rats in the swiss cheese model

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Rats in the Swiss Cheese Model Challenges with Integrated Medication Management Rhonda McManus, Pharm D Director, Clinical Operations Cardinal Health

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Rats in the Swiss Cheese Model. Challenges with Integrated Medication Management. Rhonda McManus, Pharm D Director, Clinical Operations Cardinal Health. The Swiss Cheese Model of Systems Accidents. Objectives for Pharmacists. - PowerPoint PPT Presentation

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Page 1: Rats in the Swiss Cheese Model

Rats in the Swiss Cheese Model

Challenges with Integrated Medication Management

Rhonda McManus, Pharm DDirector, Clinical OperationsCardinal Health

Page 2: Rats in the Swiss Cheese Model

The Swiss Cheese Model of Systems Accidents

Page 3: Rats in the Swiss Cheese Model

Objectives for Pharmacists

Know the prevalence of technologies used in medication management process

Describe synergies of integrated technologies Explain challenges identified with integrated

technologies Understand work-arounds end users have

established Discuss opportunities for pharmacists created by

integrated automated systems

Page 4: Rats in the Swiss Cheese Model

Objectives for Pharmacy Technicians List three technologies used in the medication

management process Describe techniques end users employ to

bypass safeguards in the medication use process

Explain the role of the pharmacy technician in monitoring the medication distribution process

Page 5: Rats in the Swiss Cheese Model

Newest Thing in Integrated Technologies

http://producten.hema.nl/

Page 6: Rats in the Swiss Cheese Model

No machine will ever take the place of good clinical judgment.

Page 7: Rats in the Swiss Cheese Model

The Perfect Integrated Solution

CPOE* PIS* ADM* BPOC* Billing

* With step-specific and service specific embedded decision support and common formulary table

Page 8: Rats in the Swiss Cheese Model

ADT Billing

Supply Chain management

CPOE

PIS

ADC

BPOC

Charting

Clinical DecisionSupport

Lab, radiology, otherancillary departments

Pharmacy storageand packaging

Page 9: Rats in the Swiss Cheese Model

Bedside Verification

1 2 3 4 5

Provider Education and Baseline Assessment

CPOEOrder

Management

Patient Monitoring and Outcome Review

ADE Review

Prescribing Transcribing Dispensing Administering

Drug Interaction Review EUM Replenishment

Point-of-CareAutomation

PatientMonitoring

InformationIntegration

Information Integration Information Integration Information Integration Information Integration

Medication Use Safety: Foundational Functionalities

Page 10: Rats in the Swiss Cheese Model

Process

Physician Orders

Order Management

Pharmacy Control and

Distribution

Patient-Specific Medication

Preparation and Dispensing

Medication Administration

at the Point of Care

* Leape, L.L., D.W. Bates, D.J. Cullen, et al. for the ADE Prevention Study Group, 1995.

“Systems Analysis of Adverse Drug Events.” Journal of the American Medication Association. 274: 35-43.

Phases of the medication management process where errors occur

Page 11: Rats in the Swiss Cheese Model

So How Many Health Systems have Implemented?

Page 12: Rats in the Swiss Cheese Model

Adoption Rates: BCMA

Schneider, Philip. “Opportunities for Pharmacists” American Journal ofHealth-system pharmacists, 64:s12-s16.

Page 13: Rats in the Swiss Cheese Model

Adoption Rate: CPOE

Schneider, Philip. “Opportunities for Pharmacists” American Journal ofHealth-system pharmacists, 64:s12-s16.

Page 14: Rats in the Swiss Cheese Model

Decentralized Distribution Trends

Schneider, Philip. “Opportunities for Pharmacists” American Journal ofHealth-system pharmacists, 64:s12-s16.

Page 15: Rats in the Swiss Cheese Model

Benefits of CPOE

Reduced errors related to handwriting Decreased order turn around time Decreased look-alike, sound-alike errors Integration with medical records and decision

support systems Decreased errors related to decimal point,

trailing zeros and use of apothecary measures Easily linked to drug-drug interaction programs

Page 16: Rats in the Swiss Cheese Model

Benefits of CPOE

Link to ADE reporting systems Links to lab for alerts Standardization of therapy Formulary control Support for cost effective drug therapy choices Decreased duplicate orders Identification of prescriber Access to data for analysis Force inclusion of reason for therapy

Page 17: Rats in the Swiss Cheese Model

Nine Unintended Consequences of Computerized Order Entry More/new work for clinicians Unfavorable work-flow issues Endless demands by the system Unwillingness to give up paper Changes in communication patterns and practices Negative feelings toward the system and those responsible

for it Introduction of new errors Unexpected changes in the power structure such as the

committee designing the computerized protocols making judgments about best practices

Over-reliance on the technology

Source: “Types of Unintended Consequences Related to Computerized Provider Order

Entry,” Journal of the American Medical Informatics Association, June 23, 2006.

Page 18: Rats in the Swiss Cheese Model

More Unintended Consequences

Order sets created without nursing and pharmacy; broad orders with clinical decisions put nurses in jeopardy of practicing medicine

Order sets increase the number of orders pharmacists review and dispense

Weak interfaces between CPOE and PIS make pharmacy corrections necessary

Physicians use notes section to enter orders if they cannot find the medication listed, so pharmacists have to check the notes section

Page 19: Rats in the Swiss Cheese Model

Examples of Errors Facilitated by CPOE User errors

Wrong patient selection Wrong medication selection Unclear log-on and log-off Failure to renew medication post surgery Loss of data and time when CPOE system is down Late day orders lost for 24 hours Uncertainty regarding changing orders, discontinuing

orders and resuming orders

Page 20: Rats in the Swiss Cheese Model

Examples of Errors Facilitated by CPOE Systems errors

Assumed dose informationMedication discontinuation failuresProcedure-linked medication discontinuationDiluent options and errorsAllergy information delayConflicting or duplicate medications

Page 21: Rats in the Swiss Cheese Model

CPOE Work-arounds

Increased verbal orders Enter orders in physicians’ notes section Override alerts and warnings Over-use of order sets Refuse to use CPOE and continue to use

paper orders Make less frequent adjustments to therapy

Page 22: Rats in the Swiss Cheese Model

Benefits of ADM

Medication is available on nursing unit as soon as pharmacist verifies CPOE order

Decreased missing doses Decreased chance for error due to

“borrowing” medications Warnings and alerts at medication

preparation phase- not at patient bedside

Page 23: Rats in the Swiss Cheese Model

ADM Challenges

Adequate equipment Profile-enabled Single drug access Refill accuracy Management of inventory levels Integrating with BCMA Perception of nursing of decentralized

distribution model

Page 24: Rats in the Swiss Cheese Model

ADM Work-arounds

Matrix drawers Pocket and belt bag stock “The Pumpkin” stock Cancel transactions Inventory feature Return to pocket feature

Page 25: Rats in the Swiss Cheese Model

ISMP ADM Focus Group

Met in March 2007 Sponsored by Cardinal Health, McKesson and

Omnicell Meeting of pharmacists users, nurse users and

vendors as well as ISMP Purpose: to define best practice around the use

of automated dispensing devices Report of findings posted on ISMP Website and

presented at ASHP in December 2007

Page 26: Rats in the Swiss Cheese Model

ISMP, 2008

ADC Core Processes

Provide ideal environmental conditions for the use of ADCs

Ensure ADC system security Use pharmacy-profiled ADCs Identify information that should appear on the

ADC screen Select and maintain proper ADC inventory Select appropriate ADC configuration

Page 27: Rats in the Swiss Cheese Model

ISMP, 2008

ADC Core Processes

Define safe ADC restocking processes Develop procedures to ensure the accurate

withdrawal of medications from the ADC Establish criteria for ADC system overrides Standardize processes for transporting

medications from the ADC to the patient’s bedside

Eliminate the process for returning medications directly to their original ADC location

Provide staff education and competency validation

Page 28: Rats in the Swiss Cheese Model

BPOC Benefits

5 Rights Billing accuracy

Page 29: Rats in the Swiss Cheese Model

BPOC Challenges

Bar codes Purchase Preparation Unexpected changes in bar codes Readable

Patient ID Pharmacy Order Entry changes Medication Management in BPOC world

Page 30: Rats in the Swiss Cheese Model
Page 31: Rats in the Swiss Cheese Model

BPOC Work-arounds

List of patients with bar codes Patient “stickers”

List of medications with bar codes Pick from patient list Pick from medication list Remove from ADM, no documentation of

medication administration: Bad documentation or diversion?

Page 32: Rats in the Swiss Cheese Model

Opportunities for Pharmacists

Take an active, leadership role in any and all technology implementations and upgrades

Clinical Decision support Database management Process redesign Ongoing maintenance Data to knowledge to action Monitor process changes for new errors

Page 33: Rats in the Swiss Cheese Model

Opportunities for Pharmacy Technicians System maintenance Data management Process redesign Increasing role in distribution

responsibilities Monitor for new errors, process work-

arounds

Page 34: Rats in the Swiss Cheese Model

Questions and Comments