Prescribing Nightmares

Today I repeated a monthly routine of stocking up 4 weekly medicine packs. Each has 7 daily containers which are further subdivided into sections for morning, mid day, afternoon and night. Each daily container has a sliding top. For the last 4 years I have allocated around 1000 individual tablets each month into appropriate sections. 200 of these were antibiotics ( 2 x 500 gram tablets 4 times a day). Now that I no longer need oral anti biotics the task has become a little easier. It still requires careful concentration and takes about 1 hour to complete.

Even with this careful approach I usually manage to mis-allocate 1 to 2 tablets each month. An error rate of 0.1 -0.2%. I am more conscious than most of what medication I am on, what it is for, when and with what it should be taken. I am therefore amazed that medication related incidents are not more of a problem than appears.

The nurse in charge of the drug cabinet on any in-patient ward is often rushed and/or interrupted by patients who want to draw attention to one need or another that has not been attended to earlier. Occasionally the nurse gets called away to help with another patient in another area of the ward or has to "cadge" or borrow tablets from another drug trolley to be able to complete the task. In my experience it is equally likely that the drug trolley will be left unlocked on these occasions as that it will be locked before leaving it unattended. I believe that under these conditions the error rate will be higher than what I manage to achieve when I have no such distractions.

Is this a real problem if the error rate remains less than 1 in a 1000? Well I think it is. A method of quality control which is increasingly being used in commercial organisations is 6 sigma. (based on the number of standard deviations from an average value that describes a distribution of actual measures. In statistical terms 3 standard deviations usually includes 99.99% of values in a normal distribution of measurements). 6 sigma companies strive to design and operate processes with a failure rate of 3.4 per million or less!

To be fair, my most recent in-patient experience had fewer drug related incidents than usual but nonetheless did follow the trend I have experienced since 1982 of having to query some of the tablets dispensed to me as part of the usual ward "drug round". There were 4 unreported incidents this time around:

• Despite several weeks before producing a list of current medication from my G.P. the ward did not have all of my medication available. I brought in a week's supply in daily drawers - not in original packaging.
  
• My steroid treatment was interrupted after the operation and it took a couple of days to resolve. Interruption to steroid treatment can compromise a patient's immune response to infection so I had to prompt for the treatment to be resumed. When it was resumed the ward could not dispense the 7 mg that I was prescribed (1x5mg and 2x1 mg tablets) as it only had 5mg and 2.5 mg tablets. For the rest of my stay therefore we "raided" the daily drawers of the weekly pack I brought in with me and when that ran out my wife brought in a second weekly pack. In the event the difference between 7mg and 7.5 mg daily was not too great a problem but given the advance notice of my regular medication I could not understand why this happened.
  
• I have chronic anaemia due to renal impairment. I have been receiving weekly injections delivered to my home and stored in a fridge to help boost my iron stores and haemoglobin levels. A few months back the weekly dose was doubled to 2 injections each week. My wife and I decided I should have the double dose at the same . My wife brought the double dose in pre-filled syringes ready to store on the ward. Unfortunately the drug card was written up for the single dose only. So on the day after the operation I was given a single dose instead of the double dose I expected. We discussed this with several nurses and eventually it was agreed that I could have the second syringe 4 days later. By this time the ward had ordered their own supply - but only a single dose each week! Knowing I would return home before too many weeks elapsed my wife and I resolved to sort things out once we returned and to be grateful for whatever the ward staff felt able to provide.
  
• The anti hypertensive regime that I am on includes furosemide ("water tablets") and enalapril among other medication. It was important to stop taking the enalapril the night before the operation and to restart the next day. In the event my blood pressure readings tended to be on the low side of normal and it was decided in the Post Operative Surgical Unit to stop the furosemide and restart the enalapril . Only 3 days later when a renal physician visited me on the ward did he say that the furosemide should have been restarted first and then, only if required, the enalapril. So 5 days after admission I reverted to my normal daily medication albeit taken at different times and supplemented by some of my own tablets.

When the ward pharmacist visited we discussed these events in a calm manner and both of us understood and agreed that the level of drug related incidents in hospitals generally is significantly under reported and left matters like that. Its just a fact of hospital life..... sadly. Perhaps once MRSA , C.difficile and other hospital acquired infections are sufficiently controlled attention might shift to reducing the level of errors related to hospital administration of patient drugs.


Now don't get me wrong my recent experience of potential drug administration problems is one of the better examples - honest! I won't bother to describe in detail the others but will just relate 4 earlier examples:

1. In 1982 I queried why I was being asked to take a large dark blue tablet I had never seen before. When I could not understand the explanation that was given I flatly refused! Now this was apparently one "incident" that was reported, I guess because the nurse concerned needed to cover herself in the event of any problems. The next day however the nurse manager for the unit did come to see me and apologise, she confirmed I was right to refuse the drug as it was a powerful unlicensed one but with toxic side effects intended for another patient. She was happy when I confirmed that I would not pursue the matter any further. I was naive in those days and would not agree so readily any more.
2. In 1995 I was admitted as an emergency and mentioned to the staff concerned that I was on some medication for hypertension that was prescribed when I was working in Saudi Arabia and although not much used in the UK was still available but should not be stopped suddenly as it would cause a "rebound" in blood pressure levels. Sure enough having been denied this particular medication for 4 days, despite daily protestations on my part, the predicted "rebound" occurred and I was discharged with uncontrolled hypertension and a referral to the general medical unit. It took the best part of 18 months to reintroduce then gradually wean me off the drug and onto a different regime.
   
3. After the emergency admission brought on by a warfarin induced massive bleed (described elsewhere) I was nursed on the urological ward for about 5 days. At this time my renal function had worsened to the extent that I was due to be added to the transplant list and was being prepared for regular dialysis. ( Over the last 4 years for a reason no clinician yet understands the situation has reversed considerably) I was at the time on a restricted diet and had to avoid food high in potassium which my kidneys could not cope with and if the levels were too high it would have implications for my heart. One way of ameliorating the effects of phosphorous in food is to chew calcium tablets with meals, particularly those which included meat. It was important that the calcium tablets were chewed with the food as this would help "bind" the phosphorous" and it would not therefore be as much of a problem. For 3 days I persuaded the ward staff to leave the calcichew tablets at my bedside and I would chew them with meals as required. On the 4th day a rather officious staff nurse decided that this could not be allowed so she confiscated the calcium tablets. As a result meals came and went and I could not bind any phosphorous content as before. What is more - as if to add insult to injury - the same nurse would do a drug round 2 hours after I had eaten and ask "Have you had your calcichew yet?" When I said no because you had taken them away she would "dispense" 2 and wait for me to chew and swallow them. She assured me she was after all responsible for the safe use of my medication while under her care!
4. When the post operative sepsis struck for the first time I was very ill and my renal function plummeted. The orthopaedic doctors completely failed to notice this and surgery was delayed several days. In fact they were ready to discharge me until the renal team were consulted at my insistence. They "rescued" me and I was transferred to a renal ward where I had dialysis for 2 weeks during which time the infected wound was cleaned out under anaesthetic.
   
   When my medical history was taken by the junior doctor my wife who was present at the time (and a doctor herself) commented that the junior doctor took no notes, When my wife questioned her the (self assured) junior doctor said it was OK she found it better to write them up afterwards.
   
   For 3 days thereafter in my weak and feeble state I succumbed to the nursing staff fitting a mask over my mouth and using a nebuliser to aid my breathing. I questioned this and was told "its OK the doctor has written you up for it". Eventually my wife queried this and discovered the junior doctor had written up a misleading medical history and added asthma to my list of ailments! Once we stated that I had never had asthma the treatment was withdrawn. We think the junior doctor confused me with another patient who was probably denied his nebuliser over this period.

Less you think I am just plain unlucky I will relate one further example that was relayed to me 3 years ago - by my favourite District Nurse. At the time I was a Patient Governor with the local Acute Hospitals Foundation Trust. We shared a number of concerns and I was told of a patient she had gone to see who "went off" with bad heart palpitations and needed to be readmitted as an emergency. The reason was that the patient had been fitted with what is called a "peg" on the ward which allows quicker absorption of medication direct to the digestive system ( I think!) Because the medication can be delivered to where it is most needed it doe snot have to be taken by mouth and as a result can be more effective at lower doses. Having run out of the lower dose version of the medication ward staff had prepared this patient for discharge by crushing the (higher strength) oral form of the tablet and forcing it into her via the "peg".

Interestingly I was unable to follow this incident up and it remained unreported. The reason? Patient confidentiality! The District Nurse had no right to pass on the patient's name or hospital number to me and she complied with this restriction for fear of losing her job. As a result whenever I mentioned this problem to the hospital's pharmaceutical, nursing and general management staff I could not substantiate the details and the "story" was dismissed as "unsubstantiated and anecdotal"!

This is one more example of why I believe Patient Confidentiality is in danger of being abused by some professional staff ( keen not to have their actions judged by others) rather than being to the benefit of patients themselves.

I did warn at the outset that this was an X rated Blog .... so as they say on Crimewatch "don't have nightmares".