11/01/2018

A quick poll

 Hospital, community, industry or other

 Who liaises with dieticians?

 Who liaises with Trust procurement team?

SAFE ADMINISTRATION OF ORAL AND ENTERAL MEDICINES

Surinder Ahuja , Safety Officer I Formulary and Governance Pharmacist The Rotherham NHS Foundation Trust 23 November 2017

Group discussion Outline

Four topics 1. Patients and enteral routes

1. What are the legal and practical implications of medicines use in these 2. Considerations and risks relating patients, medicines, patients? processes and management 2. What is the national guidance on this subject? 3. Pharmaceutical issues with administration 3. What factors contribute to medication errors? 4. Contribution of product design and devices to patient safety 4. What did the industry do to reduce risk of harm? 5. Identifying and reporting incidents 6. Factors contributing to medication errors 7. Never Events 8. Literature and resources

Five Rights of Administration Patient types

 Right Patient Unable to swallow solid formulations

 Right Route  Children

 Right  Too ill - critical care

 Right Dose  Mental health

 Right Time  Patients with swallowing disorders

 stroke

 impairment of oral structures (head and neck cancers)  respiratory (COPD)  neurological (Parkinson disease, multiple sclerosis)  dementia

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Swallowing disorders - assessment Enteral routes

Assessment by speech and language therapist (SALT)  Nasogastric (NG)

 Nasojejunal (NJ)

Recommendation may include:  Percutaneous endoscopic

 Modified diet and fluids gastrostomy (PEG)

protocol with oral diet  Percutaneous endoscopic

 Nil-by-mouth and water protocol with no oral diet jejunostomy (PEJ)

 Percutaneous endoscopic gastro- jejunostomy (PEGJ)

Enteral tubes Medicines - legal and practical issues

Via nose – long, fine-bore tubes Feedback

Via percutaneous – short, wide bore tubes Sterile water for use via jejunum

Drug absorption Gastric motility

Medicines - formulations Medicines - legal issues

 Standards tablets / capsules Medicines Act (1968):  Sugar coated / film coated Prescribers are allowed to prescribe medicine outside their  Dispersible /effervescent license:

 Buccal /sublingual  unlicensed patient groups (off label)

 Chewable or

 Enteric coated  medicines with no license (unlicensed) e.g. medicines with a non-EU license

 Modified release Prescribing liability rests with the prescriber.

 Cytotoxics May also rest with the administrator and supplier.

 Cytostatics eg finasteride, HRT

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Medicines use – outside license Pharmaceutical review

Consider:  Off label use of licensed medicines  alternative licensed routes  crush and dispersing  from oral to rectal, , injections  mixed with food  alternative formulations  Injections given oral or enteral route  from modified release to standard release

 dose changes  Use of unlicensed medicines  when switching solid to liquid formulations eg digoxin, phenytoin  Specials order liquid medicines  timing of feeding and dosage

 eg phenytoin –stop feed for 2 hours before and after dose Need to consider legal responsibilities of healthcare professionals

How to administer? Risks with administering liquid medicines

For oral and In a hospital setting

 dose measured in a

 Tablets – crush and disperse in water  administered parenteral (IV or subcutaneously)

 Capsules – opened and contents mixed  Injections – give orally or enteral Must have safeguards to prevent wrong route administration

 Require dose changes eg phenytoin

 Information on handling

 Use reference sources

What are the safeguards? National guidance

National guidance Reducing harm from misplaced enteral tubes Promoting safer use of liquid medicines

NPSA/NHS England/NHS Improvement: Patient Safety Alerts Feedback  Reducing the harm caused by misplaced nasogastric feeding tubes (2005)  Promoting safer measurement and administration of liquid medicines via oral and other enteral routes (2007)

 Problems swallowing? Resources for clients and carers (2007)

 Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants (2011)

 Placement devices for nasogastric tube insertion DO NOT replace initial position checks (2013)

 Nasogastric tube misplacement: continuing risk of death and severe harm (2016) DoH The Medicine Act Never Event List 2015-16 https://www.england.nhs.uk/wp-content/uploads/2015/03/never-evnts-list-15-16.pdf

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NPSA Alert 2007: 1 Design, supply and use of oral/enteral 2 Design, supply and use of enteral feeding system

 only use labelled oral/enteral syringes that cannot be connected to  enteral feeding systems should not contain ports that can be connected to intravenous catheters or ports to measure and administer oral liquid intravenous syringes or that have end connectors that can be connected to medicines intravenous or other parenteral lines

 do not use intravenous syringes to measure and administer oral liquid  enteral feeding systems should be labelled to indicate the route of medicines administration

 make sure stocks of oral/enteral syringes are available in all clinical areas  three-way taps and syringe tip adaptors should not be used in enteral that may need to measure and administer oral liquid medicines in a syringe feeding systems because connection design safeguards can be bypassed.

 when patients or carers need to administer oral liquid medicines with a syringe, supply them with oral or enteral syringes.

3 Organisational procedures, training and audit Poster (NPSA, 2007)

 medicines and enteral feeding policies and procedures should identify and manage the risk of administering oral liquid medicines by the wrong route

 these procedures should be part of the organisation’s training and competency assessment programmes

 annual medicines management audits should include a review of the measurement and administration of oral liquid medicines to ensure compliance with local policies and procedures.

The role of industry The role of industry

Feedback  ISO standard 80369-3

 ENFit

 feeding tubes connectors

 feeding tube adaptors for interim use

 enteral syringes  bottle adaptors

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Learning culture Factor contributing to errors

Identifying and reporting incidents Feedback

 Awareness of risk of harm

 Awareness of standards/processes/safeguards

 System for reporting

 Reporting and learning culture

Factors contributing to errors Learning – National

 Patients Never Event List (2015-16) – Wrong route  Individuals - healthcare professional The patient receives one of the following:  Team  Intravenous chemotherapy administered via the intrathecal route  Task  Oral/enteral medication or feed/flush administered by any parenteral  Communication route  Training and education  Intravenous administration of a medicine intended to be administered via  Equipment the epidural route  Environment

 Organisation  Local  National

A case of two Never Events Trust actions

 A deep dive into wrong route errors  Declared as Never Events  Trustwide audit using NPSA Checklist  Identified two wrong route incidents  Oramorph prescribed  Trustwide training - Stop the Shift  measured for oral administration (with IV syringe)  Training of new staff  administered subcutaneously  Role out of ENFit syringes at the same time  Informed Chief Pharmacist,  Revision of SOP (Medicines Policy) Chief Nurse, Medication Safety Group, Patients Safety Group, CCG, CQC  Nutrition Policy – section on medicine administration

 Declared as Never Events  Report of the actions taken

 Investigations

 Audit of checklist (Pre- registration pharmacist)

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Learning from incidents Summary

Factors Actions taken

Patient Swallowing difficulties, enteral tubes and feeds, ongoing care  Patient types  Types of enteral tubes Individuals Awareness of risks and harm and take appropriate actions  Risk of patient harm National Reporting system, Patient Safety Alerts, Never Events  Risks of medicines use in these patients Medicine Act 1968  Pharmaceutical issues Organisational Local SOPs, procurement, audits, reporting and learning culture, medicines information  Product design

Equipment Availability of oral and ENFit syringes, adaptors  Incident reporting and learning and contributing factors ENFit giving sets, ports, connectors  National guidance

 Literatures sources Training & education Competencies, ongoing

Task Prescribing, administration, dispensing, medicine information

Global Setting standards, industry product design

Literature and resources

Medicine Act 1968 Never Event List 2015-16  Thank you NPSA/NHS England/NHS Improvement: Reducing the harm caused by misplaced nasogastric feeding tubes (2005) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes (2007) Problems swallowing? Resources for clients and carers (2007)  Any questions Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants (2011) Nasogastric tube misplacement: continuing risk of death and severe harm (2016) Medicines: Barnett N and Parmar P. Tailoring medication formulations for patients with dysphagia PJ 2016) Smyth J. The NEWT guideline for administration of medication to patients with enteral feeding tubes or swallowing difficulties (3rd edition) Online access White R and Bradham V Handbook of drug administration via enteral feeding tubes ( Summary of product characteristics Incident reporting and learning: Seven Steps to patient safety (NPSA 2004) Yorkshire contributory factors framework (2012) http://qualitysafety.bmj.com/content/qhc/early/2012/03/14/bmjqs-2011-000443.full.pdf

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