Medication Errors in the under-18s

The Guardian reports that the NPSA have published their first review on patient safety among the under-18s. At least 60,000 young adults and children suffered medical errors. The excerpt below outlines some of the things that make the administration of medication problematic:

"She said nurses had to cut, crush and dissolve adult tablets and then make a difficult calculation of the dose needed by the child according to its weight.
"The doctor prescribes in milligrams but most children are given oral medicine in millilitres," she said. "Normally, the nurse has to make the calculation."
Getting the decimal point in the right place is essential, especially where the dose units have to be converted from milligrams to micrograms. A misplaced decimal point can mean a tenfold drug overdose or underdose."

Intuitively, it seems that performing multiple complex calculations involving quite variable weights in milligrams, millilitres and micrograms is vulnerable to error. Unfortunately the NPSA's data supports this.

Care Home Medication Errors

Excerpt from the website: "A study has found an “alarming” level of drug errors in care homes, The Guardian reported. The study in question looked at 256 elderly people from 55 care homes in England. The mistakes included errors in dosage and how the drugs should be taken."

Of the 256 elderly people in the study about 70% were found to have experienced medication errors. The potential harm that could be caused by these mistakes was low.

Amusing Hospital Signage

More lighthearted than usual posts: This is an amusing sign at Elhurst Emergency Trauma Center posted on failblog.

Fatal misprogrammed chemo pump taken home

This article outlines an incident where an electronic pump was taken home by a patient to recieve her chemo over a four day period, but the pump was programmed to administer the drug over four hours.

Again, and again it seems one of the messages to learn from these incidents is that they are an unfortunate combination of fairly abnormal events that would not be disastrous on their own. For example:

According to David U, President and CEO of ISMP, in this case:
"A combination of actions and conditions, which on their own would not have caused the death, happened simultaneously with tragic result."

An accident like this leads to an effort for greater learning, and we must hope that this is far reaching and lasting - but how far does this go nationally and internationally, how long lasting is it (months/years) and what are the mechanisms that faciltate this? For example, WANO is an organisation for the nuclear industry that makes announcements internationally if incidents are serious enough and others can learn from them. Could something like WANO work and be good for healthcare? This should work alongside national and local organisational learning facilities to pick up vulnerabilities and share best practice before incidents like this occur.

NHS mistakes 'harming thousands'

This was posted on the BBC website on 07.10.09

Excerpt from the website: "More than 5,700 patients in England died or suffered serious harm due to errors latest figures for a six-month period show.
The National Patient Safety Agency said there were 459,500 safety incidents from October 2008 to March 2009 - the highest rate since records began.
Patient accidents were the most common problem, followed by mistakes made during treatment and with medication."

The acknowledgement and reporting of incidents is the first stage in learning from them and improving the situation. Rather than take a sensationalist line about the rising figures of accidents I'd prefer to see the positive message that more reporting should lead to improved patient safety in the longer term.

Spine drug jabs: NHS urges firms to make improvements

This was published on the BBC's website 24.11.09. By Nick Triggle
My question: Why does it take the NPSA and the NHS to resort to these sorts of measures to get manufacturers to do what they want? The way this article is written suggests that there is huge inertia and inactivity by manufacturers on this issue. If this is true it seems alarming that they did not have an early positive response to make this change happen - instead they are taking these measures to encourage the change 12 years after it was suggested/demanded. This doesn't just seem an issue about what connectors are available in hopsitals but about how healthcare providers, regulators, and manufacturers interact.

Excerpt from article: "The NHS is threatening to stop using current drug equipment in a bid to get firms to start making safer devices.
The National Patient Safety Agency wants to see an end to universal syringe connectors which can be used for jabs into both the vein and spine.
The watchdog has set a deadline for 2013 - even though separate connectors to stop drug mix-ups are not available.
The move has been demanded since the 2001 death of Wayne Jowett when cancer drugs were injected into his spine.
Since the death of the Nottingham teenager, a number of safety measures have been introduced across England and Wales."

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001

This is a report on an adverse incident which led to the demise of a patient, which involved administering an intravenal drug (via vein) intrathecally (via spine). The inquiry should be applauded for its indepth systemic investigation and far reaching recommendations. It shows how many people, assumptions, groups, technologies, labels, packaging and similar can interact to influence the likelihood of an adverse incident occurring.

The fact that this report has been made public should also be applauded - so as many people can learn from it as possible.

Checklists and Changing Practice in the NHS

Ken Catchpole, an experienced Human Factors researcher in the healthcare domain, shared some interesting thoughts on interventions within the NHS this month (The Ergonomist, Vol.473, November 2009). In response to a study that developed a structured checklist for improving safety in surgery, his letter reminds us that new checklists, procedures and methods on their own are unlikely to have impact unless there is an acknowledgement of their value, and buy-in, by those that use them. Acknowledging that checklists are a means to an end i.e. changing work practices and improving safety, he also encourages better and broader human factors interventions for this same end.

The Ergonomist, Vol.473, November 2009:

FDA Calendar 2009: Safe Medical Device Connection Saves Lives

This calendar is a good example of trying to engage with healthcare practitioners in novel ways. It is a good idea to think about how to reach out into practice if messages like this are to be heard and responded to 'on the shop floor'.

FaintSignals on Twitter

This related Twitter is a record of everyday errors that happen, the frequency of reporting them has decreased just because so many happen, there is a cost to reporting them, and not all of them get noticed when motivation starts to fade. However, there are some typical and good examples of everyday human error.

FaintSignals

Dekker on Resilience Engineering

This is a short video by Sidney Dekker talking about Resilience Engineering. He claims it is a completely new way of understanding accidents, which moves on from more traditional approaches which have looked at 'human error'. He makes the point that traditional approaches to human error assume that systems are safe and it is only error prone humans that errode safety. The new perspective sees variance and disturbances in systems as 'normal', that these systems are imperfect because of multiple competing goals, and it is the presence of people that adapt and hold these systems together, i.e. the systems actually work because of people not despite them. Safety is seen as the presence of resilience rather than the absence of error.

HEPS 2011

Looks like a great conference, around Human Factors in healthcare, that runs every 3 years:

Healthcare Systems Ergonomics and Patient Safety

Healthcare - a wake up call to Human Factors

This video is by a husband and father who lost his wife in an attemtped routine operation. He believes that this accident can be explained by Human Factors concerns. He makes the point that other industries have a better appreciation of these concerns, to the extent that they are an integral part of their everyday work, and he wants these lessons to transfer to healthcare.