Patient Safety and Error Reduction

Most healthcare professionals take up their career because they want to make people better. It is rare—but not unknown—to find nurses deliberately harming patients. It is not always possible to cure a patient’s condition, and readers may be surprised to hear the view of Lord Justice Stuart-Smith that our ‘only duty as a matter of law is not to make the victim’s condition worse’ (Capital and Counties plc v Hampshire CC (1997) 2 All ER 865 at 883). Despite our best intentions, healthcare professionals do sometimes make the patient’s condition worse. There are too many instances of harm caused to patients. Not only does the patient suffer harm, staff will be upset (some may even give up their careers) and large compensation claims may be made which deplete NHS resources. According to the NHS Litigation Authority, in 2010–11 it received 8655 claims of clinical negligence and 4346 claims of non-clinical negligence against NHS bodies, and paid £863 million in connection with clinical negligence claims (NHSLA Annual Report and Accounts, 2011). To put that into perspective, NHS Warwickshire had a budget of £827m for that year, so this amount would fund a mediumsized PCT. For all these reasons, therefore, our first concern must be to do no harm to our patient. If we can improve their condition, so much the better, but at the very least we must leave them no worse off for having put themselves in our care. Patient safety must be everyone’s concern. It is monitored by the NHS Commissioning Board Special Health Authority. Until June 2012 there was a separate agency, the National Patient Safety Agency (NPSA), which produced a report in 2009 entitled Safety in doses: improving the use of medicines in the NHS . There were 811 746 reports to the NPSA in 2007, of which 86 085 were related to medication. The figures for July 2010– June 2011 show an increase to 1.27 million incidents, of which 133 727 were related to medication.

Keeping Up to Date

● To gain an understanding of strategies that can be used to keep your skills in medicines management up to date, including clinical supervision and change management. ● To acknowledge the implications of clinical governance as related to keeping up to date within medicines management. It is hoped that this book will provide a useful resource in the future to help keep your skills and knowledge up to date. This final chapter covers some of the strategies that may help. It will discuss some of the relevant developments and offer some thoughts about future advances in medicines management. The world of medicines management is constantly evolving although, having said that there are given constants and principles that will remain the same in all settings. For example, patient safety is obviously in the forefront of all practice as is efficacy of treatment and effective resource management. As explained within the context of this book there are a number of ways of ensuring that the instructions for giving medicines are clear and that medicines are legally and safely dispensed, supplied, and administered to patients. Other terms for ways to dispense, supply, or administer medicines are process or mechanism. Some of these mechanisms have been in place for many years; for example, before the Medicines Act 1968 . Others have been enforced more recently; nonmedical prescribing only came into being in the mid- 1990s and continues to expand in the current decade (Association for Nurse Prescribers). It can be safely stated that all of the legal mechanisms for the dispensing, supply, and administration of medicines have been reviewed and tightened up either locally, nationally, or both within the last 10 years. This reinforcement has occurred because of the following factors; you may be able to think of more:… ● Concerns about patient safety and medicines management. ● Directives for a changing and evolving health service moving, for example, towards the management of the care of patients with long term conditions in the community setting. ● Delivery of medicines management by more advanced non-medical healthcare practitioners other than doctors, such as nurses and pharmacists. ● As a result of the Fourth Shipman Report. (2004).

Medicines Management: Drug Calculations

After reading this chapter you should be able to:.. ● Understand the importance of drug calculations ● Recognize different types of calculations ● Know where you can find help with numeracy ● Successfully complete basic calculations for medicines…. Are you good at drug calculations? This is a question you must ask yourself and be honest about the answer. There is no room for inaccuracies when calculating medicine dosages and if you are not happy working with numbers then you need to practise. Drug calculation is a critical area when managing medicines and is open to error. All health professionals who are dispensing, supplying, or administering drugs will need to perform drug calculations to a greater or lesser extent. Registered professionals are accountable and responsible for their decisions and actions and cannot rely on others to check the accuracy of their calculations. The NMC’s medicines management skills cluster for pre-registration nursing programmes (2010) states that patients can trust registered nurses to undertake medicines calculations correctly and safely. Numeracy skills are required to ensure this and to enable registered nurses to perform the drug calculations required to administer medicines safely via appropriate routes. All branches of nursing must also recognize the specific requirements for children and other groups with regard to medicines’ calculations. Within this chapter we offer some explanations and the chance to practise some calculations. There is an expectation that all pre-registration health care professionals will have at least GCSE mathematics or equivalent, such as the Scottish Certificate of Education, therefore explanations will assume you have this level of knowledge. Universities recognize that some students have real difficulty with numeracy and they make additional support available from local study skill centres. Your personal tutor will have details. One area of frequent confusion is the use of SI units (International System of Units). SI units are units of measurement for example grams, milligrams, or micrograms, which measure weight; and millilitres or litres, which measure volume. When calculating drug doses, make sure that you are aware of the SI unit that is being used, for example, grams or milligrams, litres or millilitres; see Table 8.1 for equivalences of weight and volume.

Pharmaceutics and Routes of Drug Administration

All medicines must be administered as prescribed and following the manufacturers’ guidance. The main aim of medicines management is to achieve the desired therapeutic effect for the patient. In order to do this you need to:… ● give the correct medicine, ● at the correct dose, ● to the correct person, ● in the correct formulation, ● by the correct route, and ● at the appropriate time intervals…. This has already been mentioned in Chapter 1. You must consider the dosage, the patient’s weight where appropriate, method of administration , route, and timing (NMC, 2008a). Equally, when preparing to administer any medication, it is important to follow the principles of standard precautions (Glasper et al, 2009). For example, when administering oral medicines you should first wash your hands and then use a non-touch technique to prevent cross infection and to ensure that the drug does not cause you any harm. The way in which a drug is administered will affect the rate and extent of absorption. There are three basic routes for administration of medicines: enteral (via the GI tract), parenteral, and topical (Lilley et al, 2007 ). However, within these a variety of methods can be used. Medicines are introduced into the body via many routes, which include:… ● Oral ● Enteral (via a nasogastric or gastrostomy tube) ● Rectal ● Vaginal ● Respiratory ● Intradermal injection ● Subcutaneous injection ● Intramuscular injection ● Intravenous injection ● Infusions ● Intrathecal and epidural ● Topical/transdermal. …The aim of treatment is to deliver the optimal amount of medication to the part of the body where it will act. Usually we would like the concentration of drug to reach therapeutic levels (the level at which it exerts its medicinal action) as quickly as possible. This usually means that we want a particular level of drug in the bloodstream. The quickest route to achieve therapeutic levels of drugs is the intravenous route, because the drugs are delivered directly into the bloodstream and levels rise as soon as the drug is given. However, this may not be the most appropriate route for the administration of medicines for many reasons.

The Nurse’s Role in Promoting Concordance

● To support an understanding of the theory of concordance ● Working in partnership with your patient, to relate this knowledge to the achievement of concordance in the consultation process. The NMC code states that when caring for your patient: you must work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community (NMC, 2008). In the past, nurses would give medicines to patients, and the patients would usually do as they were told and take the medicine without questioning the doctor or health professional. The word used to explain this interaction in the world of medicines management is compliance. This term originates from a traditional biomedical model of care where the patient is viewed as a list of symptoms and it implies that in the act of giving medicines nurses were doing something active to treat the patient’s illness and symptoms. It also implies that the patient was receiving medicines from the nurse; the act of receiving is a passive concept whereby the patient is having something done to them. If they passively followed the instructions that they had been given and took their medicines correctly, then they would get better. The traditional biomedical model of compliance has not proved very effective in terms of patient treatment. If the patient is not given reasons why their treatment is important, or feels that they have not been involved in the decision, the common result is non-compliance. Sometimes this is intentional (the patient decides not to take their medication), and sometimes unintentional (the patient does not know what they need to take, or when). This has cost implications for the National Health Service. If prescribed drugs, often paid for by the NHS, remain unused the patient’s illness may not improve, resulting in the supply of another prescription (or other treatment) that might have been avoided if they had taken the medicine which was initially prescribed. Indeed the World Health Organization identified that less than 50% of patients adhere to their medicines’ regimens (WHO 2003). An American study identified that 33–69% of hospital admissions with ensuing expense to health care delivery are due to poor adherence to medication (Osterberg and Blaschke, 2005).

Information and Evidence: Sources and Evaluation

By the end of this chapter, you should understand… ● The range of possible sources of information about medicines ● Their positive and negative characteristics ● Some trustworthy sources of evidence ● The role of medicines information departments ● Some basic principles of critical analysis of evidence ● How the British National Formulary (BNF) is structured ● How to read a BNF monograph ● A selection of terms used in the literature about medicines…. While nurses will not usually be selecting medicines, they still need information to make the best use of the medicines prescribed for their patients. Information of all kinds is much more readily available today than it was a generation ago when the authors were students, but much of it is of low quality and today’s student must learn to test the quality of the evidence offered to see if it can be relied upon. In all fields of healthcare it has become usual to insist that practice must be evidence based. This is very desirable, but it begs the question—what is evidence? This chapter will examine some of the sources of evidence about medicines that are available and give some guidance on their reliability. Later, there will be an introduction to critical analysis of sources, and a description of some of the key terms used in evaluating clinical evidence about medicines. Sources of information may be conveniently divided into two main types—people and publications. It is natural that many healthcare professionals should rely upon their mentors and instructors to supplement the knowledge they gain in formal teaching. Indeed, for many years much of the practical information about medicines that junior doctors received came from participation in ward rounds under the tutelage of a consultant. In medical school they learned some general pharmacology, but the actions of many drugs were learned following graduation (Maxwell and Walley, 2009 ) The same will be true for nurses, and it will continue to be true throughout their careers. New medicines will come into use, and nurses will have to learn about them. It is therefore important to realize that pharmacology will be a lifelong study and does not end with registration as a nurse.

Principles of Pharmacology

From the previous chapters you will see that understanding the pharmacological aspects of the drugs you are administering is vital to keeping your patients safe. Nurses need to understand the pharmacodynamics of a medicine, or how it actually works within the body, since this will need to be explained to patients and carers. For example, how will you ensure that a patient understands the importance of taking their treatment for hypertension (especially if they are experiencing no symptoms) if you are unable to explain how the medicine will be working? Similarly, your understanding of the pharmacokinetics (the absorption, distribution, metabolism, and excretion) of individual medicines is vital to ensure compromised patients are not administered inappropriate medicines. For example, you would question the prescribing of a non-steroidal anti-inflammatory drug (NSAID) to a patient with significant renal impairment, because the kidney is essential to the elimination of NSAIDs so the drug could accumulate if the kidneys are not functioning properly. From the point of view of ensuring patient safety, you will need to understand the principles of drug interactions so that you can understand how two medicines (or food and medicine) could interact and be alert to signs that this may be happening. There are several good textbooks dealing with the uses and actions of individual medicines, including interactions. However, these will not be discussed here because at this stage of your career you are not expected to have a detailed knowledge of particular medicines, but rather an understanding of the key principles. As nurses, we are concerned with how the body handles medicines (pharmacokinetics) so that we can see how this may be affected by age, genetics, or illness, and how the actions of medicines may conflict with one another or produce toxicity because their effects are additive. Equally, we need to look at occasions in which two medicines produce the same response by two different routes; such interactions can be beneficial to the patient and avoid having to give large doses of a single medicine because the same result can be achieved with smaller doses of two medicines, thereby reducing the risk of adverse effects.

Groups at Special Risk of Adverse Effects

In Chapters 3 and 4 the general principles of pharmacokinetics and pharmacodynamics were addressed. This chapter builds on these principles and looks at specific groups and situations. After reading this chapter you should be able to:… ● Identify groups of patients at extra risk of interactions, explain why, and relate this to nursing practice. ● Identify groups of patients at more risk of adverse events from medications, explain why, and relate this to nursing practice. ● Understand why some patients might be at higher risk and how this might be managed…. This chapter will look at a range of patients from the perspective of the nurse administering medicines. Whilst care must be taken when administering medication to any patient, there are groups of patients where the risk of problems occurring as a result of having to take medication are higher and it is therefore even more important to be vigilant. For some patients the treatment will have to be altered to reduce risk. While this is not the responsibility of the student nurse it is their responsibility to be vigilant to changes in the patient and to report this to trained staff. There are some circumstances in which the risk to patients is always higher because the treatment they are receiving carries more risk. For example, patients undergoing cancer chemotherapy are receiving drugs which tend to be highly toxic. While the risk of some degree of harm is high, this is justified by the great benefit that patients can derive. However, it is vital that every effort is made to reduce risk. Similarly there are features of care in acute settings such as operating theatres and intensive care units that could increase the risk to patients (Neale et al, 2001 ). Staff may be under acute pressure, so it becomes harder to follow all the steps in a routine.

Medicines Management: Systems and Procedures

By the end of this chapter you should be able to:… ● Understand the responsibilities and accountability of the student and trained nurse with regards to medicines management ● Understand the reasons for policy to support medicines management ● Interpret the role of the nurse in relation to policies and standards for medicines management ● Understand the role of the nurse in relation to key standards and drivers for the safer administration and management of medicines…. The aims of this chapter are to support you to interpret the responsibility that you already carry as a student and will carry as a registrant when giving medicines to patients and to help you to understand what is meant by accountability and how this relates to your role now and in the future in the management of medicines. Medicines management occurs wherever there is a patient and is carried out in a variety of settings which include:… ● acute hospitals ● community hospitals ● care homes, both residential care homes and nursing homes ● the patient’s own home ● schools ● community clinics…. The National Patient Safety Agency (NPSA, 2004 ) has produced guidance for organizations on supporting patient safety. They suggested the implementation of seven steps as follows:… 1 Build a safety culture. 2 Lead and support your staff. 3 Integrate your risk management activity. 4 Promote reporting. 5 Involve and communicate with patients and the public. 6 Learn and share safety lessons. 7 Implement solutions to prevent harm…. When interpreted in relation to medicines management and nursing care this means that the employing organization has a duty of care to its employees and patients to ensure that medicines are dispensed, supplied, and administered safely and that procedures are in place to support this. Managers need to be made aware of anything that might prevent this, and must ensure that checks are in place to prevent harm from occurring. The clear and prompt reporting of concerns, risk, and errors to management is pivotal to patient safety and medicines management in nursing and, from an organizational point of view, patient consultation and involvement is vital. Lessons must be shared in a ‘low blame culture’ and changes made to support the reduction of risk and potential harm. For more on communication and on risk reduction please see Chapters 1 and 10.

Legislation and Standards

Handling medicines is only part of the nurse’s role, but it is a very important part. Handled properly, medicines can make a great contribution to improving the health of your patients. Handled badly, they can do a lot of harm. It is therefore not surprising that there is a lot of legislation relating to medicines, and that the Nursing and Midwifery Council has laid down important standards for the way in which nurses conduct the management of medicines. The legislation is complex, but it has to be learned. Nurses do not need to become lawyers, but they do need a working knowledge of the law relating to medicines so that they can keep within it. This chapter will set out some of the key legislation that will affect your practice as a student or qualified nurse. It will also look at the rights that patients have and give you the opportunity to reflect on the practice you see around you. Most of us will be patients ourselves at some time and we will have a good idea of the way in which we would want to be treated by nurses. It is too easy for people who care for others to fall into the trap of doing what they think is best for the patient, or for their own good, and ignoring the patient’s legitimate wishes. After reading this chapter, you should know how this can be avoided. You cannot register as a nurse without demonstrating knowledge of medicines management. Understanding the laws and regulations that are relevant is the first step in building that knowledge. The law on medicines is primarily designed to keep patients safe, so a nurse who does not know it is unlikely to be able to practise safely. As was remarked in the foreword, the main aim of this book is to help you do that. The concepts of accountability and responsibility are fundamental to any practice related to the administration of medicines. They are inter-related but distinct. Accountability involves being called to explain (account for) your actions or omissions by someone to whom you owe a duty. This might be a legal duty, a professional duty, a contractual duty, or a civil duty arising from a duty of care. Nurses are therefore accountable to a range of others.