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Title: Evaluating, understanding and managing medication incidents with high-risk antibiotics
Author: Hamad, Anas Ahmad E. A.
ISNI:       0000 0004 5368 4231
Awarding Body: King's College London
Current Institution: King's College London (University of London)
Date of Award: 2015
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Medication incidents (MIs) were one of the top 3 patient-safety incidents reported to the National Reporting and Learning System in England and Wales over the last 10 years. Reported rates of MIs vary widely as different study methods and definitions are often used. Preventable medication harms could cost the National Health Service (NHS) in England alone £774 million a year. Antimicrobials are a drug class most often implicated in MIs. At least one-third of hospital inpatients are prescribed an antibiotic at some point during their stay. Retrospective incident report analysis was performed to evaluate the prevalence, incidence and nature of antibiotic-associated MIs reported at two large acute teaching Trusts. This analysis confirmed that antibiotic MIs are common especially in the prescribing and administration stages. Omission and wrong dose/frequency were the most common MI types. It was also highlighted that detailed analysis of data from reports is essential in understanding MIs and in developing strategies to prevent their recurrence. A novel approach was used in the analysis of reported MIs by applying the concept of defined daily doses (DDDs), a measure of antibiotic consumption, to establish a more accurate picture of the magnitude of risk of error with this class of drugs. Using DDDs in the analysis of MIs allowed an incident rate to be determined, which provided additional information about the relative frequency of error with particular antibiotic agents than the absolute numbers alone. It also highlighted the disproportionate risk associated with less commonly prescribed antibiotics not identified using MI reporting rates alone, especially if data is analysed over shorter time periods. Therefore, incident data should be interpreted alongside consumption data when determining which drugs are most ‘risky’ in practice. Important information (e.g. drug name) was missing in some reports, therefore it is necessary to make all essential fields in incident reporting systems mandatory. As data could only be compared once categories used for MI classification had been standardised, this highlights the importance of harmonised MI categories for comparison between different hospitals. The analysis of reported antibiotic-associated MIs at one large acute teaching Trust identified that one-third of dose/frequency errors reported were related to gentamicin and vancomycin. A local Failure Modes and Effects Analysis for gentamicin identified that risks with dose calculation and prescribing were greater than risks with preparation of infusions. A systematic review was conducted to identify interventions to manage the risks identified with dosing gentamicin and vancomycin. This review identified electronic clinical decision support (CDS) as an effective intervention. The existence of electronic prescribing and patient record systems at the Trust facilitated the development of electronic dose calculators for calculating initial treatment doses of gentamicin and vancomycin. A pre-post intervention study was conducted to assess the impact of these calculators on the accuracy of initial doses. This study showed that introduction of the calculators led to a significant improvement in the prescribing of initial doses of these agents. Use of such CDS tools can give rise to improvements in clinical care and this study suggests that organisations implementing electronic prescribing systems strongly consider including such CDS tools in their programmes. An interview-based study was undertaken to explore the views and experiences of doctors in prescribing gentamicin and vancomycin and the resources and methods they use to calculate the initial dose of these drugs. The main patterns for accurate dosing found in this study were being a SHO or JCF, using the Trust dosing tools, and treating a non-elderly patient with normal renal function. Prescribers who used the calculators or guidelines accurately were more likely to prescribe a correct dose compared to those who used standard doses (e.g. 5mg/kg gentamicin). However, some prescribers could not use the calculators properly which shows that more education on their use is needed. The main factors identified by prescribers to influence dose selection were patient parameters, Trust dosing tools, Microbiology advice, and clinical condition of the patient. A number of prescribers who obtained a correct dose using the calculators did not know some of the underlying calculations/values needed for dosing (e.g. ideal body weight). This identified that some prescribers may have an overreliance on CDS tools without a sufficient understanding of the parameters required which masks a potential source of error. Some doctors criticised the design of the calculators and preferred more accessible, user-friendly calculators that are integrated with other electronic systems in the Trust (e.g. electronic patient records). Taking doctors’ comments and recommendations into consideration in designing and updating dosing tools would increase the ownership of these tools and potentially their use to enhance safe and effective prescribing.
Supervisor: Whittlesea, Catherine Margaret Cecilia Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available