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Reducing the Risk of Medication Errors Related to Electronic Medication Systems Update - July 18, 2014 Laura A. Finn, CGP, FASCP, RPh Finn Consultants Adjunct Associate Professor of Pharmacy Practice Philadelphia College of Pharmacy [email protected]

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Page 1: Reducing the Risk of Medication Errors Related to ...€¦ · Medication Errors Related to Electronic Medication Systems Update - July 18, ... FMEA Need to improve ... Medication

Reducing the Risk of Medication Errors Related to

Electronic Medication Systems Update - July 18, 2014

Laura A. Finn, CGP, FASCP, RPh Finn Consultants

Adjunct Associate Professor of Pharmacy Practice

Philadelphia College of Pharmacy

[email protected]

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Objectives: Identify ways prescribers can be alert to

systems-based sources of error in using electronic medication systems

Describe areas in medication reconciliation where electronic health records are prone to medication error risks

Develop an awareness for potential sources of medication errors in prescribing, processing and administering medication orders with electronic systems

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Benefits and Expectations for Electronic Medication Systems

Standardization of electronic health record and transfer of information between care sites(allow for earlier treatment in emergency)

E-prescribing (elimination of pharmacists’ need to read illegible handwriting)

Prescribing alerts and warnings ◦ Decision support software (CDS – clinical decision support)

◦ CGPs at point of prescribing ◦ Allergy warnings ◦ Drug Interaction warnings

Quicker access to medication adherence data Reporting of adverse events Track infections, improve population health….

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“Health IT and Patient Safety: Building Safer Systems for Better Care” IOM 2011

Greater oversight (government / private sector)

New technology learning curve = errors

Alert fatigue

Med Admin scanners vs “using eyes”

Software vendors:

Non-disclosure / Hold Harmless clauses

can’t share the screen with error-prone design

It will take more than technology to reduce medication errors.

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Medication Safety

Expectation is that electronic prescribing, decision support software, medication order processing, administration, and monitoring will reduce medication errors.

Are we sure our Electronic systems do not contribute to medication errors and negative outcomes?

Incomplete use of “paperless systems”

Can mixed Paper / Electronic systems create gaps in information resulting in negative patient outcomes?

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Scenario 1: Focus on Heart Failure-

Patient admitted to nursing home for Post-Acute Care

Post-Acute – Physician’s Orders reviewed and signed q 2 months

Electronic Medication list printed for MD review 5/18/14 and signed by MD 5/22/14.

Cardiology Apt 5/20/14 (discontinuation of furosemide)

Attending asked to see patient at request of nurse and family for “progressive edema” 6/2

Progress Note written 6/2 “No new orders; continue furosemide…”

But resident had not received diuretic in 2 weeks…

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If this patient were to be transferred to acute care hospital, would the admitting physician have accurate current medication list?

Decisions are made on inaccurate medication history and prescribing occurs based on misperceptions.

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Medication Safety with Electronic Technology

Will our electronic systems and technology improve medication safety and decrease potential for medication errors? Prescribing - medication choice errors, order entry

Warning fatigue , excessive warnings

Medication reconciliation discrepancies, duplication

Role of electronic records in unnecessary medication use

Decisions based on inaccurate, incomplete, outdated electronic health information

New technology “learning curve” and alterations to workflow

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Medication Safety with Electronic Technology

Health IT Patient Safety Action & Surveillance Plan - July 2013

Available at:

http://www.healthit.gov/sites/default/files/safety_plan_master.pdf

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Medication Safety with Electronic Technology

System-based sources of Medication Errors may contribute to negative patient outcomes:

Prescribing

Medication Reconciliation at Care Transitions

Administration

Monitoring

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Medication Safety with Electronic Technology

E-Prescribing – reduces problems with handwriting, ambiguous orders, and incomplete orders; but we must

recognize technology may also contribute to medication errors.

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Abbreviation U is NOT Acceptable either in paper order or electronic records or medication labeling.

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CPOE

Computerized Physician Order Entry became Computerized Prescriber Order Entry became Computerized Provider Order Entry.

Who is entering the orders?

Before 2009 – Estimate 6% hospitals had CPOE

ARRA -American Recovery & Reinvestment Act

provided $20 billion (incentive payments/ also financial penalties) to both outpatient physician offices and hospitals with CPOE as a core requirement

2011 – Estimated 30%+

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Scenario 2: Focus on Order Entry and Care Transitions Acute to Post-Acute

Patient with pneumonia, HTN, dry eyes

Hospital Discharge medication list included:

Cyclosporine ophthalmic bid

--------------------------------------------------------

Computerized signed physician orders state:

Cyclopentalate ophthalmic bid dx: dry eyes

Received cyclopentalate eye drops for 3 weeks

What went wrong?

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Medication Safety with Electronic Technology

Root Cause Analysis - RCA

Admission medication list (generic name)

Discharge medication list (generic name)

Telephone approval of medication list included generic name

Order entry by nurse –

System did not cross match generic with brand; no choice for generic product thus error in product choice

Pharmacy filled product (dx: dry eyes)

Attending physician approved/ signed computerized list of medications with incorrect eye medication

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Medication Safety with Electronic Technology

Comparison to old “paper system” where order would have been faxed to pharmacy to enter drug into profile and pharmacist would choose medication, complete labeling directions.

Nurse would transcribe order directly from hospital discharge list onto MAR.

MAR would be checked at time of each dose administration with label of drug product.

Electronic System – Pharmacist did not view cyclosporine order.

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Analysis leads to Process Improvement with goal to prevent future medication errors

Medication list upon hospitalization (include brand name?)

Medication Choices – Remove potential medications which would not be used in this setting

Cross-match brand with generic

Review indication with each medication order

Read medication list and be aware of all medications being signed/approved

Do not administer unfamiliar medications without check of drug information

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Definition of Medication Error

The National Coordinating Council for Medication Error Reporting and Prevention (NCCMRP) uses this definition:

“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.”

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Medication Error – “May be related to:

Professional practice,

Health care products,

Procedures,

Systems,

Includes:

prescribing, order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use”. (NCCMERP)

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Medication Safety- Organization and Individuals

Organizational and Individual Commitment:

Need for leaders of health care organization to make medication safety a high priority

Regardless of the organization, individuals still have the obligation to promote medication safety

ISMP: “For prevention efforts to be effective, they must become a priority.”

What about you?

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Medication Safety – Multidisciplinary Approach

What can we do as part of the health care team engaged in actions to improve medication safety:

• Encourage error reporting and analysis of near misses – Just Culture

• Improve degree of reporting and system analysis of near misses

• Educate other practitioners on error prevention and error causes

• Overall medication management is only as good as the “weakest link” in your practice.

• Who takes the evening, weekend call??

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Medication Safety – Multidisciplinary Approach

Utilize standard methods for medication error and near miss analysis: ◦ Root Cause Analysis - RCA ◦ Failure Mode and Effects Analysis – FMEA

Need to improve the system not just the performance of individuals

Learn from other errors reported through PSOs (public safety organizations) like ISMP and published accounts of errors

Proactively review your systems and make changes to decrease potential for medication errors

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Scenario 3: Focus on Care Transitions Acute to Post-Acute

Patient 94 yr old with immobility post-op ankle fracture

Enoxaparin 100mg/mL SQ daily x 14 days

Patient received 100mg daily…. til RPh review on day 9

Orthopedic Rx and hospital records indicated dose = 40mg daily

What went wrong?

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Misinterpretation of Drug or Dose

Interpretation of concentration as the dose

Due to incomplete medication order upon discharge med list (signed by prescriber)

Lack of dosage in medication order

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Focus on High Risk Medications

Anticoagulants

Insulin and Oral diabetes medications

Antibiotics

Cardiovascular medications

Anti-seizure medications

Liquids with a concentration

Unusual Dose/Dosing- 2 capsules, 1 ½ tabs, 0.5 tab or ¼ tab, variable dose

Narcotics

Narrow therapeutic window

Combination Medication Products

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Potential Sources of Medication Errors

Prescribers can impact safe medication orders:

Review post-acute discharge medications before signing

Recognize incomplete orders, concentration but no dose– Keppra ® 100mg/mL, Lantus ® 100 units/mL

Recognize pitfalls such as prescribing in mg but provider order entry in mL. Who makes dose conversion?

Be aware of look alike / sound alike medications. (LASA meds)

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Potential Sources of Medication Errors

Slow down, speak clearly when giving verbal order. Spell drug names if not being understood. ◦ F and S sound alike; B and D sound alike

Pronounce digits separately: ◦ Ex. “Forty milligrams – four zero mg”

Provide complete information – drug concentration, dosage units mcg, mg, meq

Include units – Dose is not just 25 or 20 or .125 Full drug name - Misinterpretation of computerized drug

names on drop down menu Ex. Order by prescriber to discontinue potassium Patient actually was prescribed NSAID - Diclofenac

Potassium

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Potential Sources of Medication Errors

Prescribing System improvements include:

Removal of problem creating menu choices from order entry drop down menu.

Use of Tall Man lettering to reduce risks of improper choice for look alike medications.

Review of default times/ dates on order entry

Review templates for accuracy

ex. Error in Zpak ® template = 6 days of azithromycin

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Potential Sources of Medication Errors

Name Confusion

Look Alike Sound Alike

◦ Lillian Williams – William Gillian

◦ James Franklin – Franklin Jones

◦ Gylburide – Glipizide

◦ Serzone ® – Seroquel ®

◦ Fosamax ® – Flomax ®

◦ Zytec ® – Zyprexa ®

◦ Wellbutrin SR ® – Wellbutrin XL ®

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Potential Sources of Medication Errors

E-Prescribing

Do not keep multiple EMR open.

Identify patient with multiple identifiers.

Ex. levothyroxine started on the wrong spouse

Dose was increased when no change in TSH on spouse not receiving the medication for 6 weeks.

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Potential Sources of Medication Errors E-Prescribing Focus: Correct choice off drop down menu – patient

name, drug name, drug salt, dose, ½ or 0.5 tablet dose (ex. lisinopril ½ tab in special instructions led to medication doubling)

Multiple EHR open at the same time

Beware of abbreviations for drug names

Short-cut abbreviations, default dose

Bypassing or “turning off” safety alerts

Use of “codes”

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Potential Sources of Medication Errors

E-Prescribing Concerns–

Who has access to your prescribing system?

Need to keep updated with guidelines, FDA warnings, software

Height / Weight software alerts may be missed resulting in dosing errors (mix up ht in cm instead of wt in kg)

Transposing numerals in height or weight

Duplication if errors in transmission occur

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Potential Sources of Medication Errors Warnings and Alerts

If interpreted at point of care by provider entering order, can be helpful if acted upon properly.

System needs review for threshold and specificity to reduce those not clinically significant.

Create “hard stops” to prevent the most outstanding patient safety errors.

When bypassed, expectation is that pharmacist will interpret

Advise safety team to review reasons for bypassed warnings frequently.

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Transfer of Medication Errors

Error with human / software interface If wrong medication / drug class

chosen from drop down menu will the error can be transferred to other electronic health records?

Risk: How much HIT is “cut and pasted”?

Thorton JD, et al. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013 Feb;41(2):382-8 http://www.ncbi.nlm.nih.gov/pubmed/23263617/

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Potential Sources of Medication Errors Administering

Do not assume patient has clear understanding of medication directions for administration.

Are labels of sufficient font, lettering, size and clarity?

Does patient understand the dose, administration route, frequency, and duration of administration?

Can the patient appropriately administer the dose?

Ex. cutting tablets in half, swallowing whole…

Are PRN medications labeled appropriately?

◦ Ex. Klonopin PRN

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Potential Sources of Medication Errors Administering

Patient may be confused about how much medication to take.

Example: “Take 0.5 tablet….”

Data entered for medication order may be user friendly to prescriber and pharmacy but is it user friendly for the outpatient to understand?

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National Patient Safety Goal 2014

Maintain and communicate accurate patient medication information.

NPSG.03.06.01

“evidence that medication discrepancies can affect patient outcomes”

What is the role of electronic systems in improving patient outcomes? vs reducing patient outcomes through medication errors and adverse events?

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Perils and Opportunities at Medication Reconciliation

Potential source of medication errors

Transfer from one point of care to another, often involves medication changes.

Institute for Healthcare Improvement estimates:

Up to 50% of all medication errors and 29% adverse

drug events in the hospitals may be associated with

communication gaps at care transitions.

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Care Transitions

Office of Inspector General Feb 2014 report:

“Adverse Events in Skilled Nursing Facilities” 653 Medicare beneficiaries discharged from

hospital to SNFs for max 35 days post-acute care

22% experienced an adverse event

additional 11% harmed during SNF stay

59% events identified as preventable by MD review

Half who experienced harm returned to hospital for treatment

At a cost to Medicare Aug 2011 = $208 million

Extrapolated to over $2 Billion in yr 2011

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Care Transitions

“up to 70% care transitions resulted in discrepancies” - 1/3 having potential to harm

Archives of Internal Medicine June 2012

30% of elderly patients’ medication information that was available to the ER staff at the time of initial diagnosis differed from that obtained from outside caregivers.

A review of 577 discharge drug summaries found 66% contained at least one inconsistency.

Institute for Healthcare Improvement

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Care - Transitions

Engage the patient (family/caregivers)

Study by Mayo Clinic found lack of knowledge in patients prescribed a new medication on hospital discharge:

15% unaware of Rx for new medication

33% could not name the new medication

1/3 could not describe how to take the new medication or what is was for

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Focus on High Risk Medications

Anticoagulants

Insulin and Oral diabetes medications

Antibiotics

Cardiovascular medications

Anti-seizure medications

Liquids with a concentration

Unusual Dose/Dosing- 2 capsules, 1 ½ tabs, 0.5 tab or ¼ tab, variable dose

Narcotics

Combination Medication Products

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Medication Reconciliation - Care Transitions

To improve medication outcomes:

reconciliation systems and procedures need to be reviewed

Not just educating an individual deemed “responsible for a discrepancy”

Increase team awareness of potential for medication discrepancies

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Medication Reconciliation - Transitions

Problem: Missing information concerning dose particularly with liquids, injections

◦ Enoxaparin 100 mg/mL = concentration, missing actual dose

◦ Lantus ® 100units/mL = concentration

◦ Leviteracetam (Keppra ® ) suspension 100mg/mL - is the concentration not dose

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Verifying Post Acute Discharge Medication Orders

Inability to determine if stopped medications were “purposely discontinued for a reason” or “inadvertently missed”

Solution: physicians review (print out) discharge summary and medication reconciliation at same time for final review and corrections

(with all the patient’s information in one place)

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Post-Acute Discharge Orders

Lack of defined duration / stop date – Difficult to determine start dates/stop dates ◦ Variable stop dates based on next cardiology

visit, orthopedic visit, etc. Ex. amiodarone 200mg bid until cardiology

appointment

Inappropriate abbreviations ◦ “levofloxacin 500mg q 48 hours x 3 d”

Does d refer to doses or days?

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Missed or inaccurate information input upon hospital admission

May result in incorrect information upon discharge:

Clinical decisions may be based on inaccurate information.

Hospital treatment may reflect inaccurate dose from point of admission.

Untreated medical conditions upon discharge (These can be unintentional discontinuation, - errors of omission)

Source: Bell, et al, Association of Hospital Admission with Unintentional Discontinuation of Medications for Chronic Diseases. JAMA, 2011: 306 (8):840

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Missed or inaccurate information input upon hospital admission

Use of most recent hospitalization discharge

meds as admission meds for newest hospital admission resulting in restart or documentation as “home meds” those that were discontinued or altered during outpatient time ◦ Old dose of levothyroxine, metoprolol, lisinopril, which were

changed months prior to admission but restarted as “home meds” upon entering hospital

Consultant Practices may also be using outdated lists by consulting practices

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Medication Safety with Electronic Technology

The Joint Commission 2014 Patient Safety Goals - Use Medicines Safely

IOM – “Electronic Prescribing and Monitoring for Errors in All Care Settings is Essential”

Target high risk medications

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Medication Safety with Electronic Technology

Adverse Event and Error Reporting:

FDA MedWatch Form is available at:

www.fda.gov/medwatch/how.htm

- USP-ISMP MERP (Medication Error Reporting Program)

www.ismp.org/orderforms/reporterrortoismp.asp

-It is essential that we report incidents related to Health Information Technology.*

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Medication Safety with Electronic Technology

Increase awareness among your colleagues with examples of the potential errors that may occur and how to screen for them

Team Focus on multi-factorial causes when identifying potential errors and the necessary changes to prevent recurrence.

Use technology to reduce medication errors but beware of how technology may contribute to errors.

Engage the patient, family, caregiver when gathering information about medication use.

“I didn’t receive any eye drops that I used to take….

”I

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References Institute of Medicine (IOM), Health IT and Patient Safety: Building

Safer Systems for Better Care (National Academy Press, 2012) available at http://www.iom.edu/Reports/2011/Health-IT-and-Patient-SafetyBuilding-Safer-Systems-for-Better-Care.aspx (last accessed July 9, 2014).

IOM, To Err Is Human: Building a Safer Health System (National Academy Press, 2000), available at http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx (last accessed July 9,2014).

Bell, et al, Association of Hospital Admission with Unintentional Discontinuation of Medications for Chronic Diseases. JAMA, 2011: 306 (8):840

Adverse Events in Skilled Nursing Facilities – National Incidence among Medicare Beneficiaries – Office of Inspector General – Feb 2014 available at: http://oig.hhs.gov/oei-06-11-00370.pdf

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References Radley DC, Wasserman MR, Olsho LE, Shoemaker SJ, Spranca MD,

Bradshaw B. Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. J Am Med Inform Assoc. 2013;20(3):470-6. doi:10.1136/amiajnl-2012-001241. http://jamia.bmj.com/content/early/2013/01/27/amiajnl-2012-001241.full

How to Guide: Prevent /Adverse Drug Events by Implementing Medication Reconciliation. Cambridge,MA: Institute of Healthcare Improvement; 2011

National Coordinating Council for Medication Error Reporting and Prevention. “What is a Medication Error?”

http://www.nccmerp.org/aboutMedErrors.html Accessed 4/3/14

Thorton JD, et al. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013 Feb;41(2):382-8 http://www.ncbi.nlm.nih.gov/pubmed/23263617

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Resource

Website of resources: www.ismp.org

Institute for Safe Medication Practices

“The great aim of education is not knowledge but action.”

H. Spencer

Thank You !

[email protected]