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Safe Administration of Oral and Enteral Liquid Medicines

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Safe Administration of Oral and Enteral Liquid Medicines 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 LIQUID MEDICINES Surinder Ahuja , Medication 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 Drug 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 1 11/01/2018 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) Water 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 2 11/01/2018 Medicines use – outside license Pharmaceutical review Consider: Off label use of licensed medicines alternative licensed routes crush and dispersing from oral to rectal, transdermal, 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 enteral administration In a hospital setting Liquids dose measured in a syringe 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 3 11/01/2018 NPSA Alert 2007: 1 Design, supply and use of oral/enteral syringes 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 4 11/01/2018 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) 5 11/01/2018 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 6.
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