NPC Archive Item: Preventing fatalities from medication loading doses

22 December 2010

Introduction

In November 2010, the National Patient Safety Agency (NPSA) issued a Rapid Response Report (RRR)¹ with supporting information² on ‘preventing fatalities from medication loading doses’.

The NPSA describe a loading dose as an initial large dose of a medicine used to ensure a quick therapeutic response; usually given for a short period before therapy continues with a lower maintenance dose. The complexity involved in prescribing, dispensing and administering both loading and maintenance doses can increase the likelihood of human error, leading to over- or under-medication.²

Background
Between 1^st January 2005 and 30^th April 2010, 1,165 patient safety incidents related to loading doses were reported to the National Reporting and Learning System (NRLS).

Research undertaken on the NRLS data found that the most common type of loading dose error related to the prescription and administration of loading doses (approx 41%). The next most frequently reported types were omitted and delayed medication (approx 24%) and communication failures (approx 9%), especially on handover of care and across the secondary to primary care interface. Other error types included loading doses repeated in error; continuation of loading doses; and failure to start a maintenance dose after discontinuation of a loading dose.²

Of the total number of reported incidents, two were fatal (with a further fatality reported by coroner’s letter), four caused severe harm and 102 caused moderate harm. The fatal and severe harm incidents all related to incorrect loading doses, omitted or delayed administration of loading doses, or unintentional continuation of loading doses.¹ ‘Critical medicines’, including warfarin, amiodarone, digoxin and phenytoin accounted for 36% of all patient safety incidents involving loading doses.²

Action
To reduce the risk of harm the NPSA RRR¹ has identified the following recommendations for immediate action by all organisations in the NHS and independent sector. (Deadline for completion of these actions is 25^th November 2011).

An executive director, nominated by the chief executive, working with the lead pharmacist and relevant medical nursing staff should ensure:

1. All medicines used by the organisation that are likely to cause harm if loading doses and subsequent maintenance doses are not prescribed and administered correctly are risk assessed and used to produce a list of critical medicines (which may contain speciality subsections). This must include warfarin, amiodarone, digoxin, phentyoin and any other medicines identified locally.
2. There is effective communication regarding loading dose and subsequent maintenance dose regimens when prescribing, dispensing or administering critical medicines. This should include handover of patients between healthcare organisations. Tools such as loading dose work sheets, loading dose prescription charts, handover and clinical protocols, and patient-held information should be considered.
3. Clinical checks are performed by medical, nursing and pharmacy staff (when available) so that loading and maintenance doses are correct. Appropriate information should be available to support these checks.
4. Healthcare professionals in the community know when to challenge abnormal doses of the identified critical medicines.

What does this mean to medicines management?
The use of loading doses of medicines can be complex and error prone.¹ Healthcare organisations, including those in primary, secondary and community settings, need to ensure that appropriate steps are taken to minimise the risk of harm involving medication loading doses.

Having safe and efficient medicines management systems and processes in place for the prescribing, dispensing, administration and monitoring/checking of medication loading doses will help. These may include:

• Ensuring appropriate training is in place for the effective use of loading doses (especially those involving critical medicines such as warfarin, amiodarone, digoxin, phenytoin)
• Supporting the implementation of dose calculation tools and making best use of the skills of clinical pharmacists to check doses
• Simplifying and standardising communication and documentation procedures to support good practice and help reduce any unintended harm to patients
• Optimal labelling and appropriate storage of medicines commonly used in loading doses (reviewing stock locations where appropriate)
• Following current clinical guidelines on the use of loading doses for the treatment of a range of clinical indications
• Learning from previous example incidents like those reported in the ‘preventing fatalities from medication loading doses’ RRR – supporting information²
• Using review and audit to learn, and help others learn, from patient safety incidents and ‘near misses’ e.g. by using the NPSA’s Significant Event Audit Tool

How does this relate to other publications or evidence?
In 2008 Patient Safety First published their ‘How-to guide for reducing harm from high risk medicines’³ aimed at team members involved in implementing changes to reduce harm from high risk medicines. This report in particular highlights some of the common problems that can result from critical medications when wrong doses are prescribed/administered.

The Safety in Doses 2009 report – Improving the use of medicines⁴ reports on the review of the medication incidents reported to the NRLS in 2007, which can support health professionals in learning from previous medication errors and to improve their own understanding and awareness of the types of medication errors that are likely to occur.

References

1. NPSA Rapid Response Report – NPSA/2010/RRR018. Preventing fatalities from medication loading doses.
2. NPSA Rapid Response Report – NPSA/2010/RRR018. Preventing fatalities from medication loading doses – supporting information.
3. Patient Safety First (2008). How-to guide for reducing harm from high risk medicines.
4. National Patient Safety Agency (2009). Safety in Doses – Improving the use of medicines in the NHS.

More information relating to Preventing fatalities from medication loading doses can be found in the following NPC topics: Reducing medication errors; Medicines management – reducing risk; Medicine reconciliation; and Introduction to medication review

Recent NPC medicines management blogs relating to medication errors that you may find useful include; ‘reducing harm from omitted and delayed medicines and hospital’; ‘new safety insulin guidance issued to reduce wrong dosages’; and  ‘reducing treatment dose errors with low molecular weight heparins’.

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