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Creating a Culture of Creating a Culture of Safety to Reduce Safety to Reduce Medication Harm Medication Harm Megan Winegardner, Pharm.D. Megan Winegardner, Pharm.D. Medication Safety Coordinator Medication Safety Coordinator Henry Ford Hospital, Detroit MI Henry Ford Hospital, Detroit MI International Safety Symposium November 10 th , 2011

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Creating a Culture of Safety to Reduce Medication Harm. Megan Winegardner, Pharm.D. Medication Safety Coordinator Henry Ford Hospital, Detroit MI. International Safety Symposium November 10 th , 2011. Objectives. - PowerPoint PPT Presentation

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Page 1: Creating a Culture of Safety to Reduce Medication Harm

Creating a Culture of Safety to Creating a Culture of Safety to Reduce Medication HarmReduce Medication Harm

Megan Winegardner, Pharm.D.Megan Winegardner, Pharm.D.Medication Safety CoordinatorMedication Safety CoordinatorHenry Ford Hospital, Detroit MIHenry Ford Hospital, Detroit MI

International Safety Symposium

November 10th, 2011

Page 2: Creating a Culture of Safety to Reduce Medication Harm

ObjectivesObjectives Describe the incidence and severity of adverse drug Describe the incidence and severity of adverse drug

events in the United Statesevents in the United States Explain the differences between a Punitive Culture, a Explain the differences between a Punitive Culture, a

Blame-Free Culture, and a Just CultureBlame-Free Culture, and a Just Culture List steps that can be taken to establish a culture of List steps that can be taken to establish a culture of

safety to reduce medication harmsafety to reduce medication harm

Page 3: Creating a Culture of Safety to Reduce Medication Harm

Causes of Death in the USCauses of Death in the US

Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.

Page 4: Creating a Culture of Safety to Reduce Medication Harm

Adverse Events in Adverse Events in Hospitalized PatientsHospitalized Patients

13.5% of Medicare patients experience a 13.5% of Medicare patients experience a seriousserious adverse event during hospitalization adverse event during hospitalization (134,000 pts/month)(134,000 pts/month)

Most common causes:Most common causes: Medications (31%)Medications (31%) Ongoing patient care (28%) Ongoing patient care (28%) Surgery (26%)Surgery (26%) Infection (15%)Infection (15%)

• Bleeding

• Delirium

• Hypoglycemia

• Acute renal failure

• Hypotension

• Respiratory complications

• Allergic reaction

Office of Inspector General. Adverse events in hospitals: National incidence among Medicare beneficiaries. November 2010.

Page 5: Creating a Culture of Safety to Reduce Medication Harm

An An additionaladditional 13.5% of Medicare patients experience 13.5% of Medicare patients experience temporarytemporary harm during hospitalization harm during hospitalization

Most common causes:Most common causes: Medications (42%)Medications (42%) Ongoing patient care (36%) Ongoing patient care (36%) Surgery (18%)Surgery (18%) Infection (4%)Infection (4%)

50% of medication-related events considered 50% of medication-related events considered preventablepreventable

• Delirium

• Hypoglycemia

• Opportunistic infection

• Allergic reaction

• Others

Office of Inspector General. Adverse events in hospitals: National incidence among Medicare beneficiaries. November 2010.

Adverse Events in Adverse Events in Hospitalized PatientsHospitalized Patients

Page 6: Creating a Culture of Safety to Reduce Medication Harm

RecommendationsRecommendations Enhance patient safety leadership and knowledgeEnhance patient safety leadership and knowledge Use error reporting systems to learn from errorsUse error reporting systems to learn from errors Set performance standardsSet performance standards Create safety systemsCreate safety systems

Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.

Page 7: Creating a Culture of Safety to Reduce Medication Harm

Culture of Safety TimelineCulture of Safety Timeline

Before 1990sBefore 1990s Mid 1990sMid 1990s 2000s2000s

Punitive Culture Blame-Free Culture Just Culture

• Fear of retribution

• Decreased reporting

• Work-arounds

• Lack of accountability

Institute for Safe Medication Practices. Medication Safety Alert. Sept 7, 2006.

Page 8: Creating a Culture of Safety to Reduce Medication Harm

Just CultureJust Culture

Type of Behavior Description Suggested Response

Human Error Unintentional acts Console

At-Risk Short-cuts Coach

Reckless IntentionalSubstantial risk

Outside the norm

Discipline

Institute for Safe Medication Practices. Medication Safety Alert. September 21, 2006.

Page 9: Creating a Culture of Safety to Reduce Medication Harm

Type of BehaviorHuman error

At-riskReckless

Just CultureJust Culture

ResponseConsoleCoach

Discipline

During a busy shift, a pharmacist fails to check a patient’s renal function when entering an

order for an antibiotic. The patient is not harmed.

Page 10: Creating a Culture of Safety to Reduce Medication Harm

Type of BehaviorHuman error

At-riskReckless

Just CultureJust Culture

ResponseConsoleCoach

Discipline

A pharmacist inadvertently hits the zero key an extra time and enters an order for 100 mg instead of 10 mg. The patient receives an

overdose and must be transferred to the ICU.

Response is dictated by type of behavior, not outcome of patient.

Page 11: Creating a Culture of Safety to Reduce Medication Harm

Creating a Culture of SafetyCreating a Culture of Safety

1.1. Critically evaluate your reporting systemCritically evaluate your reporting system2.2. Increase medication safety incident reportingIncrease medication safety incident reporting3.3. Develop a system for follow-up of reportsDevelop a system for follow-up of reports4.4. Analyze incident report dataAnalyze incident report data5.5. Provide feedback to staff membersProvide feedback to staff members

Page 12: Creating a Culture of Safety to Reduce Medication Harm

1. Evaluating a Reporting System1. Evaluating a Reporting System Standard fields:Standard fields:

Patient Patient Date/time/locationDate/time/location Description of eventDescription of event OutcomeOutcome

Additional fields to consider for medication-related Additional fields to consider for medication-related eventsevents See NCC MERP Taxonomy of Medication ErrorsSee NCC MERP Taxonomy of Medication Errors Provides standard language and structureProvides standard language and structure

Page 13: Creating a Culture of Safety to Reduce Medication Harm

NCC MERP Taxonomy for NCC MERP Taxonomy for Medication ErrorsMedication Errors

Product InformationDosage form

PackagingDrug Class

Type of ErrorWrong drug

Wrong patientDose omission

CausesCommunicationName confusion

Labeling

Contributing FactorsLighting

InterruptionsStaffing

* Not an all-inclusive list National Coordinating Council for Medication Error Reporting and Prevention, 1998.

Page 14: Creating a Culture of Safety to Reduce Medication Harm

Maximizing OutputMaximizing Output Minimize free-text fieldsMinimize free-text fields

Lose ability to “pull” dataLose ability to “pull” data May be necessary for description of eventMay be necessary for description of event

Sortable/retrievable lists:Sortable/retrievable lists: Drug name (generic or brand)Drug name (generic or brand) Drug classDrug class Type of errorType of error Process node (prescribing, dispensing, administration)Process node (prescribing, dispensing, administration) Causes / contributing factorsCauses / contributing factors

Page 15: Creating a Culture of Safety to Reduce Medication Harm

2. Increasing Incident Reporting2. Increasing Incident Reporting

Classen DC et al. Health Affairs 2011;30:581-589.

Page 16: Creating a Culture of Safety to Reduce Medication Harm

Ideas to Increase ReportingIdeas to Increase Reporting Provide educationProvide education Set targetsSet targets Provide incentivesProvide incentives

Pharmacy Department Incident Reporting

Page 17: Creating a Culture of Safety to Reduce Medication Harm

3. Incident Report Follow-up3. Incident Report Follow-up Required follow-upRequired follow-up

Does a pharmacist review ALL medication incidents?Does a pharmacist review ALL medication incidents? Division of responsibilityDivision of responsibility

Large group: smaller workload, hard to spot trendsLarge group: smaller workload, hard to spot trends Small group: larger workload, easier to spot trendsSmall group: larger workload, easier to spot trends

Ensuring accuracy of information in reportEnsuring accuracy of information in report Example: severity level often too “high”Example: severity level often too “high” Garbage in = garbage outGarbage in = garbage out

Page 18: Creating a Culture of Safety to Reduce Medication Harm

4. Analyzing Your Data4. Analyzing Your Data Create a medication safety dashboardCreate a medication safety dashboard

January February March

Total # of reports

# of reports submitted by your dept.

# of high severity reports

Types of errors

Medication class involved

Process node

Patient location

Causes

Contributing factors

Type of response (system-based?)

Page 19: Creating a Culture of Safety to Reduce Medication Harm

Analyzing Your DataAnalyzing Your Data Create dashboard cross-tabs to answer questionsCreate dashboard cross-tabs to answer questions

Medication class most commonly reported to cause patient Medication class most commonly reported to cause patient harm?harm?

Medication class x “High severity” incidentsMedication class x “High severity” incidents Wrong patient errors occurring during medication Wrong patient errors occurring during medication

prescribing?prescribing? ““Wrong patient” error type x “Prescribing” process nodeWrong patient” error type x “Prescribing” process node

Compare yourself to national dataCompare yourself to national data USP MEDMARX databaseUSP MEDMARX database IHI 5 million lives campaignIHI 5 million lives campaign OthersOthers

Page 20: Creating a Culture of Safety to Reduce Medication Harm

5. Providing Feedback to Staff5. Providing Feedback to Staff Share examples of system-based changesShare examples of system-based changes

New manufacturer for look-alike vialsNew manufacturer for look-alike vials Change to instruction field of MARChange to instruction field of MAR

Create a medication safety annual reportCreate a medication safety annual report Summarize dashboard dataSummarize dashboard data Point out high risk medications, processesPoint out high risk medications, processes Identify areas for future quality improvement activitiesIdentify areas for future quality improvement activities

Establishes a non-punitive culture of openness, Establishes a non-punitive culture of openness, transparencytransparency

Page 21: Creating a Culture of Safety to Reduce Medication Harm

Creating a Culture of SafetyCreating a Culture of Safety

1.1. Critically evaluate your reporting systemCritically evaluate your reporting system2.2. Increase medication safety incident reportingIncrease medication safety incident reporting3.3. Develop a system for follow-up of reportsDevelop a system for follow-up of reports4.4. Analyze incident report dataAnalyze incident report data5.5. Provide feedback to staff membersProvide feedback to staff members

Page 22: Creating a Culture of Safety to Reduce Medication Harm

ChallengesChallenges Criminal penalties for medication errorsCriminal penalties for medication errors

2006: 2006: Wisconsin nurse charged with criminal neglect for an epidural Wisconsin nurse charged with criminal neglect for an epidural

error that resulted in the death of a pregnant patienterror that resulted in the death of a pregnant patient 2009: 2009:

Ohio pharmacist sentenced to prison for a chemotherapy error Ohio pharmacist sentenced to prison for a chemotherapy error that resulted in the death of a childthat resulted in the death of a child

www.ismp.org

Page 23: Creating a Culture of Safety to Reduce Medication Harm

Creating a Culture of Safety to Creating a Culture of Safety to Reduce Medication HarmReduce Medication Harm

Megan Winegardner, Pharm.D.Megan Winegardner, Pharm.D.Medication Safety CoordinatorMedication Safety CoordinatorHenry Ford Hospital, Detroit MIHenry Ford Hospital, Detroit MI

International Safety Symposium

November 10th, 2011


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