Page 85 - Registrar Orientation Manual 2016

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132 medication events
• 23 related to opioids
• 19 related to anticoagulants
• 7 related to insulin4
medication events
is the estimated annual cost of preventable ADEs in New Zealand.10–12
4. Health Quality & Safety Commission Reportable Events http:// www.hqsc.govt.nz/our-programmes/reportable-events/serious- and-sentinel-event-reports/.
12. KunacDL,KennedyJ,AustinNetal.Incidence,preventabilityandimpactofadversedrug events (ADEs) and potential ADEs in hospitalized children in New Zealand. Pediatr Drugs 2009; 11(2): 153–160.
During 2005–2010 the National Reporting and Learning System in England and Wales had:
ADE collaborative
822 medication incidents reported causing death and severe harm
oral methotrexate
The medicines that were most commonly implicated for causing an ADE were:13
• 91 related to anticoagulants
• 89 related to opioids
• 46 related to insulin5
medication incidents
33% 10%
opioids
5. Cousins D, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005-2010). Br J Clin Pharmacol Oct 2012; 74(4): 597-604.
13. Seddon ME, Jackson A, Cameron C et al. The Adverse Drug Event Collaborative: a joint venture to measure medication-related patient harm. NZMJ 25 January 2013, Vol 126: 9–20.
High-risk medicines
National Patient Safety Campaign
3/4 of New Zealanders are estimated to have had a
Up to
prescription for one or more medicines in the year ended 30 June 2013.1
are thought to be
13% with two medicines 58% with ve medicines 82% with seven or more3
1. Extrapolation based on PHARMAC Annual report 2012/2013.
Between July 2007 and June 2013: 2159 reported serious adverse events
warfarin
Up to $158m
insulin
high-risk medicines6-9 include
insulin
6. 7. 8. 9.
Institute for Safe Medication Practices (ISMP). ISMP’s List of High-Alert Medications. 2012. Available at http://www.ismp.org/Tools/highalertmedications.pdf.
Institute for Healthcare Improvement (IHI). 2012. How to Guide: Prevent Harm from High-risk Medications. IHI, Cambridge, MA. Available at www.ihi.org.
60% of adverse drug events (ADEs)
Frequency of ADEs
preventable.2 Medication
errors and adverse drug
reactions (ADRs) are the
main causes of ADEs.
2. Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995; 274:29–34.
3.
Patterson S, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews 2012, Issue 5.
Health Quality and Safety Commission. Medication Alerts. Available at www.hqsc.govt.nz/ assets/Medication-Safety/Alerts-PR.
National Health Service (NHS). 2008. The How-to-Guide for Reducing Harm from High-risk Medicines. (last accessed 2 April 2013). Available at www.patientsafety rst.nhs.uk/ashx/Asset. ashx?path=/How-to-guides-2008-09-19/Medicines%201.1_17Sept08.pdf .
anticoagulants
10. BriantR,AliW,Lay-YeeR,DavisP.Representativecaseseriesfrompublichospitaladmissions199: drug and related therapeutic adverse events. NZ Med J 2004; 117 (1188).
11. BrownP,McArthurC,NewbyLetal.CostofmedicalinjuryinNewZealand:aretrospective cohort study. J Health Serv Res Policy 2002; 7: 29–34.
heparin
concentrated potassium
opioids
insulin
morphine
anticoagulants
anticoagulants
opioids