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Medication Error Safe ( er ) Prescribing Gentamicin in Neonates

Medication Error Safe ( er ) Prescribing Gentamicin in Neonates. Anil Tuladhar C Harikumar Debbie Bryan. The Medication Error Iceberg. Top 10 incidents at NTHFT. Gentamicin & Vancomycin. Commonly used Highly active Narrow therapeutic window Significant toxicity

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Medication Error Safe ( er ) Prescribing Gentamicin in Neonates

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  1. Medication ErrorSafe(er) PrescribingGentamicin in Neonates Anil Tuladhar C Harikumar Debbie Bryan

  2. The Medication Error Iceberg

  3. Top 10 incidents at NTHFT

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

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

  6. What does the alert say?

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

  8. PDSA cycle applied to gentamicin

  9. Three steps to measurement

  10. Care bundle compliance chart Complete the compliance chart Care bundle daily audit chart Extranet / run chart 243 128 4627 01/01/2010 16.07

  11. Care bundle compliance chart Complete the compliance chart Care bundle daily audit chart Extranet / run chart

  12. Care bundle compliance chart Fill out the audit chart and totals Care bundle daily audit chart Extranet / run chart

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

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

  15. Audit (Nov’11 – Jan’12)

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

  17. 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.

  18. Human Error

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