medication safety good hospital practice 2012. objectives of this presentation to highlight the...
TRANSCRIPT
Medication safety
Good Hospital Practice 2012
Objectives of this presentation
• To highlight the importance of ensuring the safe use of medications in Medical City
• To present the roles of the Medical City staff in promoting medication safety
• To discuss how to report, monitor and prevent adverse drug reactions
What is a medication error?
"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. “
Incidence of preventable adverse drug events
Each year
380,000 – 450,000 in
hospitals
800,000 in long-term care facilities
530,000 among outpatients
What factors are related to medication errors?
• professional practice, • health care products, procedures, and systems of
• prescribing; • order communication; • product labeling, packaging, and nomenclature; • compounding; • dispensing; • distribution; • administration;• education; • monitoring; and use."
• We have about 2,000 admissions every month
• We give about 3 to 5 medications per patient
• Even if our correct medication rate is 99% we would still expect 60 to 100 medication errors per month.
Some reasons for medication errors
• poor communications within healthcare team• verbal orders
• poor handwriting• improper drug selection• missing medication• poor teamwork
• look alike / sound alike drugs
• polypharmacy
• availability of floor stock (no second check)• drug interactions
• hectic work environment• lack of computer decision support
Relationship between ADEs, potential ADEs, and medication errors. (Reproduced with permission from Morimoto T, Gandhi T, Seger A, Hsieh T, Bates D. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care 2004; 13:306–14.)
The classification of medication errors based on a psychological approach. (Reproduced with permission from Ferner RE,Aronson J. Clarification of terminology in medication errors. Definitions and classification. Drug Saf 2006; 29:1011–22.)
Prescribing errors• Lack of knowledge of the prescribed drug, its recommended dose,
interactions with food and drugs • Lack of knowledge of patient details• Illegible handwriting.• Inaccurate medication history taking.• Confusion with the drug name.• Inappropriate use of decimal points. A zero should always precede
a decimal point (e.g. 0·1). Similarly, tenfold errors in dose have occurred as a result of the use of a trailing zero (e.g. 1·0).
• Use of abbreviations (e.g. AZT has led to confusion between zidovudine and azathioprine).
• Use of verbal orders.
Dispensing errors
• Drug interchange due to look alike / sound alike drugs• Wrong patient, wrong dose
Administration errors• Drug interchange due to look alike / sound alike drugs• Wrong patient, wrong dose
Common errors resulting in ADRs1. Math error when calculating dose. 2. Nurse uses wrong patient weight. 3. Nurse does not check patient’s armband. 4. Nurse draws up wrong amount in syringe. 5. Nurse administers wrong strength bolus. 6. No double check of pump completed. 7. Uses estimated patient weight. 8. Uses inaccurate patient weight. 9. Double check of dose is only cursory.
The role of ALL doctors
1. Choose medications wisely. Limit the number of medications to avoid adverse drug events.
2. Check for drug allergies and interactions always.3. Write all prescriptions and medication orders legibly. 4. Ask your nurse to READ BACK your written orders to
avoid medication errors. 5. Order medications that are in the formulary. Formulary
drugs are reviewed for efficacy and safety. They are cheaper than non-formulary brands.
6. Use the generic name of the drug AND write it in FULL.7. Allow generic substitution of ordered medications. Do not
insist on your brand. Do not make your patients pay more and wait longer for emergency drug purchases.
The role of ALL doctors
8. Write the clinical indication for the drug, e.g., leurpolide to block testosterone. Writing the indication helps reduce wrong drug administration and educates patients and the care team.
9. Compare the patient’s list of meds being taken at home with the list of meds to be ordered on admission and reconcile the two lists. Communicate the finalized list to healthcare team members and the patient. Repeat the process whenever meds are added or removed. .
10.Respond to pharmacists’ queries promptly. Pharmacists are required to review every new drug order for therapeutic appropriateness, correct dosing, interactions with food and drugs, etc
The role of ALL doctors
11.Do not use Forbidden Abbreviations. Residents and nurses will ask you to replace all Forbidden Abbreviations.
12.Avoid phone orders save for extreme emergency and sign the orders within 24 hours.
13.Write and reconcile all drugs after a procedure. “Resume all meds” is an illegal order and will not be followed.
14.Do not allow brought in medications to be taken during confinement, except for a few exempted drugs (mostly topicals). “Meds care of patient” is an illegal order and will not be followed.
15.Report all adverse drug events to the Therapeutics Committee.
Do Not Use
Potential Problem
Use Instead
U (unit) Mistaken for “0” (zero), the number “4” (four) or “cc”
Write "unit"
IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten)
Write "International Unit"
Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d, qod, EOD (every other day)
Mistaken for each other Period after the Q mistaken for "I" and the "O" mistaken for "I"
Write "daily" Write "every other day"
Trailing zero (X.0 mg)* Lack of leading zero (.X mg)
Decimal point is missed Write X mg Write 0.X mg
MS MSO4 and MgSO4
Can mean morphine sulfate or magnesium sulfate Confused for one another
Write "morphine sulfate" Write "magnesium sulfate"
> (greater than) < (less than)
Misinterpreted as the number “7” (seven) or the letter “L” Confused for one another
Write “greater than” Write “less than”
Abbreviations for drug names
Misinterpreted due to similar abbreviations for multiple drugs
Write drug names in full
μg Mistaken for mg (milligrams) resulting in one thousand-fold overdose
Write "mcg" or “micrograms”
cc Mistaken for U (units) when poorly written
Write "ml" or “milliliters”
Some Forbidden Abbreviations
9 reasons why you should watch out for ADRs in older patients
1. Smaller bodies and different body composition2. Decreased ability of the liver to process drugs3. Decreased ability of the kidneys to clear drugs out of
the body4. Increased sensitivity to many drugs5. Decreased blood pressure-maintaining ability6. Decreased temperature regulation.7. More diseases than affect response to drugs8. More drugs being taken, thus more ADRs and
interactions9. Inadequate testing of drugs in elderly before regulatory
approval
The role of nurses
1. Read back all written and verbal drug orders, clearly repeating the generic name of the drug, the dosage ordered, and indication. Request for confirmation from the prescriber.
2. Refer to the head nurse and pharmacist when faced with conflicting information from prescribers and published drug literature.
3. When administering medications, confirm with the patient his or her identity AND the generic and brand name of the medication you are administering to him or her.
The role of nurses
4. Follow all procedures on drug calculations, drug preparation and drug administration to the letter. No shortcuts.
5. Ensure that the medications are given on a timely basis and as prescribed.
6. Store all medications according to policy.7. Be particularly careful in preparing, administering and
storing drugs in the DrugWatch list. 8. Monitor all first dose effects.9. Ensure medication reconciliation at all critical points during
confinement.10. Verify and replace all forbidden abbreviations.
The role of nurses
11. Report all adverse drug events to the Therapeutics Committee.
12. Report all medications errors and near misses to your head nurse.
13. Educate patients about their medications and about medication safety.
What are adverse drug reactions (ADRs)?
An adverse drug reaction is any unexpected, unintended, undesired, or excessive response experienced following the administration of a drug or combination of drugs that is associated with ANY ONE of the following:
A. Requires discontinuing the drug, or changing the drug therapy, B. Requires significant dose modification, C. Necessitates admission (for ambulatory patients) or significantly
prolongs the length of stay (for inpatients) D. Necessitates supportive treatment, E. Significantly complicates diagnosis or negatively effects prognosis F. Results in temporary or permanent harm, disability, or deathG. Is a therapeutic failure.
You must report suspected ADRs • ADRs may or may not be related or
caused by drug intake and this may be difficult to determine.
• The important thing is to alert the Medical City that a patient on a particular set of drugs has experienced an adverse event so that appropriate study can be carried out.
What should you do if you suspect an ADR?
1. Stop the medication immediately.2. Report the ADR by filling out the ADR
Reporting Form and hand it over to the Clinical Pharmacist. Any hospital staff member, even if unsure, may report a potential ADR preferably while the patient involved is still confined. Reporting may be done anonymously.
3. Coordinate with the Clinical Pharmacist in managing the patient’s ADR.
How will your report be handled?
• The Clinical Pharmacists, through evaluative questions and professional judgment, initially screens and assesses your ADR report. Once verified, they will advise you on how to manage the patient’s ADR.
• Your report goes into the Medical City ADR database maintained by central pharmacy.
• ADR reports are monitored and analyzed and provide the basis for educational programs to help the hospital staff in avoiding ADR occurrence and improving patient care
• ADR reports are also sent to the manufacturer and/or BFAD.
The role of pharmacists
1. Follow all procedures on drug storage, labelling, dispensing, recall and disposal.
2. Be particularly careful in the dispensing and storing of drugs in the DrugWatch list.
3. Ensure medication reconciliation at all critical points during confinement.
4. Regularly conduct random sampling of charts in their units and check for
a. Timeliness of nurses’ accomplishment of physicians’ medication orders
b. Legibility of physician’s orders,c. Completeness of medication ordersd. Completeness of prescriptions .
The 2012 DrugWatch List
1. Look-alike and sound-alike drugs
2. Drugs with narrow therapeutic index
3. Inotropic agents
4. Insulin preparations
5. Chemotherapeutic agents
6. Dangerous Drugs
7. Concentrated electrolytes
8. Non-steroidal anti-inflammatory drugs (NSAIDs)
9. Anticoagulants
10.Total parenteral nutrition given through the central line
The role of pharmacists
5. Alert the Therapeutics Committee when look-alike and sound-alike drugs are admitted into the formulary in order to take steps to identify these drugs as “high risk” for potential errors.
6. When look-alike and sound-alike drugs are allowed on the formulary, or are ordered on a non-formulary basis, they should be identified as being medications at "high risk" for potential error and extra steps should be taken to assure safety in ordering, dispensing and administering such products.
7. If a forbidden abbreviation is used, verify the prescription order with the prescriber prior to its being filled..
The role of pharmacists
8. Review all new drug orders and prescriptions in terms of
a) the appropriateness of the drug, dose, frequency, and route of administration;
b) therapeutic duplication;
c) real or potential allergies or sensitivities;
d) real or potential interactions between the medication and other medications or food;
e) variation from organization criteria for use;
f ) patient’s weight and other physiological information; and
g) other contraindications.
The role of pharmacists
9.Report all medication errors and near misses10. Report all adverse drug events11. Educate staff and patients about medications safety
Examples of best practices in combating medication errors
• Standardization/simplification of drug handling
• Eliminate look-alike/sound-alike drugs
• Forcing functions (lock-outs/time-outs)
• Checklists
• Structured communication (read back orders to patients or to doctors)
Hierarchy of Barriersfor Error Reduction
Most Effective Physical (Forcing Functions)Natural (Distance, Time)Information (Labels, Signs)Measures (Tests, Inspections)Knowledge (Training, Coaching)Administrative (Checklists, Policies)
Least Effective
Final take home messages
• Prescribers:– use sound med reconciliation techniques– avoid verbal orders except in emergencies– avoid abbreviations (U for units seen as a 0)– inform patients of indications for all medications– work as a team with pharmacists and nurses– use special caution with DrugWatch
medications– report errors and ADEs
Reducing medication errors
• Pharmacists:– monitor the medication safety literature– in conjunction with doctors and nurses,
develop, implement, and follow medication reconciliation
– verify the accurate entry of data on new prescriptions (clarify all abbreviations);
– report errors and near misses to MQIO
Reducing medication errors
• Nurses:– foster a commitment to patients’ rights
(YOU are the patient’s advocate)– be prepared and confident in questioning
prescribers about their medication orders– participate in, or lead, medication safety
projects– support a culture that values accurate
reporting of medication errors
Reducing medication errors
The Science of Safety
The key to improving
safety lies not in
changing the human
condition, but in
changing the conditions under which humans work
Reason J. Human Error. Cambridge, UK: Cambridge University Press; 1990
Are you a safe medication practitioner?
1. Which of the following are in the Medical City Drugwatch list?a. Potassium chlorideb. Insulinc. Magnesium sulfated. All of the aboveAnswer: ?D
2. Which of the following practice/s promote/s medication safety?a. Writing orders and prescriptions legiblyb. Insisting that the pharmacy stock up your brand of antibioticc. Arranging drugs alphabetically by brand names d. All of the aboveAnswer: ?A. Choices b and c lead to mixing up sound-alike drugs.
Are you a safe medication practitioner?
3. Which of the following will lead you to report a possible ADR?a. The drug needed to be stopped or changed. b. A significant dose modification is required. c. The patient suffered temporary or permanent harm.d. All of the aboveAnswer: ?D
4. When reporting a possible ADRa. You must be absolutely sure that it was caused by a drug.b. You must always sign the report with your name.c. You must immediately file the report while patient is confined.d. all of the aboveAnswer:? C. You don’t have to be sure of drug causation and you can file the report anonymously.
Are you a safe medication practitioner?
5. Which of the following is an inexpensive but effective intervention to help the pharmacist screen for medication errors?a. Write the side effects on the prescriptionb. Write the drug indication on the prescriptionc. Avoid the forbidden abbreviations.d. all of the aboveAnswer: ?B
6. Which among the following is a/are good way/s to prevent ADRs?a. Have nurses read back orders to MDsb. Reprimand nurses who make erroneous computations.c. Suspend residents who write illegibly.d. all of the aboveAnswer: ?A
Are you a safe medication practitioner?
7. Which strategy is the LEAST effective way for preventing ADRs?a. Physical (Forcing Functions)b. Natural (Distance, Time)c. Information (Labels, Signs)d. Administrative (Checklists, Policies)Answer: ?D. Forcing functions are the most effective. Policies can be broken.
8. The following is/are reason/s why elderly are more prone to ADRs:a. Old people have trouble remembering their drugs.b. Old people have poor liver and kidney drug handling capacities. c. Old people have lower fat deposits in which drugs are stored.d. All of the aboveAnswer: ?D
Are you a safe medication practitioner?
8 out of 8 – your patients are safe from medication errors!6 or 7 out of 8 – your patients safety level is above average4 or 5 out of 8 – your patients safety level is just about
barely adequate2 or 3 out of 8 – you can improve the safety of your
medication practice!*0 or 1 out of 8 – let us try again; meanwhile try to keep your
medication use on patients to the bare minimum!** Please go over the slides again.
Summary of this presentation
• Our ability to ensure the safe use of medications can spell the difference between health and illness, even life and death, for many patients.
• Our staff have critical roles to play in promoting medication safety
• We must report, monitor and prevent adverse drug reactions to spare our patients from further harm.
This SIM Card certifies that
______(please overwrite with your name, thank you)__, MD
has successfully completed the
Self Instructional Module on Medication
Management and Use(Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose Acuin
President and CEO Director, Medical Quality Improvement