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