Dr. Diarmuid Quinlan, GP Glanmire
•Télécharger en tant que PPTX, PDF•
0 j'aime•930 vues
Repeat Prescribing 'None so blind as those........
Recommandé
Recommandé
Contenu connexe
Similaire à Dr. Diarmuid Quinlan, GP Glanmire
Similaire à Dr. Diarmuid Quinlan, GP Glanmire (20)
Plus de Investnet
Plus de Investnet (20)
Dernier
Dernier (20)
Dr. Diarmuid Quinlan, GP Glanmire
- 1. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Repeat prescribing "None so blind as those....." Dr Diarmuid Quinlan Clinical risk assessor, MPS November 2014 Copyright 2010 All Rights Reserved
- 2. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Journey
- 3. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT
- 5. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Repeat prescribing...deceptively complex
- 6. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Prescribing errors in general practice – a prospective study ▪ 28 GPs, 3 days: 3948 scripts ▪ 12%contained one or more error. (1 in 8) ▪ 2.4% potentially serious error. ( 1 in 40) ▪ 148 telephone calls to GPs ( 2/GP/day) ▪ Overall error rate = 6.2% per 100 items prescribed Sayers Y M et al. European Journal of General Practice 2009 1-3
- 7. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Prescribing errors can be lethal........ .
- 8. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT
- 9. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT
- 10. Medication errors are like ghosts… They will haunt you, FOREVER!
- 11. Could it be you? “There are none so blind as those who will not see” (Heywood 1546)
- 12. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT In general practice …. ▪ Approx 20% MPS claims-medication errors ▪ Contraindicated drug ▪ Wrong drug ▪ Wrong dose MPS Casebook: Learning from clinical claims in primary care Vol. 19 no. 3 - September 2011
- 13. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Top key risks in UK and Ireland general practice 2013 ▪ 100% Communication ▪ 100% Confidentiality ▪ 97.4% Health and safety ▪ 95.4% Prescribing ▪ 89.5% Record keeping ▪ 88.9% Infection Control ▪ 88.9% Staff Training ▪ 88.2% Test results MPS analysis of CRSAs undertaken during 2013
- 15. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Professional responsibilities “Providing medical treatment necessarily involves some degree of risk However, you must ensure as far as possible that the services you provide are safe and comply with the standards of the professions” http://www.medicalcouncil.ie/_fileupload/misc/171109%20Final%20Version%20Ethics%20Guide%20Update %20For%20Printer.pdf
- 16. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT GMC: United Kingdom The GMC states: ▪ Para 55 - “You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate.” ▪ Para 57 - “You must be satisfied that procedures for prescribing with repeats and for generating repeat prescriptions are secure.” Good practice in prescribing and managing medicines and devices (January 2013) http://www.gmc-uk.org/Prescribing_Guidance
- 17. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Monitoring of toxic medications ▪ Ireland has four times more adverse methotrexate events than UK Delaney T (2011) Safe treatment with oral methotrexate HSE
- 18. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Reduce the risk… ▪ Specify 2.5mg tabs only ▪ Specify day of week ▪ Do the blood test / issue the script ▪ PATIENT HELD SAFETY CARD ▪ Undertake an audit ▪ Patient safety UK has useful information: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59800 ALERT This patient is currently on IMMUNO SUPPRESSING DRUG TREATMENT. If you feel unwell, or have a fever, sore throat, easy bruising, bleeding, mouth ulcers, shivering see a doctor urgently & request an urgent blood test. Consider NEUTROPENIC SEPSIS (See overleaf for details)
- 19. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Medication protocols ▪ Legislation ..... ▪ Written directions ▪ Authorisation of the nurse, by the GP ▪ Prescription not required when a medication protocol is in effect ▪ Supported by An Bord Altranais http://www.nursingboard.ie/en/homepage.aspx
- 20. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Exercise In small groups, identify medicines management risks and some possible solutions for those risks, associated with repeat prescribing ▪ Please use the template provided 1. Chart how a patient initially requests a repeat medication and follow the journey through the system to the end process of obtaining the medication 2. Identify bottlenecks/risks within the repeat prescribing system and where duplication takes place 3. Are there any steps in the system that could be simplified or changed to make the system safer and save time? ▪ Be prepared to share your answers with the larger group
- 22. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Repeat prescribing – don’t repeat the risk ▪ Repeat prescribing in your practice................? ▪ high quality, seamless & safe service Or ▪ high-risk, error prone & ‘ad hoc’ activity? ▪ Make sure your repeat prescribing is a ‘win-win’ situation ▪ MPS repeat prescribing workshop
- 23. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT Thank you, and... Dr Diarmuid Quinlan http://www.medicalprotection.org/uk
- 24. MEDICAL PROTECTION SOCIETY EDUCATION AND RISK MANAGEMENT
Notes de l'éditeur
- Thank you for joining me at the workshop regarding repeat prescribing. Do you all offer repeat prescribing in your practices. Medications are common in general practice and many relate to the systems rather than a clinician's judgment of a drug. And so for this short time spent we will be concentrating on the repeat prescribing system and I hope that by the end of the session you will take away some tips to iimprove your repeat prescribing process and reduce avoidable harm to your patients from medication errors. The workshop is designed to be interactive and I hope that you will share your views and opinions as we work though the hours session. I am going to start with a few slides then I have an exercise for you to participate in followed by a discussion. I have provided some hand-outs for you. Repeat prescribing can be a win-win situation: good for patients and good for doctors. It is convenient for patients and practices can experience a more structured workload, fewer “urgent” requests, fewer phone calls and less traffic at reception. Repeat prescribing has been described as: “A partnership between patients and prescriber that allows the prescriber to authorise a prescription so it can be repeatedly issued at agreed intervals, without the patient having to consult the prescriber at each issue.” However, “The authorising prescriber must ensure that arrangements are in place for any necessary monitoring of usage and effects, and for the regular assessment of the continuing need for the repeat prescription.”2 Repeat prescribing accounts for some 75% of prescriptions issued in general practice, with approximately half of all patients receiving repeat prescriptions.3 One in eight patients has prescribing or monitoring errors in their repeat prescription.1
- So lets think about your journey here today How many of you came by train? Cycled? You take your life in your hands!! Drive? Maybe you got stuck in some bottlenecks hopefully not like this! I am sure that if you are regular travellers you know where the bottle necks are e the risks and take appropriate action to get the best out of you journey and arrive on time. Repeat prescribing is a journey – a particular complex journey involving over 20 steps from the initial decision to prescribe to the patient finally swallowing the medication. Patients, staff GPs pharmacists all have a role to play to minimise error. RP is everyone's responsibility. Ultimately the doctor who signs the script is legally responsible. There are many risks and bottles necks along this journey and important to identify them and think of solutions to ensure the system ifs safe and robust. For the remainder of this session I invite you now to take part in mapping the repeat prescription journey. We have mapped out 5 important stages and we will look at the steps of each stage. Now we only have a short period to do this and we welcome your discussions. If we get bogged down on one particular area I may have to move us on, please don’t think I am being rude if I have to stop you but am keen to get all areas discussed. Diane will record our journey on the white board. In your folder I have provided you with the steps to jot down your thoughts. Thank you.
- Cycled? You take your life in your hands!! And don’t forget there are risks with any journey we make! I am sure that if you are regular travellers you know where the bottle necks are e the risks and take appropriate action to get the best out of you journey and arrive on time. Repeat prescribing is a journey – a particular complex journey involving over 20 steps from the initial decision to prescribe to the patient finally swallowing the medication. Patients, staff GPs pharmacists all have a role to play to minimise error. RP is everyone's responsibility. Ultimately the doctor who signs the script is legally responsible. There are many risks and bottles necks along this journey and important to identify them and think of solutions to ensure the system ifs safe and robust. For the remainder of this session I invite you now to take part in mapping the repeat prescription journey. We have mapped out 5 important stages and we will look at the steps of each stage. Now we only have a short period to do this and we welcome your discussions. If we get bogged down on one particular area I may have to move us on, please don’t think I am being rude if I have to stop you but am keen to get all areas discussed. Thank you.
- Prescribing is one of the commonest tasks in daily general practice. Surprisingly there is little published research on errors that occur in this area. The aim of this study was to estimate the seriousness and level of prescribing errors that occurred in general practice. This prospective survey documented errors in prescriptions from 28 general practitioners as they occurred over a 3-day period in 12 community pharmacies. From a total of 3,948 prescriptions, 491 (12.4%) contained one or more errors. From a total of 8,686 drug items, 546 (6.2%) contained one or more errors. Of the errors the majority were minor (398, 72.9%), a smaller number (135, 24.7%) were major nuisance errors, and there were 13 (2.4%) potentially serious errors. The most common errors related to drug directions and dosage. Most common drug category was cardiovascular drugs Common errors = related to directions 148 telephone calls were made from 12 pharmacists to GPs Read More: http://informahealthcare.com/doi/abs/10.1080/13814780802705984
- Key teaching points Medication errors are a significant cause of patient harm and many of them can be ascribed to mistakes in prescribing. In the chain of events leading from a decision to treat a patient with drugs to the successful execution of a tolerated response, there are many potential sources of error: Patients can be receiving medication, remedies, supplements and complementary products from a whole range of sources, most of whom will be unaware of each other. The scenario highlights the need for robust communication between all health professionals, the patient and the patient’s carers about medication Lets follow Mrs Jones Here is Mrs Jones taking her pills. And here is her GP who prescribes them – simple! But in reality there’s a whole load of other GPs who care for Mrs Jones – GP partner, GP registrar, locum and the out-of-hours provider. They all write prescriptions. Then there’s the nurses – the practice nurse is a nurse prescriber and also prescribes for Mrs Jones when she attends the asthma clinic. The there are the district nurses, who are also prescribers and attend to Mrs Jones. Then there's Mrs Jones’s family. They collect her medication from the pharmacist They also occasionally give her well meaning remedies of their own that they bought at the health shop. They administer Mrs Jones’s tablets but sometimes they forget. The pharmacist prepares her medication. He also knows the products she buys over the counter, but no-one else does! Oh but sometimes this is closed when Mrs Jones wants her medications, so she visits her supermarket’s pharmacy that’s open out-of-hours eg Sunday. Then there's the hospital doctors: the cardiologist she sees following her heart attack And the eye surgeon for her glaucoma The geriatrician still sees her every 6 months following that dizzy spell she had. (But in fact she never sees the consultants it’s usually the SHO who sees her and alters her medication – next job in Durham so she doesn’t see him again). Then Mrs Jones attends the dentist and he gives her some antibiotics for her tooth abscess. Mrs Jones then occasionally sees an alternative health practitioner who provides Mrs Jones with a herbal remedy for her back pain. Mrs Jones believes that by taking both complimentary and conventional medication her recovery from her back problems will be expedited. Is any of this recorded – well yes but in many places. Some GPs are diligent at recording medications in the medical record, others less so, especially following home visits, pharmacist makes his own notes, OOH theirs, dentist his, hospital theirs, DN their own – do these records concur with each other??? . Sometimes! Then there is the receptionist who generates her prescription This is a typical picture of a patient. May be you can identify with Mrs Jones and have many of these on your practice list. All these people play an important part in the care of a patient but the challenge is providing overall control and coordination: a task that often falls on the GP. As you can see due to the complex nature of healthcare, there are many risks associated with medicines which we need to try to reduce or eliminate.
- .Errors in toxic medication are like ghosts; THEY WILL COME BACK TO HAUNT YOU....FOREVER......
- Clint Eastwood knew all about luck in his film “Dirty Harry”. The stark evidence is that Lady luck is not on our side. The question you & I need to ask in the next 5 minutes is “Do I feel lucky?” Oxford dictionary defines luck as;“The force that causes things to happen to you by chance, and not as a result of your own efforts or abilities” Is it like the lotto leaving to chance? There Are None So Blind As Those Who Will Not See: • According to the ‘Random House Dictionary of Popular Proverbs and Sayings’ this proverb has been traced back to 1546 (John Heywood), and resembles the Biblical verse Jeremiah 5:21 (‘Hear now this, O foolish people, and without understanding; which have eyes, and see not; which have ears, and hear not’). In 1738 it was used by Jonathan Swift in his ‘Polite Conversation’ and is first attested in the United States in the 1713 ‘Works of Thomas Chalkley’. The full saying is: ‘There are none so blind as those who will not see. The most deluded people are those who choose to ignore what they already know’.
- Issues relating to prescribing and medication are the second commonest reason for MPS to settle a claim on behalf of one of it’s members at around 20% of settled claims. MPS Case book Learning from clinical claims in primary care Casebook sept 2011 599 MPS GP claims 1/12/2007 – 31/12/2010 Vol. 19 no. 3 - September 2011 http://www.medicalprotection.org/uk/casebook-september-2011/learning-from-clinical-claims-in-primary-care The second most common area for settlement of claims in primary care is that of prescribing and medication errors. Of the prescribing errors, the most frequent involved a contraindicated drug (most commonly antibiotics), followed by choosing the wrong drug (eg, unsuitable choice of antibiotic for wound infection) and selecting the incorrect dose of the correct drug (most commonly opiates).
- wakila/iStockphoto.com Analysis of the findings of practice risk assessments (CRSAs) MPS has undertaken in the UK and Ireland during 2013 (153 practices) reveal communication and confidentiality as the top risks, with 100% of practices identifying issues in this. Communication is split into 2 categories internal and external ie with patients. The data was collected by analysing the results of 153 Clinical Risk Self Assessments (CRSAs) of general practices conducted in 2013. These are provided by MPS Educational Services and involve trained clinical risk facilitators undertaking visits to practices and working with practice staff to identify risks. 100% Communication 100% Confidentiality 97.4% Health and safety 95.4% Prescribing 89.5% Record keeping 88.9% Infection Control 88.9% Staff Training 88.2% Test results
- 95.47% of practices had risks associated with prescribing. Having a repeat prescribing protocol is not only good practice but also will ensure you can demonstrate to CQC compliance with Outcome 9 regulation 13 management of medicines How many of you have made errors in prescribing? Has the pharmacist telephoned you and asked if you meant to prescribe this doctor has this happened to any of you, most I would think. One of my colleagues here is Ireland asked the pharmacist to keep a log of all the errors and concerns for a month, so that practice could systematically review these at the practice. A staggering amount. So lets look at the common areas of risk We have analysed these practices and found the following common risk areas: Uncollected script do you review these before shredding may be of significance. No robust repeat prescribing policy 49.7.9% of practices visited during 2012 by MPS did not have a robust repeat prescribing protocol. If this is the case for your practice, you should discuss and draw up a comprehensive repeat prescribing protocol that formalises all the good prescribing systems that take place at the practice. Ensure that all staff are trained in the procedure and have access to the protocol, which should be dated and regularly reviewed. Need protected time with access to the computer to check each prior to signing Anti coagualnats Hca dosing no protocl for escalating concerns etc Reception staff are allowed to add medication to the computer – acute and repeat medications. The story I told you at the beginning of the talk related to this of course. 22.5% INHERENT DANGERS IN PERMITTING STAFF TO INITIATE OR AMEND MEDICATION. If you do allow this essential that GP checks. Adequate time to check. Tell story when a practice slipped a script in the GPs pile for baked beans – he signed it!!! Monitoring of toxic medications
- Your professional responsibilities are written down in the Medical Council's Guide to Professional Conduct and Ethics. New version 7th published in 2009. It states: So it is absolutely imperative that you ensure that your systems in the practice are safe and robust to trap errors and thus ensure patient safety. Page 19
- Just out of interest the UK GMC goes in to more detail….
- Identify bottlenecks within the repeat prescribing system and where duplication takes place Are there any steps in the system that could be simplified or changed to make the system safer and save time? How many steps are there? Could some tasks be carried out by one person instead of several people? Is there any duplication of work? Are there any bottlenecks? How much error correction / rework is being carried out? What is the approximate time between each step? Are we doing the right things in the process? Are we doing things in the right order? Is the right / best person doing it? What information do we give to patients at what stage and is the information useful?
- Ireland has an unenviable reputation - four times more adverse incidents with patients taking methotrexate than in the UK. something is dangerously amiss with our patient safety systems and culture. This 2011 Tim Delaney HSE safe treatment with oral methrotrexate report highlights that patients in Ireland experience x 4 more adverse Mtx events than occur in the UK. Either Irish patients are uniquely susceptible to the adverse effects of Mtx, or our patient safety systems & patient safety culture are seriously inadequate Almost 40% of Irish patients take 10mg tablets, compared to just 8% in the UK.1 Many of these patients take both 2.5mg and 10mg tablets.1 Drs Quinlan and Ryan wrote an article about this in casebook see in your pack
- Our patients experience x 4 more adverse Mtx events than occur in the UK. Patient safety systems & patient safety culture are seriously inadequate. It could be you................ Do you simply cross your fingers & hope its not you?? In 2008 following a CRSA one practice in Ireland audited patients taking methotrexate in their practice. The results were predictable..........but disturbing. The number of patients was just 11, so the workload in doing audit & monitoring blood tests was not onerous. One patient had no blood test in a year, while another had 11. One simple safety improvement was to simply link prescribing and blood testing; do the test/issue the script for 2-3 months only. No test = no script. Easy solutions. This is not rocket science. They are currently repeating the Mtx audit, but incorporating new recommendations ( specify 2.5mg tabs only, specify day of week, ensure taking folic acid, ensure patient aware of s/s of MTX toxicity & action to take –written on each script- but we have gone further; pop up alerts on the computer system & auditing whether the patient has received appropriate vaccinations (flu & pneumococcal). ............... We are seriously raising the bar on our expectations of our quality of care. We are trialling a patient held safety card, the size of a credit card. I brought some here to share & your feedback is most welcome. Prescribe, dispense and administer oral methotrexate ONCE WEEKLY (usual dose range 7.5mg – 20mg orally once weekly), specifying the day of the week Specify the number of tablets (“10mg, i.e. 4 x 2.5mg tablets”) to be taken per dose. Ensure that the patient understands their therapy, including dose and frequency, when and where monitoring will be carried out, the signs and symptoms of toxicity and what to do should they occur Patient safety UK has useful information: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59800
- Of the CRSA in Ireland 2012/2013 (approx 13) no practices visited used medication protocols. I was asked specifically to cover this are in my talk. Of the 92,726 nurses registered with the nursing board in Ireland, only 532 are nurse prescribers. Practice nurses who are not nurse prescribers, and who are administering medication without a named prescription, should use medication protocols. These are written directions that allow for the supply and administration of a named medicinal product by a nurse in identified clinical situations. A medication protocol involves the authorisation of the nurse, by the GP, to supply and administer a medication to groups of patients in a defined situation, which meets specific criteria. An individually named prescription is not required for the supply and administration of medication when a medication protocol is in effect. An Bord Altranais supports the developments of medication protocols using a nationally recognised template based on international evidence and best practice.5 The legislative basis for medication protocols for the supply and administration of medication is the Medicinal Products Regulations of 1996 and 2003 (Prescription and Control of Supply). Article in Practice matters Edition 1 Practice nurses - practise safely
- process mapping Process mapping is a useful tool to use when redesigning a system/process. It is often used at the beginning of an improvement process for identifying the current situation and looking at each of the interconnected steps involved in the process. Split the group into smaller groups, ensure that you have a mix of clinicians and admin staff in each group. Give out flipchart , post it notes & marker pens for the groups to use. Ensure that everyone understands what they are going to do- Start by listing all persons involved in the process in your practice Then chart how a patient initially requests a repeat medication and follow the journey through the system to the end process of obtaining the medication. You can use the template on page 15 as a prompt. Identify bottlenecks within your repeat prescribing system and where duplication takes place. You can use the information from the previous task ( identified in the risk assessment). Are there any steps in the system that could be simplified or changed to make the system safer and save time? (Show the next slide during the process mapping in order for the delegates to use as a prompt) Managing risk is a continuous process of evaluation, action and re-evaluation, rather than a one-off event. It is important to review the system regularly and make appropriate changes as necessary in order to maintain a quality and safe system. Purpose of the Exercise Encourage discussion and involvement Encourage involvement from the whole practice team to review their own repeat prescribing system Spend approx 30 minutes on this task
- Identify bottlenecks within the repeat prescribing system and where duplication takes place Are there any steps in the system that could be simplified or changed to make the system safer and save time? How many steps are there? Could some tasks be carried out by one person instead of several people? Is there any duplication of work? Are there any bottlenecks? How much error correction / rework is being carried out? What is the approximate time between each step? Are we doing the right things in the process? Are we doing things in the right order? Is the right / best person doing it? What information do we give to patients at what stage and is the information useful?
- So what can you do: I would like you to undertake not one, but two changes in your practice; Don’t let there be ghosts in your system to haunt you. We will all make errors but having robust systems in place can capture those errors. A win situation for you, your staff and patients. Consider undertaking the mapping in your practice Do the risk assessment if you need help MPS have a three hour prescribing workshop that is available in house for all the practice team.
- .