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Medication Errors & Safety Practices
Transcript of Medication Errors & Safety Practices
PHPR 490 Introduction Prevalence, Cause, & Impact Errors in Prescribing Errors in Transcribing Errors in Dispensing Errors in Administration & Monitoring Root Cause Analysis Reporting Med Errors Road Map
Where are we going? Current State of Med Safety Practices System Errors That Lead To Med Errors Social Impact
Patients' health at risk
Friends/family experience emotional pain
Health care providers experience guilt and loss of confidence # of deaths due to AEs > # of deaths caused by MVA, breast cancer, or AIDS ~1.3 million people in U.S. are injured/year by medical treatments;
180,000 die from these accidents 99.9% success rate?
Major plane crash every 3 days
107 erroneous med procedues/day Patient Information Modes of Communication Prevalence, Cause, & Impact Social and Economic Impacts of Med Errors Drug Information Economic Impact
Extended hospital stay
Loss of productivity of patients and healthcare staff
Total national costs for adverse events = $37.6 billion to $50 billion Quality processes and risk management Enviromental factors
& staffing patterns Staff competency
& education Drug labeling, packaging, and nomenclature Drug standardization, storage, and distribution Drug Information ISMP's 10 Key Elements of the Medication System Patient Information Patient Education Communication related to medication Medication delivery device acquisition, use, and monitoring Complete list can be found at: http://www.ismp.org/Tools/errorproneabbreviations.pdf http://online.wsj.com/article/SB10001424052748703626604575010932945077528.html Support a culture of safe medication use Include medication history-taking and reviews upon entry into the organization; medication counseling and training during the discharge process; and follow-up after the transition to home Have daily meetings, with the primary focus on safety and quality issues Spark Establish systems to ensure organizational awareness of medication safety gaps Steps for Pharmacy Leaders Past ADEs Burgess LH, Cohen MR, Denham CR. A new leadership role for pharmacists: a prescription for change. J Patient Saf 2010;6:31-37. Perform safety walk-rounds to evaluate medication process, and request front-line staff's input about medication safety practices Prevalence, Cause, & Impact Errors in Prescribing Medication Error Prescription Error Dispensing Error High risk medications Estimated that each hospitalized patient in America experience 1 medication error every day Account for ~20% of all medical errors in inpatient institutions reduces the probability of treatment being timely & effective Most common;make up 39-49% of medical errors Doing something wrong Failing to do the right thing involving medications Leads to an undesirable outcome Significant potential for such an outcome What is a Medication Error? What impact (i.e. social, economical, etc.) does this Josie King’s story have?
As a pharmacy student and future pharmacist, what specific actions can pharmacists take to improve Josie’s situation? Reflection Dispensing Transcribing Prescribing The Medication
Use Process Administering Monitoring ~ 1 of 131 patient deaths is attributable to a medication error Often result of failure of communication between prescribers and pharmacists Achieving
I.E. DO I DOPE? 5 Rights Indication Effectiveness Diseases Other similar drugs Interactions Dosage Orders Period Economics Reducing Inappopriate Prescribing Patient education
Avoid inappropriate meds
Utilize EMRs, MARs, and CPOE
Implement clinical pharmacy services to provide drug info services and perform medication reconciliation - shown to reduce errors by 13-51% Of the prescribing elements, which could you have the most impact on and how? Reflection Transciption Errors Written Verbal 15 vs. 50 Fentanyl drip 5,200mcg per hour vs. Fentanyl drip 50 to 100mcg per hour 20 mg of hydromorphone in 250 mL normal saline (80 mcg/mL) entered instead of 2 mg (8 mcg/mL)
The bag was mislabeled as 8 mcg/mL and nursing did not catch the mistake prior to administration because the concentration matched the original order
70 year old patient received x10 overdose Dilaudid
Cause: Misinterpreted circle around prescriber’s initials as a zero Handwritten order for LIPITOR mistaken for ZYRTEC Each group receives a common problem that leads to transcription errors Other groups - try to identify the error, causative factors, and solutions presented Design a skit - act out:
Solutions Spark Focus skit/presentation on the following:
Ways to improve or resolve the error Form groups of 3 - 4 people Small Group Exercise Errors in VERBAL Order Transcription Problems Overuse of spoken orders Causes:
Misunderstanding of prescriber's accent or pronunciation
Patient's having same/similar names How to Improve:
Limit # of people recieving telephone orders
Be redundant: read orders back, spell drug names, ask for indications Cause: Convience/Habit Cause: Lack of access to patient record How to Improve:
Improve access Cause: Chart unavailable = delayed transcription & possible mental slips Cause: Trancription onto wrong chart How to Improve:
Simplify: Document directly into med record; 5 Rights
Be redundant: Verify patient's identity Mis-transcribed spoken orders Misheard or misinterpreted Errors in WRITTEN Order Transcription Problems Marks on order forms Causes:
Incorrect med hx
Med profile not updated Causes:
Incorrect manual data entry
Interruptions How to Improve:
Electronic Rx systems
Perform med rec
Prevent interruptions Causes:
Coorection of an error How to Improve:
Correct errors w/ single line
Designate areas for initials
Provide areas for checkmarks Cause:
Similarity or even identical physical characteristics
Not even space between drug name and drug strength How to Improve:
Use lower case consistently
Use mixed case letters for LASA drugs How to Improve:
Space between name and dose Misidentification of alphanumeric symbols Mistranscribed drug regimen details EMR, eMAR, CPOE Prevention Introduce a punishment-free system Lead by example Of the prescribing elements, which could you have the most impact on and how? Reflection Prescribing Errors Transcibing Errors Dispensing Errors What errors can occur? Wrong route Wrong quantity/ wrong verbal information to patient Error causing death Error causing harm Potential for harm (potential ADE) Classification of Dispensing Errors Circumstances that have the capacity to cause error Expired medications identified on the shelf Omission Error causing no harm 650 mg APAP dispensed when 325mg ordered Dispensed medication to patient with known serious allergy Heparin 10units/mL ordered -
10,000 units/mL dispensed Why Do Errors Occur? Because of human factors! Because we have poor workflow! Because of transcribing errors! Different
perspectives vs. Expired med Wrong dosage form Strategies for Improvement Name one thing/process you could implement in a pharmacy setting to prevent these types of errors. Reflection Errors in Administration & Monitoring Because this is just the tip of the iceburg Harm to a Patient This is a huge mountain Published in ISMP's Medication Safety Alert! on January, 13 2011 Remember me? 5 Rights What if I go wrong? Types of Admin Errors Wrong patient Wrong Medication Wrong Route Different routes have the same container or med bin Unclear labeling or stickering Nurses have multiple patients Meds placed in wrong patient's bin/room Barcoding AFTER administration Medication pulled from override out of med cabinet Medication cabinet improperly loaded More Admin Errors Wrong Rate Wrong Dose Wrong Time Reminders not
busy Nurses do not know critical medications No standardization Dose limits not set or turned off Bolusing of wrong IV bag Not verified properly Wrong
concentration Why do we need too... collect patient information? (allergies, lab values, age, height, weight, etc) monitor the patient? (BP, pain score, nausea, fever?) communicate? (tell patients what they're receiving and why, document adminstration and doses held, document floor transfers and mising doses) pay attention to labeling, packaging, and nomenclature? Assess Your Knowledge Adverse Drug Effects (ADEs) are the ... leading cause of death in the United States? 15,000 150,000 150 million Day Week Month 3rd 4th 5th One person dies each ...
as a result of medication errors Pharmacists make more than... calls to doctors offices every year to clarify what was written on the paper prescription MJ is a 32 year old Female admitted to OSH for a full hysterectomy due to advanced cervical cancer found 3 months prior. The operation with smoothly and the patient was sent to the floor following the surgery. The nurse received orders for MJ for a Fentanyl 10mcg/mL at a rate of 50mcg/hr and 1/2NS at 100ml/hr. The nurse verified the medications against the order and they were correct. The pharmacy had also made the fentanyl correctly. The nurse set the IV pump correctly…..However, her tubing got switched when connecting to the pump and Fentanyl was administered at the rate of her IV fluids. SB was a 57-year old man suffering from acute lymphoblastic lymphoma. The intravenous injection of vincristine and daunorubicin together with intrathecal administration of methotrexate, cytosinarabinoside and dexamethasone should happen. Unfortunately the syringe for intrathecal injection was missing and the resident took the syringe with vincristine. Immediately after realizing the error, therapy was started. However the patient also developed ascending paralysis, sensory and motor dysfunction and died 4 weeks later. The resulting respiratory failure has occurred despite the use of thorough flushing of the subarachnoid space along with other intensive supportive care. SJ was a 46 year old male admitted to the SICU after receiving an invasive whipple surgery. While admitted to the SICU he developed a DVT despite prophylactic anticoagulation. He was started on a hospital protocol of Heparin that requires q4h testing and adjustment to rates according to aPTT. However the computer never flagged the nurse to take an aPTT and the patient was maintained on the same drip rate of Heparin without adjustments. As a result the patient’s aPTT became supertherapeutic and the patient developed a severe intra-abdominal hematoma requiring emergency surgery. GR was admitted to the MICU for septic shock. During a routine examination the resident noticed that the patient was posturing and showing extreme abdominal discomfort. In addition the examination showed the abdomen was distended and hard. Due to this finding, the resident ordered PO contrast to be given and a CT scan of his abdomen. The CT was given, but the patient never received contrast. The CT was read, but was found to be inconclusive due to poor imaging. The patient coded later that evening and passed away. The autopsy showed that the patient had a perforated colon which was the source of the patients sepsis. Patient Cases How would you communicate with the patient the importance of follow-up? Reflection Root Cause Analysis Why?
No limits were set for pediatric patients in the computerized IV system Result
Hospital has been free of dosing errors for 3 months Why?
The hospital did not have a medication safety committee in place to monitor such issues. Sentinel Event
Pediatric patient received fatal dose of medication Solution
Hospital formed a medication safety committee and set guiderails for pediatric dosing in TPNs Why?
Pharmacist entered 300mg of zinc into TPN bag; order was for 300mcg.
Blame her? Example What: a step by step questioning to identify basic or causal factors of an error or "near miss"
When: Used in a health care setting when an adverse event needs to be understood or a sentinel event needs to be prevented. Stress, fatigue, & hastle Assumptions & Distractions Resources & Constraints "Blunt End"
Why did it happen?
What can be done to prevent it from happening again? Organizations, Policies, & Culture "Sharp End"
Patient Required components:
Needs to focus on systems - not people - no blaming
Digs deep - ask why x 5
Stimulates re-design/new system
Participation/support from leadership and by individuals most closely involved with the incident being reviewed.
Everyone should: be professional; be open minded; speak candidly; be honest; & keep all information confidential Understand
of actions Identify root causes vs. contributing factors Develop a Risk Reduction Plan Gather the facts using a timeline and interviews Basic Steps of RCA Disclosing Medical Errors What do patients want to hear... how do they want to hear it? Ensure the conversation takes place in a private setting
Ascertain what information the patient already may have
Convey the information in simple terms Identify and offer support
Let the patient/family know the follow-up plan
Express appropriate regret
If the event is serious, have the meeting as soon as possible Error Reporting Error Reporting Knowledge & Accountability WHEN Should Errors Be Reported? WHERE Should Errors Be Reported? How to encourage reporting?