medication error prevention in 2014
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Medication Error Prevention in 2014. Wendy Perry, Pharm.D . September 28, 2013. Objectives. Describe a Medication Safety Officer’s responsibilities. List new safety challenges that are a result of technological advances. Discuss the mechanisms for obtaining medication error data. - PowerPoint PPT PresentationTRANSCRIPT
Medication Error Prevention in 2014Wendy Perry, Pharm.D.
September 28, 2013
Objectives• Describe a Medication Safety Officer’s
responsibilities.• List new safety challenges that are a result of
technological advances.• Discuss the mechanisms for obtaining medication
error data.• Describe a data analysis process and appropriate
follow up.• Define “Just Culture.”• Discuss methods to reduce medication errors.
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Why Medication Error Prevention in 2014?
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Medication Safety Officer
Job Description– Guide and coordinate the organization’s medication
safety activities– Analyze data to identify trends and recommend
priorities– Examine entire medication use system– Engage key stakeholders– Knowledge expert on committees– Present educational sessionsLarson CM, Saine D. Medication Safety Officer’s Handbook. ASHP;2013
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New Technology Safety Challenge
Computer Prescriber Order Entry (CPOE) andClinical Decision Support (CDS)
Alert fatigueUnforeseen challenges
Bar Code Medication Administration (BCMA)
WorkaroundsMissing or incorrect barcodes
Automated Dispensing Cabinets (ADC) Non-profile areasVolume of barcodesMaintenance of alertsOverride lists
Smart IV Pumps Bypassing drug library
Robotics System integration
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Computerized Provider Order Entry (CPOE) and Clinical Decision Support (CDS)
• Pros– Decreased number of steps in the medication
process, pre-populated fields, etc. improves safety– Provision of clinical info related to allergy, dose,
duplicate therapy, etc. improves safety• Cons
– Complicated screens– Easier to make incorrect choice in patient, drug
sentence– Alert fatigue
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Post – CPOE1 st PSE received: Wrong PatientOrder for insulin received by pharmacist who was
familiar with patient and recognized not appropriate
Wrong patient was selected by MDPrevention methods:
Only one patient MR open at onceCreate patient list
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Bar Code Medication Administration (BCMA)• Background
– 34% of all med errors occur in administration– 50% of hospitals in 2011– 25% of nursing time spent on med-related activities
• Prospective before and after observational study– 386 bed academic teaching hospital– 2 medical-surgical units, 2 ICUs– Med admin errors assessed by comparing observed med
administered to med intended for that patient
Helmons PJ. Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. Am J Health-Syst Pharm. 2009;66:1202-10.
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Results
• Error rate = # of errorstotal opportunities
for error• Separated wrong time errors from other errors• Med-surg: overall 8% to 3.5% (p<0.0001)
omissions 4% to 1% (p<0.0001)ICUs: NS, charting compliance improved
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14Raising the Bar for BCMA: Addressing Pharmacy Challenges, NursingEngagement, and Data Analysis to Improve Practice; Beaumont Hospital; ISMP Webinar 2013.
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BCMA Safety Opportunities
• Scanning omissions• Bypass alert• Work-arounds
– Barcode copies– Wrong time
• Front or back scanning for convenience, patient availability• To complete documentation
– Wrong reason chosen
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Automated Dispensing Cabinets (ADC)• Non-profile units• Override medications• Incorrect medication fill – decreased with bar
codes– Spill over– LASA medications– Replacement by nurses– Quantity to be scanned
• Alert fatigue
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Smart IV Pumps
• Override functionality – drug libraries are the core safety feature
• Alert fatigue• Lack of interface
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Tools to Identify Safety Needs• Voluntary reporting data• Trigger tools• Culture surveys• Published literature and reporting sources• Walk around• Pharmacist clinical interventions• Med administration BCMA scan failures• Bypassed alerts and overrides• Failure mode and effects analysis (FMEA)
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Voluntary Reporting
• Reported medication error rates are simply a measure of the ability of the organization to recognize and report medication-related problems.
• Therefore, an organization with a large number of error reports may actually (and in many cases is likely to) have a lower true underlying medication error rate than an organization where few reports are received, analyzed, and acted on.
Larson CM, Saine D. Medication Safety Officer’s Handbook. ASHP;2013
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Specific Event TypeMandatory: YesPick List Values (Single-pick)
• Adverse Drug Reaction• Administration Technique
Incorrect• Dose Incorrect• Drug With Known Allergy• Medication Administered Not
Ordered• Narcotic Count Incorrect• Illegible Order• Time Incorrect/Delayed• Outdated/Unusable
Medication
• Drug Incorrect• Monitoring Issue • Patient Incorrect• Omission• Route Incorrect• Storage Incorrect• Drug Preparation Issue• Pump Programming Issue• Documentation Error• Other (please specify)
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Contributing Factors Mandatory: No Pick List Values (Multi-pick):
• Communication/Handoff Failure
• Competency of Staff• Lack of Training/Education• Insufficient Staff• Action by Family Member/Caregiver• Action by Patient• Policy/Procedure Issue• Physical Environment
Condition/Design• Insufficient Monitoring/Supervision• Work Environment-Fatigue• Language Barrier• Administration Issue/Calculation
Error• Drug Name Confusion(e.g. Look
Alike & Sound Alike)
• Medication Not Available• Distractions/Interruptions Monitoring –
Vital Signs Not Checked• Patient Unavailable• Incomplete/Ambiguous Order• Preparation – Delayed Delivery• Preparation – Wrong
Drug/Dose/Strength• Transcription Issue – Incorrect
Computer Order Entry• Transcription – Order Not Entered In
Computer System• Drug Info Missing – Inadequate
Medication Reconciliation Process• Patient Info Missing – Allergies• Patient Info Missing – Lab Values• Patient Info Missing – Weight• Other (please specify)
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ADR vs ADE
• Medication ErrorA preventable error occurring in any step of the
medication process• Adverse Drug Event
An undesirable occurrence associated with a medication
• Adverse Drug ReactionAn idiosyncratic reaction or other adverse effect of a
medication that is not preventable
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MedErrors
ADEADR
Near Miss
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Interpretation
• Near Misses are Med Errors– Caught by chance– Caught by following a safety process
• ADRs are not Med Errors– All ADRs are ADEs– Not all ADEs are ADRs– Focus and follow up is different
• Involves patient management• Future prevention and education• Reporting if necessary
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C, DMed
ErrorsADE
ADR
Near Miss
B
E - I
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Purpose of Nomenclature and Definitions• Communication within institutions and
corporations• Regulatory self-assessment• Trending and consolidation• Monitoring performance• Benchmarking
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Don’t get overwhelmed with data collection and/or analysisThe most important aspect of medication safety is
to apply what has been learned to implement changes in the organization to decrease the potential for harm to patients.
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How to Set Priorities
• National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP) – Categories A – I
• Causes of a level where harm occurred often also seen in near misses
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Data Analysis• Departmental
Event Type: Pump ProgrammingContributing Factor: Hand-off FailureSeverity: E-IMedication: InsulinLocation: 5NE
• Interdisciplinary CommitteeMedication Management: Nursing and Pharmacy, monthly
• Hospital Committee E-IPatient Safety Event Review: Multidisciplinary, biweekly
• Quality DepartmentRoot Cause Analysis (RCA)
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Tools from Highly Reliable Industries
1. Failure Mode and Effects Analysis (FMEA)FMEA is an ongoing quality improvement process that is carried
out in healthcare organizations by a multidisciplinary team. It can
be employed to examine the use of new products and the design
of new services and processes to determine points of potential
failure and what their effect would be – before any error actually
happens. FMEA is a proactive process used to look more
carefully and systematically at vulnerable areas or processes. In
this regard, FMEA differs from Root Cause Analysis (RCA).
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2. Root Cause Analysis (RCA)
Usually RCA is a reactive process, employed after an error occurs, to identify its underlying causes.
Required by The Joint Commission for sentinel events, defined as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”
Includes an action plan, and monitoring the effectiveness of the plan.
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Just Culture
Whack-a-Mole by David Marx, J.D. 2009
This book argues that our Whack-a-Mole approach to inevitable and often predictable human error is ineffective, inefficient, and unjust; it does nothing to enable us to learn what we might do differently next time, or what systems we might put in place to minimize the chances of causing the same adverse outcome again.
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Just Culture
We spend far too much time looking at the severity of the adverse outcome (how bad was it?) and who was the unfortunate soul to be closest to the harm. In turn, we spend far too little time addressing the system design that got us there and the behavioral choices of the humans in those systems that might have ultimately contributed to the adverse outcome.
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Just CultureThe Behaviors We Can Expect:• Human error -inadvertent action; inadvertently doing
other that what should have been done; slip, lapse, mistake.
• At-risk behavior –behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified.
• Reckless behavior -behavioral choice to consciously disregard a substantial and unjustifiable risk.
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Just Culture
• Console the human error.• Coach the at-risk behavior.• Punish the reckless behavior.• Independent of the outcome.
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It’s About Changing Staff Expectations(from Just Culture literature)
• Looking for the risks around me• Reporting errors and hazards• Helping to design safe systems• Making safe choices
–Following procedure–Making choices that align with organizational values–Never signing for something that was not done
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Error Prevention Strategies• Improve communication and handoff
• Situation, Background, Assessment, Recommendation (SBAR)
• Handoff Checklist
• Catch phrases• Multidisciplinary or team safety meetings• Technology• Catch of the Month• Double Checks
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Double Check
The virtues of independent double checks – they really are worth your time!
ISMP December 17, 2009 The average “checking error rate” (errors missed during a double-check) is about 5%. In studies where “artificial errors” were introduced into medication carts and sample pharmacy orders, 93% to 97% of such mistakes were identified during an independent double-check.
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Double-checks work best when they are conducted independently.• The person checking has to form an independent judgment without
cues from the person doing the initial work (why ISMP encourages “independent double-checks”).
• It would be more effective, for example, to have two people calculate a dose separately and then compare their answers, than to have them perform the calculation together or to have one share his answer with the other before the double-check occurs.
• People may be swayed by the opinions of others, even more so if the other person holds a position of authority or has more experience.
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• Heparin 25,000 units/500 ml standard solution• Store in high risk section; boxes placed below• Tech places HEPARIN sticker on bag;
pharmacist initials when checks• Tech ran out of bags, placed HEPARIN sticker
on additional bags that were not checked by pharmacist
• Additional bags were actually Lidocaine
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Limit checks to high-risk situations• While it’s true that independent double-checks
are not as effective as system changes that make it hard for people to make mistakes, if performed properly, they can reduce the risk of an error reaching the patient
• Challenge: when does technology suffice
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• Learn from captured errors.– Document mistakes discovered during double checks– Analyze to understand the reasons behind them– Identify precautions that need to be taken– Not doing so has resulted in fatal errors
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What is your action plan?