medication error in hospital

8/14/2019 Medication Error in Hospital

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High Alert Medications:

Reliable Methods to EnsureSafer Use

Christian Hartman, PharmDMedication Safety Officer

Assistant Professor of Medicine


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Organization Profile

UMass Memorial Medical Center - Worcester, MA

834 bed academic medical center

Multi-campus system

Level 1 trauma center

Level 3 NICU

2008 Winner ISMP CHEERS Award

2008 Winner ASHP Affiliate Pharmacy of the YearAward

Last Joint Commission Survey - Nov 2008 No Medication Management RFIs


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Objectives

Define high-alert medications according to

TJC, IHI, and ISMP

Discuss accreditation and regulatoryrequirements for high-alert medications

Outline error prevention, identification, and

mitigation strategies and best practices


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Everybody gets so much information all

day long that they lose their common

sense.- Gertrude Stein


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Statistics

1.5 million preventable adverse drug events (ADEs) occur each yearin the United States.

Of 221,000 medication errors reported via MEDMARX 1998-2005 inthe perioperative setting:

80% of the medication errors that result in patient harm are caused by20% of medications administered by practitioners.

The leading medications involved: Insulin 11.3% Morphine 2.3%

Heparin 3.5% Fentanyl 2.9% Hydromorphone 2.7%

Committee on Identifying and Preventing Medication Errors. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, Editors.

Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; July 2006.


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Alphabet Soup


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Definitions

IHI - medications that are most likely to causesignificant harm to the patient, even when usedas intended

TJC - medications that have the highest risk ofcausing injury when misused

ISMP - mistakes may not be more common inthe use of these medications; when errors occur

the impact on the patient can be significant


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Standards: Institute for Safe

Medication Practices (ISMP) limit access to high-

alert medications auxiliary labels and

automated alerts

standardize ordering,storage, preparation,and administrationemploying

redundancies such asautomated orindependent double-checks


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Standards: The Institute for

Healthcare Improvement (IHI) 5 Million Lives Campaign

Goal: reduce harm from high-alert

medications by 50% by December 2008

Aim: Anticoagulants, Narcotics and

Opiates, Insulin, Sedatives


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Standards: The Joint

Commission (TJC) National Patient Safety Goals

NPSG 3

Medication Management MM 01.01.03

MM 03.01.01

MM 08.01.01


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TJC Requirements: NPSG

03.03.01 The hospital identifies and, at a minimum, annually

reviews a list of look-alike/sound-alike medications usedby the hospital and takes action to prevent errorsinvolving the interchange of these medications

EP1: The hospital identifies a list of look-alike/sound-alikemedications used by the hospital. The list includes a minimum of10 look-alike/sound-alike medication

EP2: The hospital reviews the list of look-alike/sound-alikemedications at least annually

EP3: The hospital takes action to prevent errors involving theinterchange of the medications on the list of look-alike/sound-alike medications

Joint Commission: 2009 Hospital Accreditation Manual.


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TJC Requirements:

MM 01.01.03 The hospital safety manages high-alert and

hazardous medication EP1 - The hospital identifies, in writing, its high-alert

medications

EP2 - The hospital has a process for managinghigh-alert medications

EP3 - The hospital implements its process formanaging high-alert medications

EP4 - The hospital minimizes risks associated withmanaging hazardous medications



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TJC Requirements:

MM 03.01.01 The hospital safety stores medications

EP9 - The hospital keeps concentrated electrolytes

present in patient care areas only when patientsafety necessitates their immediate use and

precautions are used to prevent inadvertent

administration



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TJC Requirements:

MM 08.01.01 The hospital evaluates the effectiveness

of its medication management system. EP5 - Based on analysis of its data, as well as review of the

literature for new technologies and best practices, the hospitalidentifies opportunities for improvement in its medication

management system

EP8 - The hospital takes action when planned improvements

for its medication management processes are either not

achieved or not sustained



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TJC Sentinel Event Alerts

Issue 41 September 24, 2008: Preventing errors relating to commonly

used anticoagulants

Issue 39 - April 11, 2008: Preventing pediatric medication errors

Issue 34 - July 14, 2005: Preventing vincristine administration errors

Issue 33 - December 20, 2004: Patient controlled analgesia (PCA) byproxy

Issue 23 - September 1, 2001: Medication errors related to potentially

dangerous abbreviations

Issue 19 May 1, 2001: Look-alike, sound-alike drug names


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Where do we begin?

Specific medications

General drug classes

Specific processes Specific patient populations


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Specific Medications: Insulin

MEDMARX - 9,135 errors in perioperativesetting; 4.2 % causing harm

Problem-

Multiple products available Look alike sound alike names and products

Abbreviations (Lantus 15Units)

Difficult dosing regimens

Hicks RW, Becker SC, Cousins DD. MEDMARX Data Report: A Chartbook of Medication

Error Findings from the Perioperative Setting from 1998-2005. Rockville, MD: USP Center forthe Advancement of Patient Safet .


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Specific Medications: Opiates

Largest category of drugs associated with

error related deaths

Problem-

Name confusion (oxycodone vs oxycontin)

Dose conversion (morphine vs. dilaudid)

Overlapping regimens

Multiple dosage forms (PO, IV, TD, etc)

Koczmara C, Hyland S.. Preventing narcotic associated adverse events in critical care units.

Dynamics 15:7-10, Fall 2004.


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Specific Medications:

Anticoagulants Bates and colleagues report that anticoagulants

accounted for 4% of preventable ADEs and 10%of potential ADEs.

Problem- Multiple products (Heparin) Difficult dosing regimens

Abbreviations (Heparin 5000Units)

Look alike sound alike names and products (Heparinvs. Hespan)

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse

drug events: Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34.


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Concentrated Electrolytes 5 to 10 patients die annually due to

concentrated KCl in the United States

Reversal is difficult

Problem-

Access and storage

Procurement

Joint Commission Resources: Reducing the risk of errors associated with concentrated

electrolyte solutions. Joint Commission: The Source 6:1-2, Mar. 2008.


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Specific Medications: Sedation

Sedation is a continuum and often difficult topredict patient response; types (1) minimal, (2)moderate, (3) deep, (4) anesthesia

Problem- Dosing confusion (ie midazolam onset ofaction)

Inappropriate monitoring

Expertise, qualification, and credentialing ofstaff

High-Alert Medications: Strategies for Improving Safety. Joint Commission Joint Commission

Resources.


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Specific Medications: NMB

According to USP, there have been morethan 50 reports of significant misuse ofNMB

Problem- Improper storage (ICU vs floor)

Look alike sound alike (Vanco vs Vec)

Inappropriate monitoring Medication use process

Smetzer JL. Preventing errors with neuromuscular blocking agents. Jt Comm J Qual Patient

Saf 32: 56-59, Jan. 2006.


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Adrenergic Agents Ben Kolb - syringe that was supposed to

contain lidocaine actually contained

epinephrine

Problem-

Look alike sound alike names and packaging

Multiple manufacturers

Large vial sizes


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High Risk Processes: Oncology

In the US, 1.2 million are diagnosed withcancer each year; 48,000 experiencesome type of adverse event

Problem- Selection/procurement/storage

Ordering and monitoring

Transcribing Preparation and administration

Joint Commission Resources: Medication safety with the use of chemotherapy agents. Joint

Commission Perspectives on Patient Safety. 8:1-5, Mar. 2008


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High Risk Processes: Pediatrics

Similar medication error rates as adults butthree timesthe potential to cause harm

Over 50% of new approved medications have not hadsufficient pedi research

Problem- Complex regimens and dosing

Medication preparation

Immature ability to metabolize

Lack of communication

Joint Commission Resources: Preventing pediatric medication errors. Joint Commission

Perspectives on Patient Safety. 7:5-6, Sept. 2007


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High Risk Processes: Elderly

Insulin, warfarin, and digoxin were implicated in one in

every three estimated ADEs treated in ED and 41.5% of

estimated hospitalizations

Problem-

Altered metabolism

Decreased renal function

Polypharmacy

Communication and technology

Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency

department visits for outpatient adverse drug events. JAMA. 2006;296:1858-1866.


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"Anyone can make the simple

complicated. Creativity is making the

complicated simple."- Charles Mingus


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Strategies for Success

General recommendations for all

medications and processes

Specific recommendations for select

medications

Additional recommendations


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Design Process to Prevent

Errors and Harm Standardize order sets, preprinted order forms,

clinical pathways

Standardize concentrations and dose strengths

Reminders about appropriate monitoringparameters

Consider protocols for vulnerable populationssuch as the elderly, pediatric, and obese

patients

5 Million Lives Campaign. Getting Started Kit: Preventing Harm from High-Alert Medications.

Cambridge, MA: Institute for Healthcare Improvement; 2008.


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Design Methods to Identify

Errors and Harm Ensure that critical lab information is available to those

who need the information and can take action

Implement independent double-checks where

appropriate

Instruct patients on symptoms to monitor and when to

contact a health care provider for assistance




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Methods to Mitigate Harm

Develop protocols allowing for the

administration of reversal agents without

having to contact the physician

Ensure that antidotes and reversal agents

are readily available

Have rescue protocols available




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How do we make mistakes?

-Exercise

Two teams

Team 1 count bounce passes for

players in WHITE shirts

Team 2 count chest passes for players

in WHITE shirts

http://viscog.beckman.uiuc.edu/flashmovie/15.php
http://viscog.beckman.uiuc.edu/flashmovie/15.phphttp://viscog.beckman.uiuc.edu/flashmovie/15.php


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Changing Practice/Behavior

Forced Functions

Constraints

Check lists/pathways Policy

Guidelines

Education


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General Recommendations:

Anticoagulants Format anticoagulation orders to follow the patient

through transitions of care

Use an anticoagulant dosing service or "clinic" ininpatient and outpatient settings

Use ONLY oral unit-dose products and pre-mixedinfusions as available

Staff training and competency assessment

Conduct an Antithrombotic Therapy Self-assessment or

FMEA http://www.ismp.org/selfassessments/asa2006/Intro.asp


http://www.ismp.org/selfassessments/asa2006/Intro.asp


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Patient Information

Drug Information

Communication of Orders

Storage

Device Use Staff Competency

Patient Education

Risk Assessment


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Specific Recommendations:

Heparin Weight-based heparin protocol/nomogram

Preprinted order forms or ordering protocols

Account for the use of thrombolytics and GIIg/IIIainhibitors

LMWH and Heparin conversion standards Standard concentrations

Separate like products

Hep-flush ordered and available in syringe

Monitoring parameters are implemented




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S f


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Warfarin Narrow therapeutic index - centralized dosing

and monitoring service

Standardize dosing, monitoring, reversal

Minimize available strengths; no tablet splitting Nutrition consult for patients on warfarin to avoid

drug/food interactions

Patient education and follow-up



G l R d i


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General Recommendations:

Opiate and Narcotics Standardize protocols

Monitoring for adverse effects of narcotics andopiates

Protocols for reversal agents Centralized pain services

Independent double-checks

Minimize multiple drug strengths and

concentrations where possible Mutual pain assessment and toileting



S ifi R d ti


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Insulin Eliminate or standardize sliding scales

Independent double-check

Pre-printed insulin infusion orders and flowsheets

Separate LASA; standardize manufacturer

Prepare all infusions in the pharmacy

Standardize to a single concentration for IV

Safeguards on high-dose insulin concentration; reversalprotocols




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Concentrated Electrolytes Eliminate storage on patient care units when

possible

Segregate bulk supplies within the pharmacy

Secure after hours access to medicationsupplies

Utilize premix/pre-packaged where feasible

Auxiliary labeling and packaging

Pop-up warnings/alerts in ADM


Resources.


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S ifi R d ti


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Sedation Stock only one concentration of moderate sedation

agents

Preprinted order forms/sets

Monitor all children on chloral hydrate

Age/size appropriate resuscitation equipment

Adequately trained personnel

Fall prevention program


Resources.

S ifi R d ti


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NMB Secure/segregate storage

Restrict access to ICU, ED, OR only

Auxiliary labeling and packaging

Alerts and pop-up warnings Do not store on unit dose cart/ADM matrix

drawer; ADM single item only

Standardize formulary and prescribing

Prompt removal of product after D/C


Resources.htt ://www.ism -canada.or /download/caccn/CACCN-S rin 07. df


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Adrenergic Agents Premixed solutions and prefilled syringes when

feasible

Standardize concentrations

Apply LASA standards Standardize ordering (ie do not use titrate to

effect)

Extravasation policy and kit

Utilize different manufacturers when feasible toensure packaging looks different


Resources.

S ifi R d ti


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Oncology Procurement/Dispensing - standardize

Storage - physical separation, negative pressure room,

LASA

Ordering - standard order sets, CPOE, ordering policy,

dose limits, pair with protocols, forced - weight, blood

counts

Transcribing - prohibit verbals if possible, transcription

policy, independent verification


Resources.

S ifi R d ti


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Oncology Preparation/Dispensing - independent verification, check offs, staff

protection (USP 797, closed systems, etc), labeling

Administration - independent verification of new starts/rate

changes/etc, smart pumps, clearly marked catheters

Monitoring - interdisciplinary monitoring, standard orders for

laboratory monitoring, cumulative dose


Resources.

Specific Recommendations


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Pediatric Segregate medications from adult storage areas

Standardize concentrations

Compounding and dilutions should occur within thepharmacy

Oral syringes for oral liquids Patient specific unit dosing provided by pharmacy

Mandatory weights and ongoing assessment

Pediatric P&T Committee and formulary

Ordered using weight based formula (mg/kg) Visual cues for pediatric orders and records


Resources.


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Elderly Polypharmacy assessment

Concurrent renal dosing monitoring

program

Comprehensive falls risk assessment

Adoption of Beers criteria and mitigation

strategies


Resources.


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Beers List

Donna M. Fick, James W. Cooper, William E. Wade, Jennifer L. Waller, J. Ross Maclean, and Mark H. Beers. Updating the Beers

Criteria for Potentially Inappropriate Medication Use in Older Adults: Results of a US Consensus Panel of Experts. Arch Intern Med,

Dec 2003; 163: 2716 - 2724.

Additional Recommendations:


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Dedicated Teams Anticoagulation management team

Interdisciplinary pain management team

Dedicated pediatric and oncology

coverage

Annual risk assessment team - Failure

Mode and Effect Analysis


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Technology Computerized Practioner Order Entry/ePrecribing Bar Coded Medication Administration (BCMA)

Dispensing verification

RFID

Smart Pumps

Medication carousel

Electronic, real-time surveillance of trigger drugs, labs,etc


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Clinical Surveillance


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A Robust Program

Analyzes medications and processes

Applies standards and regulations

Develops strategies to prevent, Identify,

and mitigate errors and harm

Utilizes technology when feasible

Engages the patient and family


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Contact Information

[email protected]

The American Society of Medication Safety Officers

www.asmso.org

www.twitter.com/ChrisHartman
mailto:[email protected]://www.asmso.org/http://www.twitter.com/ChrisHartmanhttp://www.twitter.com/ChrisHartmanhttp://www.asmso.org/mailto:[email protected]

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