks.

27. Reflections: Picked up retrospectively. EPMA gives a clear audit trail. Incidents might have previously gone un-noticed Pharmacist at mortality review with EPMA record to validate the clinical record against what actually happened. Ensure EPMA team involved in the investigation to provide an accurate picture of what happened. Are missed first doses a big patient safety issue that EPMA is highlighting or is it an EPMA issue?

28. Reflections Been in coroners twice in my career- both for missed doses The first time was the reason I was so determined to put EPMA in. Did I do the right thing? I now have the data & audit trail so I can do something about it!

29. Missed Doses Critical Meds

31. Thanks for Listening!