CYNTHIA TURNERMEDICATION SAFETY PHARMACIST

VANCOUVER ISLAND HEALTH AUTHORITYBCPSQC QUALITY FORUM 2012

CYNTHIA.TURNER@VIHA.CA

High Alert MedicationVariance Tool

Disclosure Statement

nothing to discloseno involvement with industry/

organizations that may potentially influence the presentation of the educational material

cannot identify any potential conflict of interest

The problem: ROPs vs. VIHA reality

Accreditation Canada ROPs state: There are no concentrated electrolytes stored in client service areas The organization has removed (exceptions include palliative care):

HYDROmorphone inj concentration > 2 mg/mL morphine inj concentration > 15 mg/mL

VIHA Reality: Pharmacies not open 24/7 Remote locations serviced by other facilities ~ 3 day delay Timely access of High Alert Meds critical

Morphine ordered in opioid naïve patientHYDROmorphone 10 mg/mL selected instead

of morphine 10 mg/mL - errorPt respiratory arrest Naloxone administered - pt recovered

VIHA HYDROmorphone event

69 units had as ward stock61 units had removed

= Removed from 88% of wards

High Alert HYDROmorphone = injection greater than 2 mg/mL

High Alert HYDROmorphone

8 remaining wards applied for a variance to carry as ward stock

Aim: QI initiative ~ Variance Tool

A documented process that can be applied consistently and objectively across all areas

Allows program to self-evaluate RISKMitigate the risk with CONTROL

STRATEGIES

Risk Matrix – assess the Risk

VARIANCE DOCUMENTStep 1: Identify the need

High Alert Med

Accreditation standard

Unit describes WHY they NEED the high alert med

Step 2: Outline risks

What risks How occur Impact if occurredRequest

Alternative 1 What risks How occur Impact if occurred

Alternative 2 What risks How occur Impact if occurred

Step 3: Control Strategies, Monitoring

RemindersConstraintsStandardize and simplifyImprove access to infoEducationIndependent Double Checks

Regular monitoring e.g. weekly/monthly

Program Manager signature

Program Physician signature

Medication Safety Pharmacist Review

Variance submission

Collaborative processExecutive team notifiedReviewed by Med Safety Quality CouncilApproved variance audits

6 month audit 12 month review

Medication events reported/PSLS

Quotes – tool helps decision making

“We have to do what to get the meds?”

“I don’t think our nurses have any idea what it takes to get these meds as wardstock”

“If removing high potency HYDROmorphone prevents one nurse from crying in my office, because of a mistake she made, let’s do it!”

Overall impact of the intervention

Hypertonic saline variances23.4% - 1 unit in VIHA14.6% - 2 units in VIHA3% - 9 units in VIHA

High potency opioid variancesHYDROmorphone – 8 units in VIHAMorphine – 6 units in VIHA

Accreditation Surveyor accepted