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Medicines Group To Target Six High Risk Drugs

Six High Risk Drugs To Be Targeted By Safe Use Of Medicines Group

A project team drawn from the 21 district health boards is working on making medications safer to use in New Zealand hospitals and across the interface between hospitals and primary care.

The Safe Use of Medicines Group, under the chairmanship of Dr Dwayne Crombie CEO of Waitemata DHB, has identified six high risk medicines recognised internationally as being significantly linked to adverse incidents. Medication Alerts are to be developed for each drug. The first Alert being discussed at the Conference - on Potassium Chloride Injection – has already been issued.

Dr Crombie says, “The drugs we have chosen have all been identified as being high risk ones that contribute to a high level of adverse or potentially adverse events. We believe our Alerts will help minimise their occurrence. However, before we continue any further we want to be sure we are on the right track and our colleagues support their introduction. The feedback we get will guide us in our future work.”

The six medications are:

Potassium Chloride Concentrate, added to intravenous replacement fluid is used only in a hospital setting. Ampoules of Potassium Chloride can be easily confused with ampoules of Sodium Chloride. There is also the potential for confusion over the strength of the dosage given. At its most severe, errors can cause the heart to stop functioning but more commonly result in an unstable heart rhythm.* Setting wrong infusion rates or choosing and giving Potassium ampoule instead of a sodium chloride ampoule are common types of error with this drug.

Warfarin, a blood thinning drug used post operatively for people given artificial valves and, more generally, for blood clots (deep vein thrombosis) and atrial fibrillation. This drug is used both in hospital and in the community and comes in three strengths. There are problems around starting the drug and a need for regular ongoing monitoring of patients, whose blood thickness levels can be affected by a number of changing factors such as stress levels, diet and other medications. Patient compliance in the community is also a factor.

Heparin, an intravenous drug used post operatively in hospital as part of the procedure process in hospital. Heparin is a blood thinning drug that needs to be used with caution, and the group is looking at how best adverse side effects can be avoided when it is used. Problems include incorrect strengths and dosages.

Diltiazen, a calcium channel blocker drug used after angina (and for blood pressure. It dilates the arteries and veins and affects the way heart pumps blood around the body. It is both a hospital and a community drug. The issue with diltiazen is that it comes in two forms, an immediate release preparation used as a first dose to identify the ongoing dosage needed for the patient and a slow release preparation for ongoing maintenance. Giving quick release when slow release is intended can lead to a slow heart beat, hypotension (low blood pressure), heart block and cardiac failure…

Insulin, required and used daily by people with Diabetes. There are a variety of insulin preparations available with different strengths. This is both a hospital and a community preparation. Most people with diabetes in the community are very aware of their own variety of insulin and manage it very effectively. Work will be aimed at minimising the potential for error when people come into hospital so that they get their correct variety and strength at the right time. Incidents in hospital have included late doses, missed doses, wrong doses, wrong syringe size, and double doses where a patient self administers and then nurse repeats shortly afterwards. Errors with insulin can lead to loss of consciousness and, in severe cases coma and death.

Morphine a pain relief drug used in hospital, hospice and home settings in a variety of strengths. The work will be aimed at ensuring that prescribing, dispensing and administration errors are minimised. Overdoses depress the respiratory system and if taken in sufficient quantity the patient stops breathing and dies.

The Alerts are primarily for drugs in the hospital setting. However, Diltiazen, Insulin and Morphine are also used in the community and the hope is that primary care will also use the Alerts that apply in non hospital settings when they become available.

A systems approach to the safe use of medicines is a subject close to the heart of the Group’s Chair. Dr Crombie says, “I have long been a strong supporter for a systems approach in healthcare, such as exists in aircraft industry.

“Nowadays we have people living with very complex health conditions for much longer because we can give them an incredible array of very complex drugs. Many of these drugs are lifesavers in the right dosages but can also be killers when incorrectly taken. We want to eliminate as far as possible the human error factor and make sure that we give the right drug to the right patient at the right time and in the right way.” Ends.

The Safe Use of Medicines Conference is being sponsored by DHBNZ; Pharmac; The Ministry of Health; The Australasian Society of Clinical and Experimental Pharmacologists (ASCEPT) and PreMec.

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