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06 September 2010
Introduction
In July 2010, the National Patient Safety Agency (NPSA) issued its Rapid Response Report: Reducing treatment dose errors with low molecular weight heparins (LMWHs)1, making six recommendations in all for immediate action by NHS and independent sector organisations. The supporting information2 for the report gives further detail, reviews the evidence and includes additional resources, good practice examples and a suggested compliance checklist, all aimed at reducing the number of dosing errors associated with LMWHs.
Action
The NPSA recommends the following action points be completed by all healthcare sectors and specialities where the prescribing, administration, monitoring and dispensing of treatment doses of LMWHs occur, including community settings:
1. A patient’s weight is used as the basis for calculating the required treatment dose of LMWH. The weight must be accurately recorded in kilograms (kg) in the inpatient medication chart (when in use) and clinical record. Patients should be weighed at the start of therapy and, where applicable, during treatment.
2. Renal function is considered when prescribing treatment doses of LMWHs. The renal function test should not delay initiation of the first dose but every effort must be made to base subsequent dosing on these results.
3. Dose calculation tools are available for a range of body weights, specific clinical indications and LMWH products, and that consideration is given to rationalising the range of LMWH products used in the organisation.
4. Essential information such as dose, weight, renal function, indication and duration of treatment is communicated at transfers of care (e.g. by discharge letters) and used to ensure that future doses are safe.
5. Dosing checks based on patient information are made by healthcare professionals who review, dispense or administer LMWHs when this information is readily available to them.
6. System improvements should be demonstrated through the collection and review of data, such as incident reports, clinical pharmacy interventions, audit or other relevant outcome measures.
The deadline for completion of these action points is 28th January 2011.
Background
Between January 2005 and September 2009, the NPSA received 2,716 patient safety incident reports relating to dosing errors concerning LMWHs. These include one incident reported to have led to death and three reports of severe harm. A review of NHS Litigation Authority claims identified one further death.
What does this mean to medicines management?
Healthcare organisations, including those in primary, secondary and community settings, need to ensure that appropriate steps are taken to minimise the risk of medication errors involving LMWHs, and having good medicines management systems and processes in place can help. For example:
- Ensuring that staff receive appropriate training in the effective use of weight-based dosing guidelines
- Supporting the implementation of dose calculation tools and making best use of the skills of clinical pharmacists to check doses
- Following current clinical guidelines on the use of LMWHs for the treatment of a range of clinical indications
- Using clinical, evidence-based sources for guidelines on dosing patients with renal impairment
- Learning from previous example incidents like those reported in the Rapid Response Report supporting information2
- Using review and audit to learn from patient safety incidents and ‘near misses’ in their own practice, (e.g. by using the NPSA’s Significant Event Audit Tool)
- Implementing medicines reconciliation and medication review procedures to ensure that those involved in prescribing, administering, monitoring and/or dispensing LWMHs accurately record essential information including dose, body weight, renal function, clinical indication and duration of treatment.
How does this relate to other publications or evidence?
The 2003 NPC MeReC bulletin on Venous thromboembolism (VTE) explores the signs and symptoms of VTE, and the management issues surrounding its treatment. Risk factors that increase the likelihood of developing VTE and a discussion of travellers’ thrombosis are also included.
References
1. National Patient Safety Agency (2010). Rapid Response Report NPSA/2010/RRR014: Reducing treatment dose errors with low molecular weight heparins
2. National Patient Safety Agency (2010). Rapid Response Report NPSA/2010/RRR014: Reducing treatment dose errors with low molecular weight heparins – supporting information
Further information supporting a reduction of treatment dose errors associated with LMWHs can be found on the NPC therapeutics floor: Cardiovascular (inc: Diabetes), which has a section dedicated to Venous thromboembolism, and the medicines management topic: Improving safety & managing risk in medicines management systems and processes, which includes a section focusing on Reducing medication errors.
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