Medicines Safety Group

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					                          Medicines Safety Group


       May 2009                                                               Issue No. 12

This newsletter focuses on drug related incidents that have been reported in the Trust. The
intention is to highlight these incidents so that we can learn from them and minimise the chances of
them happening again.

If you have any comments regarding the incidents in this newsletter or you think a specific incident
should be included please contact Shameem Mir on 020 7655 4038.

To ensure the lessons learnt have an impact on clinical practice the Medicines Safety Group
recommend that each clinical team use the newsletters as a focus for reflection on their
own practice.

                      Rapid dose increase with clozapine
 A patient had their clozapine dose increased from 50 to 400mg. The patient received one dose
 of 400mg before it was noticed by the pharmacist who recommended the dose be changed.

    Many of the adverse effects of clozapine are dose-dependent and associated with the
     speed of titration of clozapine. This includes hypotension, which could result in a patient
     collapsing, and having seizures. To reduce these problems the dose of clozapine should
     be increased slowly.
    Two clozapine initiation prescription charts are available to help with dose titration. One
     doesn’t have the dose pre-printed on it and enables the prescriber to state the dose and
     the other has the doses pre-printed.

 Clozapine Prescription and Administration Chart – Blank

 Clozapine Prescription and Administration Chart – Dose Pre-printed

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                    Wrong strength of nicotine patch administered
A patient was prescribed a nicotine replacement patch 15mg/16hrs to help them stop smoking.
The 10mg/16hrs was administered which was noticed when the patient complained their patch
was not helping.

   This error occurred because the packaging of the different strengths of nicotine patches
    look very similar and it easy to pick up the wrong pack. This applies to a number of
    different medicines and is a common cause of error. This is highlighted in the 10Rs of
    safe administration of medicines which lists the things that should be checked before a
    medication is administered to a patient. The 10Rs are:

              Right Patient
              Right Consent
              Right Time
              Right Medicines
              Right Expiry
              Right Dose
              Right Route
              Right Documentation
              Right Effect
              Right Education

                     Medication being put back in the wrong box.
A patient was given the wrong medication because a strip of quetiapine XL had been put into a
box labelled as Lithium.

   In this case the patient did not receive the correct medication they were prescribed, they
    were also administered a medication that was not prescribed. This mistake can happen
    if a patient is on several different medications and all the strips are taken out at the same
    time. It can also happen if there are different strengths of the same drug next to each
    other and the correct box is not checked when the medication is put back.

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                     Taking unprescribed medication
A patient complained of toothache. He self-medicated with paracetamol that he had brought into
hospital with him from home. Paracetamol had not been prescribed on the prescription chart.

   The risks with this are the patient could have been prescribed and administered
    paracetamol on the prescription chart. This could have resulted in the patient taking
    more than the recommended dose. The other risk is that it could have been a
    medication other than paracetamol e.g St Johns Wort which could interact with
    prescribed medication.

      On admission, all patients should be asked if they are taking any other medication and if
       they have brought any medication in with them. This is covered in the Medicines
       Reconciliation Policy:

   Medicines Reconciliation Policy

      Any medication the patient brings in with them is their property. It should either be
       returned to them when they are discharged or given to a carer or relative to take back
       home with them. If the patient no longer needs the medication it can be destroyed by
       pharmacy with the patient’s consent.

                     Clozapine administered when blood result red.

A patient had a regular clozapine blood test which produced a red result. This was not
discovered until 3 days after the test. The clozapine continued to be administered for these 3

   About 2.7% of patients on clozapine can develop neutropenia. Risk factors include being
    Afro-Caribbean, young and having a low baseline white cell count. Risk is not dose
    related. About 0.7% of patients can go on to develop agranulocytosis, which can be
    potentially fatal. The risk is greatest in the first 18 weeks of treatment. This is the reason
    why full blood counts have to be done on a weekly basis for the first 18 weeks of
    clozapine treatment, so if the patient develops neutropenia, it can be detected and
    reversed quickly. In this case the patient was at risk of a potentially fatal side effect of

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                        Wrong formulation of quetiapine administered
A patient was prescribed quetapine XL 300mg but the ordinary, immediate release quetiapine
was administered at a dose of 300mg. On discovery of the error, the patient’s blood pressure
and pulse were monitored. The patient did not experience any adverse effects although there
was a risk of the patient experiencing postural hypotension.

   Quetiapine XL is a modified release once a day formulation that has recently been
    approved for use in the Trust. It releases the drug slowly and reduces the side effects
    that are associated with peak drug concentrations on ordinary release, twice daily,
    quetiapine e.g orthostatic hypotension. The usual starting dose of quetiapine ordinary
    release is 25mg or 50mg twice daily depending on indication. The risk, in this case, was
    that the patient could have collapsed due to orthostatic hypotension resulting from
    administration of 300mg of the immediate release preparation.

          Not all patients should be automatically switched to quetiapine XL. Patients considered
           suitable for quetiapine XL are:
                Those at a high risk of adverse effects to quetiapine (e.g. orthostatic
                   hypotension) or those experiencing adverse effects that are related to peak
                   concentrations on twice a day quetiapine (e.g. sedation and somnolence)
                Those requiring rapid dose titration
                Patients where once a day dosing is beneficial e.g. patients who are chaotic with
                   tablets or do not remember to take tablets.

          The full guidelines for the use of quetiapine XL are available on the intranet:

Guidelines for the use of quetiapine XL

                  Review of Rapid Tranquilisation Guidelines

         The aim of rapid tranquilisation is to calm the severely agitated patient. The aim is not
          to induce sleep or unconsciousness.

         Rapid tranquilisation should not be prescribed routinely to all patients when they are

         Prescribing rapid tranquilisation can result in a patient being on a high dose of
          antipsychotic medication. The recent POMH-UK audit on high dose and combination
          prescribing done in Feb 2009 found that 59% of our patients were on high doses. Some
          of these would be due to the co-prescription of rapid tranquilisation. This is slightly
          higher than when we audited last year when 49% of our patients were on high dose

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      Non-drug methods should always be tried first.

      Oral medication should be tried first.

      Consideration should be given to the patient’s regular medication to see if any
       adjustments can be made.

      Monitoring should be according to recommendations in the guidelines; this should also
       be recorded on the form in the guidelines.

      The reason for administering rapid tranquilisation and the response should be
       documented in the notes.

      Rapid tranquilisation should be crossed off the prescription chart when it is no longer

      NICE invite patients to write their experience in the notes.

                                Overview of Trust Reporting

A total of 154 medication-related incidents were reported in the Trust last year. The majority of
these were administration errors. This is expected given the high level of administration activity
compared to prescribing and dispensing.

                                    Reported Medication Incidents Jan - Dec 08






















This was also reported by the National Reporting and Learning System, which compares the
number of incidents we report against other Mental Health Trusts. Our Trust is represented by the
black bar in the graph below. Organisations that have higher numbers of incidents reported are
considered to have more robust systems for reporting in place and staff that are encouraged to

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report incidents. This is with the aim of improving systems and to prevent the same errors re-

Patient Safety incidents Reported to NRLS April 2008 – September 2008

Incident rate per thousand bed days Apr 08 – Sept 08

Incident type Apr 08 – Sept 08

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