Medication Priorities Sydney Prof CF Hughes 22nd June 2007

Medication Priorities
Prof CF Hughes
Sydney
22nd June 2007
NSW MVA Statistics
CF Hughes
15th June 2007
Risks in Policies
CF Hughes
15th June 2007
NSW Trend IIMS Notifications 2005/2006/2007
2005
12000
12072
12193
12320
11816
11594
11023
10023
10000
9388
9097
No of notifications
2007
13855
13824
14000
2006
9295
11019
9636
10173
9779
11232
10909
10710
10457
11590
10454
9424
10626
9385
8000
5775
6000
6087
4282
4000
2703
2000
0
Jan
Feb
CF Hughes
15th June 2007
Mar
Apr
May
Jun
Jul
Month
Aug
Sep
Oct
Nov
Dec
CF Hughes
15th June 2007
Principal Incidents Types (PITs)
Oxygen Gases Vapours
Pathology Laboratory
Buildings Fittings Fixtures Surrounds
Security
Nutrition
Blood Blood Products
Complaints
Health Care Associated Infection Infestation
Aggression - Victim
Organisation Management Services
Medical Devices Equipment Property
Pressure Ulcer
Accidents Occupational Health and Safety
Documentation
Behaviour human performance
Aggression - Aggressor
Clinical Management
Medications IV fluids
Falls
Number of Notifications
14000
12000
10000
8000
6000
4000
2000
0
2500
2000
Number
1500
1000
500
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
Dec-05
Nov-05
Oct-05
Sep-05
Aug-05
Jul-05
0
Month
Falls
CF Hughes
15th June 2007
Medications
Clinical Management
Aggression - Aggressor
Behaviour / Human Performance
CF Hughes
15th June 2007
Top 25 medication involved
Metoprolol tartrate
Prednisolone
Cephalexin
Metronidazole
Buprenorphine hydrochloride
Fentanyl or its derivatives
Ceftriaxone sodium
Tramadol
Vancomycin hydrochloride
Gentamicin
Temazepam
Digoxin
Potassium chloride
Diazepam
Aspirin
Frusemide
Heparin sodium
Other
Enoxaparin sodium
Insulin
Methadone hydrochloride
Oxycodone hydrochloride
Warfarin sodium
Paracetamol
Morphine sulfate
Number of Notifications
400
350
300
250
200
150
100
50
0
7000
6000
Number of Notifications
5000
4000
3000
2000
1000
0
SAC 1
SAC 2
SAC 3
SAC Score
CF Hughes
15th June 2007
SAC 4
(blank)
CF Hughes
15th June 2007
Top 25 Specific Services
Medical Oncology
Haematology
Oncology
Obstetrics - Maternity
Palliative Care
Respiratory medicine
Neurology
Renal medicine
Rehabilitation (Stroke & Aged Care)
Paediatrics
Paediatric Oncology
Ambulatory Care
Surgical - Orthopaedics
Cardiology
Drug - Alcohol Services
Rehabilitation
Mental Health
Intensive care
Emergency medicine
Other
Surgical - General
Aged Care - Geriatrics
Pharmacy
(blank)
Medicine - General
Number of Notifications
1400
1200
1000
800
600
400
200
0
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
1
2 to 5
6 to 10
Number of doses or bags
CF Hughes
15th June 2007
Mor e than 10
(bl ank)
CF Hughes
15th June 2007
Time Band
Unknown time
23:00 to 23:59
22:00 to 22:59
21:00 to 21:59
20:00 to 20:59
19:00 to 19:59
18:00 to 18:59
17:00 to 17:59
16:00 to 16:59
15:00 to 15:59
14:00 to 14:59
13:00 to 13:59
12:00 to 12:59
11:00 to 11:59
10:00 to 10:59
09:00 to 09:59
08:00 to 08:59
07:00 to 07:59
06:00 to 06:59
05:00 to 05:59
04:00 to 04:59
03:00 to 03:59
02:00 to 02:59
01:00 to 01:59
00:00 to 00:59
Number of Notifications
1200
1000
800
600
400
200
0
CF Hughes
15th June 2007
Problems
Presentation
Undesired drug effect
during therapeutic use
Supply/ordering problem
Storage/wastage/security
Narcotic/controlled drug
discrepancy
Delivery problem
(blank)
Other
Dispensing problem
Prescribing problem
Administration
Number of Notifications
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Blood Transfusion Improvement Collaborative
CF Hughes
15th June 2007
Staff based solutions
CF Hughes
15th June 2007
CF Hughes
15th June 2007
CF Hughes
15th June 2007
CF Hughes
15th June 2007
Asthma
re-presentation rate
Baseline
%
Post Imp
With Plan
Without Plan
4
3
2
1
0
CF Hughes
15th June 2007
Representation
p = 0.01