Intelligent Medication Administration and Patient Safety at the Point of Care: An Evaluation of Implementation and Return on Investment

Transcription

1 Intelligent Medication Administration and Patient Safety at the Point of Care: An Evaluation of Implementation and Return on Investment A continuing education program for nurses and pharmacists Program Faculty Linda Morgan, RN Healthcare Consultant Hixson, Tennessee This program was supported by an unrestricted educational grant from Hospira, Inc.

2 Intelligent Medication Administration and Patient Safety at the Point of Care: An Evaluation of Implementation and Return on Investment EDUCATIONAL OBJECTIVES Upon completion of this activity, pharmacists and nurses will be able to: Develop an implementation plan for bar code medication administration technology Develop an implementation plan for intelligent pump infusion technology Describe how to make a business case for intelligent technology ACCREDITATION ProCE, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity Number H05-P has been assigned to this knowledge-based home-study CE activity (initial release date ). This program is approved for 1.0 contact hour (0.1 CEU) in states that recognize ACPE providers. The program is provided at no cost to participants. Statements of credit will be issued online upon completion of the program evaluation and the post-test with a score of 70% or higher. No partial credit will be given. Nurse CE is provided for this activity through collaboration between ProCE, Inc. and Wild Iris Medical Education, Inc. Wild Iris Medical Education, Inc. is accredited as a provider of continuing education by the American Nurses Credentialing Center's Commission on Accreditation. This activity provides 1.0 contact hour of nurse CE credit. Continuing education credit for this activity is available through January 10, 2014 EDUCATIONAL FUNDING This program was supported by an unrestricted educational grant from Hospira, Inc. DISCLOSURE It is the policy of ProCE, Inc. to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer of any commercial product(s) discussed in an educational presentation. Ms. Morgan reports serving as faculty for Hospira-funded educational programming. Please note: The information and views presented in this monograph are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this program may discuss the use of drugs and/or devices for unlabeled indications. Use of drugs and/or devices outside of labeling should be considered experimental. Participants are advised to consult and verify manufacturer product - informa tion, the professional literature and use his/her professional judgment in applying the presented information in patient care activities. FACULTY Linda Morgan, RN Healthcare Consultant Hixson, Tennessee Linda Morgan is a registered nurse and health-systems consultant based in Chattanooga, TN. She began her career in nursing in the late 1970s, practicing mainly in the emergency department setting. She obtained her nursing degree from The University of the State of New York in 1990, and quickly moved into a management role in She has served as a Nurse Manager, Clinical Director, Director of Nursing. Today, while working with many aspects of nursing operations, her true passion lies with patient safety technologies. Much of her career was at Erlanger Health Systems in Chattanooga, Tennessee, which is an 819 bed, Not-for Profit Academic Medical Center, where she served recently as the Director of Operations. Born at Erlanger and a patient there many times in her life, Linda continues to be dedicated to the advancement of patient safety. - Her accomplishments over the past few years have included the implementation of many patient safety medication administration systems. Linda has authored several publications and has spoken locally and nationally on intelligent technology.

3 In 1991, results published from the Harvard Medical Practice Study showed that adverse medical events (AMEs) occurred in approximately 4% of the hospitalizations in the state of New York, with almost 14% of those events leading to death. 1 The estimate of 44,000 to 98,000 annual patient deaths due to AMEs quoted in reports from the Institute of Medicine (IOM) Committee on Quality of Healthcare in America entitled, To Err is Human: Building a Safer Health System 2 and Crossing the Quality Chasm: A New Health System for the 21 st Century 3 was derived in part from this study. The study also showed drug complications were the most common type of AME occurring in 19% of the cases. 4 Another study showed that medication errors occur in nearly 1 of every 5 doses given to patients in a typical hospital with approximately 7% of those errors being rated as potentially harmful. 5 This is an important outcome to focus on for patient safety issues because many adverse drug events (ADEs) are the result of medication errors (MEs). In the same study, it was shown that wrong dose errors were the most common errors committed during nurse administration. By combining the data from the Harvard Medical Practice Study with the data that shows where errors most frequently occur and are detected, it becomes apparent that healthcare professionals need to focus their attention on drug administration as an area where patient safety can be improved and where the greatest yield can be realized. The Swiss Cheese Model: In the hospital, there are barriers and defenses built into the processes that are designed to protect the patient from hazards inherent to the system. Each defensive layer should prevent errors from reaching the patient. In reality, each layer of defense has holes like a piece of Swiss cheese. The presence of a hole in one of the slices does not necessarily correlate to a bad outcome, but in instances when a hole in each sequential slice lines up, it is possible that the error might reach the patient. These holes represent active failures and latent conditions. 8 (Figure 1). Medication Errors: An error is an unintended action, either of omission or commission, or an act that does not achieve its intended outcomes. 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 healthcare professional, patient, or consumer. 6 Leape, et al., showed where medication errors took place within the medication-use system and what percentage of those errors were intercepted before they reached the patient. 7 (Table 1) Areas where potential ADEs are intercepted are those where there are double-checks in place, with almost half of the physician ordering errors being intercepted because both nurses and pharmacists check these orders before a drug is administered. As one moves closer to the patient, it is less likely that a potential ADE will be intercepted. This is because at the drug administration area, there is no one to intercept the error, unless another nurse or the patient, can double-check what is being administered. 7 Active failures. 8 Active failures are unsafe acts committed by individuals with direct patient contact. For example, a physician may prescribe ampicillin to a penicillin-allergic patient not realizing ampicillin is a penicillin-derivative, or a nurse may administer vancomycin too rapidly causing red man syndrome. These events are usually short-lived because once the mistake is realized, that same mistake may not be made again. Usually these types of errors are violations of the process and represent a minority of the errors. These types of errors are not because of weaknesses in the system and are difficult to predict. Latent failures/conditions. 8 These conditions are weaknesses in the system, sometimes referred to as resident pathogens, that arise when the system is designed and procedures are written. Latent failures explain the majority of the errors that occur. This type of failure can cause error-prone conditions (i.e., time pressure, understaffing, fatigue, inexperience, etc.) and create long-lasting holes in the system (i.e., unworkable procedures, design and construction Table 1. Common places where MEs occur and ADE interceptance rate. Task MEs that Occurred ADEs Intercepted Physician ordering 39% 48% Pharmacy dispensing 11% 34% Transcription/verification 12% 33% Nurse administration 38% 2% 1

4 Figure 1. Swiss Cheese Model. 9 seasoned nurses. This lack of mentorship can lead to serious medication errors. Distractions. As always, there are a number of distractions that could lead to a medication error occurring. These include: call lights, phones, pagers, physician rounds, clinical alarms, and increased documentation workload. All of these distractions take away a nurse s ability to concentrate on error-free patient care. deficiencies, etc.). These conditions can remain dormant for long periods of time before they combine with an active failure to produce a negative outcome in a patient. The good news regarding latent failures is that they can be identified and fixed before an adverse outcome occurs. Within nursing, there are a number of latent failures that could cause serious errors. These failures include: Increased nurse workload. There are an increasing number of tasks required of nurses including more time required for documenting care, many times electronically. This, coupled with nurses who may be less comfortable with technology, could lead to an increased risk of errors occurring. Increasing number of medications. The increasing number of medicines on the market has required nurses to increase their pharmacology knowledge. Unfamiliarity with newer (or older) medications can lead to serious errors in patients, especially with parenteral medications. Increased patient acuity. Over recent years, there has been a change in the mix of patients admitted to hospitals with an increased number of sicker, more acute patients being admitted. These patients require more nursing care and require more medications than less sick patients. Additionally, these patients generally require greater lengths of stay. All of these factors can lead to increased risk of medication errors. More new graduates at the bedside. There has been a recent exodus of experienced nurses from the work force, primarily due to retirement. As a result, there are more, less experienced nurses taking care of patients, with less guidance from 2 How can technology help? Table 2 lists the five rights of medication administration. Applying technologies such as bar code medication administration (BCMA) or intelligent (smart) pumps at the point of care as an additional check before a medication is administered to the patient can help assure the patient of their five rights. 10 These technologies: Deal with the drug administration step where there are no double checks. Deal with high-risk medications. Deal with intravenous medication administration (primarily intelligent pump). Deal with patient safety. Can be used as a measurement instrument and part of continuous quality improvement (CQI) initiatives. Table 2. The patient s five rights The right drug The right patient The right route The right dose The right time This monograph will describe methods and procedures for setting up processes to utilize BCMA and intelligent pump technology within an institution and how these technologies contribute to patient safety. An example will also be presented that discusses the potential return on investment for implementation of these systems within an institution. Bar Code Medication Administration Bar code medication administration technology involves hardware and software that enables the nurse to accurately administer and document medication administration. A bar code is defined as a machinereadable identifier utilizing a number of printed bars and spaces of various widths to encrypt and carry

5 11, 12, 13 (Figure data. 2) The bar code is programmed to contain specific information that can be read using a scanner that is attached to appropriate reader software. For example, in a grocery store, the bar code on an item contains specific information about the item, such as the item s name, unit size, etc., but most importantly, it contains information about the price of the item. When the item is scanned at the check-out counter, the price of the item is added to the buyer s check-out list. Bar coding in the retail setting enables the retailer to eliminate the need to put a price tag on every item in the store and to monitor inventory levels. Figure 2. Bar code. benefits which included improved: work flow, documentation, billing, and public relations. 12 Table 3 lists some potential advantages and disadvantages of BCMA. Table 3. Potential advantages / disadvantages of BCMA technology 13 Advantages Disadvantages Automated Improved patient documentation safety and accuracy Increased charge accuracy through automation Controlled-substance tracking Nursing convenience Marketing tool for organization Cost Nurse workflow disruption if not planned appropriately All medications must be bar coded Should be used in a wireless environment to be most effective Nursing must accept this change for the technology to be successful Similarly, in a hospital, bar code technology allows the nurse to have a check in place when the drug is being administered so that the nurse will be sure that the right drug is being given to the right patient in the right dose by the right route at the right time. There will be three bar codes that need to be scanned, The nurse s, which will contain information specific to the nurse (i.e., name, employee number, etc.). The patient s, which will contain information specific to the patient (i.e., name, patient number, allergy information, etc.). The medication s, which will contain information specific to the medication (drug name, dose, expiration date, etc.). The nurse s bar code will be scanned, followed by the patient s bar code, followed by the medication s bar code. The nurse will be alerted to any discrepancies (wrong drug, wrong dose, etc.) from the information in the patient s medication administration record (MAR) and a medication error will be avoided. Deciding whether to implement BCMA: Deciding whether to purchase and implement BCMA technology requires a great deal of thought and a multidisciplinary team to make the decision. One group found that the primary reason for implementing BCMA was patient safety, followed by secondary Once the decision to use BCMA is made: Once the decision is made to implement barcode technology, a BCMA-system must be selected. There are a number of vendors for this technology and there is no right or wrong decision on which vendor to choose. Selection of a vendor will be institutionspecific. It is recommended that the following general stepwise approach be taken within the institution when implementing BCMA: Upgrade information technology (IT) infrastructure. 2. Examine and understand the policies and procedures (P&Ps) for the medication-use process within the institution. 3. Initiate bar coding for patients followed by, bar coding for staff, then bar coding for medications. 4. Piloting the system on different units before rolling out to entire hospital. 5. Hospital-wide education. 6. Monitor success and make adjustments to improve the system. 7. Continue to educate the staff. 3

6 The implementation process will take one to two years for BCMA. Closing loopholes and pharmacy/nursing workarounds, rapid elimination of the old system, and input and support from pharmacy and nursing will lead to successful implementation. 12 The first stages of implementation should include a multidisciplinary committee that includes: Administration Medicine Nursing Pharmacy Biomedical engineering Respiratory therapy Admissions IT department This committee needs to develop a strategic plan for how BCMA technology will be selected and implemented. Technology should be chosen based on capabilities of the IT system and institution workflow. A list of comparable hospital references should be provided by the vendor to research a product. Other technology considerations should include: An integrated electronic medication administration record (emar) should be implemented and running prior to implementation of BCMA. Two-dimensional scanners are recommended for their ability to read any bar code symbology. A wireless environment is recommended but real-time, secured wireless or hard-wired communications between the scanner and the server is recommended to facilitate updates to the system. Leasing equipment should be considered due to evolving technologies in this area. Implementation recommendations: 12 Again, the IT infrastructure should be assessed and upgraded prior to implementation. Key members of the multidisciplinary team used in the early assessment/ implementation phase, particularly pharmacy and nursing, should review the entire medication-use process and upgrade and revise P&Ps to accommodate the BCMA workflow. The drug formulary list should be updated so that all drugs will have an assigned bar code. There should be 100% unit dose dispensing for scheduled medications prior to implementing BCMA. Prior to pilot testing, there should be methods in place for bar coding all patients, staff, and the majority of medications. Interface testing between the different 4 hospital databases and the BCMA system should be completed prior to pilot testing. Pilot testing should be conducted on different units (i.e., acute care, intensive care units, etc.) to determine how BCMA will work in areas with differing workflows. After pilot testing is completed, input from the users should be evaluated. Changes to procedures, based on pilot tester comments, should be completed prior to going live. Nurse training: 14 All nurses within the institution will need to be trained. Training tools such as user guides, videos, compact discs, etc., need to be developed and should be available from the BCMA vendor. Initially, internal nurse education instructors and the trainers from the vendor should conduct training sessions while the technology is being learned. Over time, nursing should gradually assume the training role with less help from the vendor. Experienced consultants should also be utilized for input on training content. Training sessions should be held away from the patient care area to avoid distractions. Functional equipment should be made available at the training location. It might be reasonable to train before or after a shift to provide more focused learning. These training sessions should be hands-on and long enough to provide ample practice and question/answer time. Once the nursing staff is completely trained, the hospital can go live with the system. Once the system is live, it will be important to continually assess compliance and how the system is working. Regular meetings with the nursing staff will allow for feedback and help with making appropriate adjustments to optimize the workflow and patient safety that should be provided by the BCMA system. Intelligent Pumps Another technology that will improve patient safety is the intelligent pump. The intelligent pump is a pump that contains software that holds drug libraries of parenteral medications used within the institution. These drug libraries include the medications, concentrations, dosing units, and minimum/maximum dose limits. Prior to infusion, the nurse programs the pump. The pump automatically determines whether the dose programmed is within the appropriate range. If the dose is outside of the facility-defined dose limit range, the nurse is alerted and the discrepancy must be 13, 15 addressed, thus averting a medication error.

7 Once the decision is made to utilize intelligent pump technology, a product must be selected. The selection of a particular intelligent pump vendor will need to be made based on the vendor s ability to satisfy a hospital s specific needs. The IT requirements associated with intelligent pumps are not as intensive as those required with BCMA technology, but should be upgraded to meet the requirements of the technology being installed. An important consideration that should be made in the initial planning phase is to decide whether to use wireless technology. Operating intelligent pumps in a wireless environment will improve efficiencies of the technology. A wireless environment will allow for immediate transmission of data between the pumps and the network server allowing for immediate updating of the drug libraries and immediate retrieval of data from the pumps. Additionally, a wireless environment will allow for near real-time asset tracking of the pumps. The Drug Library: 15,16,17 The drug library is a file in the intelligent pump s software that contains a list of parenteral drugs that will be infused to patients in the institution. As stated earlier, this list includes drug names, concentrations, dosing units, and dosing limits. Essentially, the drug library contains the rules under which a drug can be infused. As a result, when building the library, it is important that input is received from all groups involved in the medication administration process. An interdisciplinary team should be assembled to develop the drug library. This team should include: Pharmacy for their drug expertise. Pharmacy should own the library because of its drug knowledge and intimacy with the drug use process in the institution. Consider including: Staff/clinical pharmacists and pharmacy technicians who have knowledge of the ordering practices within the institution. Clinical specialist pharmacists to research the literature, develop, and proof the libraries in their areas of expertise. Pharmacy managers who will be responsible for directing the implementation, editing, and maintenance of the libraries. Nursing for their drug administration expertise. Consider including: Staff nurses for their expertise in how the pump will be utilized and programmed at the bedside. Nurse practitioners/managers for their expertise in understanding drug administration P&Ps, developing libraries for specific clinical care areas (CCAs), and assistance in setting dose limits. Hospital administrators for their role in supporting the technology. Biomedical engineering/it for their support of the hospital information system and pumps. Prescribers for their knowledge of how drugs are ordered. Pharmacy and Therapeutics (P&T) Committee for their role in the drug library approval process. Setting up the library is a labor-intensive process both from a planning and data-input perspective. A great deal of thought should be given to this process as appropriate planning will increase an institution s chances of a smooth transition during implementation. While a hospital can use a library template provided by a vendor or other institution that has already started using intelligent pump technology, in most cases, a drug library will need to be built from scratch using the hospital s documentation regarding drug use. These documents include: 15,16,17 Standard drug concentrations IV preparation guidelines/p&ps IV infusion administration guidelines/p&ps Standard order sheets/protocols Once this documentation is gathered and analyzed, it is important to give consideration to various aspects of setting up the drug library, including: Data evaluation and report monitoring the drug library should be set up to provide valuable data to assist in clinical improvement initiatives and report monitoring Bar coding will data encoded into bar code technologies correspond with data in your drug library Library updates / editing will the drug library be set up to ensure efficiency in the need for updates, while maximizing safety 5

8 Additional considerations are shown in table 4. Table 4. Drug library set-up considerations. Rule sets for each drug: High alert medications Hard and soft limit look / sound-alike medications determination TALLman lettering Bolus/infusion setting Specialized display limits names Loading and infusion doses for patientcontrolled analgesia (PCA) Setting up display icons to: Identify when drug being infused is outside limits Identify when drug is being infused with no safety limits in place Clinical Care Areas: Outside of making rule sets for each drug (i.e., hard and soft limits, standard concentrations, etc.) one of the more important decisions is in how the CCAs should be defined. Clinical care areas are defined units that drugs are being used on. There are generally three ways CCAs are defined: By demographic or specific hospital unit (i.e., pediatrics or surgical step-down). By consolidated groupings, which is a combination of multiple patient care units that use similar drugs/prescribing practices. By a combination of both methods above. Clinical care area definitions will have an effect on how nurses utilize the intelligent pumps and how information retrieved from the pumps will be utilized to improve patient care. Defining the CCA by demographic unit will allow for data collection for the specific unit, promote common practice within the unit, and allow for less scrolling to find a drug within the library. However, when programming CCAs by demographic units, there is a risk of running out of CCAs within the pump and more initial programming will be required when dividing CCAs by this method. Consolidated groupings offer the advantage of easier sharing of the drug library across the hospital and the promotion of common practices within the hospital. Disadvantages of consolidated CCA groupings include more scrolling to find a drug within the library and report data from multiple demographic units is 6 rolled up into one CCA. This will make it more difficult to determine utilization for a specific demographic unit. As a result, some hospitals may find that using a combination of the two CCA division methods may help optimize their use of the intelligent pumps. Drug library testing: The drug library and pumps should be tested by select clinicians in their specific clinical areas to see how the technology works in their patient population. When approximately 65% of the library is built, select clinicians can test the technology to: Identify medications that need to be added to the library. Determine whether display names are adequate. Validate bar codes. Determine whether drug limits have been applied to specific drugs. When 90% of the library is completed, these same testers will: Continue to evaluate the above-mentioned parameters. Test the upper and lower soft and hard dose limits so that they are in line with the P&Ps and treatment protocols for specific clinical areas. Evaluate medication concentrations in an effort to standardize medication practice. All commonly used medications should be included in the drug library because if nurses find that some of the common medications are not included, they may not be compliant with using the safety software. Additionally, it is important that the upper and lower dose limits, both hard and soft limits, are as accurate as possible before implementation to the entire hospital. Staff education. During the library building process, staff education and training should be taking place within the institution. There are a number of methods that can be used to train staff. Which method(s) to use will be at the discretion of the individual institution. (Table 5) Table 5. Training examples. Vendor-sponsored educators. Live demonstrations. Train-the-trainer symposia. Written materials Use super-users at each CCA as an additional resource.

9 Intelligent Pump Reporting: An advantage of utilizing intelligent pumps is the reporting capability with the data collected from the pumps. The reports allow the pumps to be integrated into the hospital s CQI process. These reports can be utilized by hospital managers to: monitor and improve patient safety by decreasing the risk caused by high-risk medications; identify opportunities to improve IV practices and operational efficiencies; and tracking of the pumps within the institution. There are generally three categories of reports available: clinical reports, operational efficiency reports, and asset management reports. Clinical reports are generally used to monitor compliance with the safety software and user response to safety alerts. These types of reports could be used to: Determine whether the right dose is being administered to the patient at the correct rate. Monitor critical catches that are made and determine whether the catch saved a life, saved money, saved time, or averted an increased length-of-stay. Monitor whether medication errors or ADEs are being prevented. Identify therapeutic trends. Drive quality improvement initiatives. Identify clinically appropriate dosing limits. Operational efficiency reports will allow the manager to monitor workload and pump utilization. These types of reports can be used to: Determine the time medication events occur. Identify peak times when high-risk medications are administered. Figure 3. Example reports. Edit Variance Report Determine workload practices. Monitor and measure implemented changes. Show compliance with the use of the safety software. Show clinicians responses to alerts. Identify operational improvement opportunities. Identify workload practices. Asset management reports are primarily used to track where pumps are within the hospital and whether they are in use. These types of reports are also used to monitor drug library transfers. Figure 3 shows two example reports. Monitoring success: In general, these reports should be used as part of a hospital s CQI initiatives and analyzed by clinical managers to improve compliance, evaluate near miss medication errors, and to assess the need for drug library revisions. For example, it may become apparent that a particular drug may have one of its soft limits consistently overridden. It could be that the overrides are due to assigned prescribed limits in the drug library being different than the limits in the order set for that particular drug or CCA. Adjustment of the drug limit, within the library, to the appropriate safe amount, will alleviate the need for the override. Return on Investment Intravenous medications account for 56% of all 18, 19 medication errors and 54% of potential ADEs. Each preventable ADE adds $8,750 (2006 dollars) 20 to the cost of a hospital stay. Assuming there are 400,000 preventable ADEs that occur each year, this translates into a total annual cost of $3.5 billion, not counting lost wages or productivity. 21 Infusion Summary Report 7

10 Table 6 shows the return on investment for BCMA, intelligent pump, and PCA pump technologies for an actual hospital. The following assumptions were used in this table: The cost of an ADE was $8,750 The total investment was determined by adding all of the costs associated with the technology including: Software costs Database costs Licensing costs Education costs Consultant fees Pump costs Maintenance fees Intercepted errors were quantified by attempts to override the hard limit, not accounting for reprogramming of soft limit alerts that may also have been associated with a potential adverse event. Error data was collected for a one-month time period. Total returns are calculated based on the premise that only 7% of those intercepted errors would have caused harm in a patient. 5 Conclusion Medication safety technology is expensive and requires careful planning within an organization, but there can be a significant return on investment if medication errors can be prevented. Technology reduces variation at the point of care and thus, reduces the chance of error, making medication administration safer for the patient. In order for this technology to work, there must be a patient safety culture throughout the institution, starting at the executive team level. There also has to be buy-in from nurses in order for the systems to work. Because of this, staff education is key and should continue after implementation. The technologies offer an array of reports that will fit well into the hospital s CQI initiatives and the data from those reports should be shared with the front-line staff in an understandable and consistent manner. If planned and implemented correctly, investment in medication safety technologies such as BCMA and intelligent infusion pumps will provide a return on investment both in terms of dollars and patient safety. Based on table 6, assuming that 7% of the intercepted medication errors would have resulted in a harmful ADE, it would take approximately 1.6 months, 2.7 months, and 8.5 months for a hospital to recoup its investment for BCMA, general infusion intelligent pump, and PCA intelligent infusion pump technologies, respectively. Table 6. Return on investment. Technology Cost of ADE A ($) Number of Errors Intercepted in One Month B Monthly Cost Savings of All Intercepted Errors C ($) Monthly Cost Savings of 7% of Intercepted Errors D ($) Annualized Cost Savings of 7% of Intercepted Errors E ($) Total Annual Investment F ($) Projected Annual Return on Investment G ($) Time to Recoup Investment (Months) H BCMA 8, ,932, ,275 4,983, ,049 4,302, Intelligent Pump 8, ,725, ,750 3,969, ,862 3,084, PCA 8, ,500 57, , , , Total 1,312 11,480, ,600 9,643,200 2,054,645 7,588, A. The cost of an ADE is a fixed cost discussed earlier in the paper. B. This is the actual number of errors intercepted at the author s hospital over a one-month period for each of the technologies. C. This was calculated by multiplying the cost of an ADE ($8,750) by the number of errors intercepted over a month. This number reflects the costs avoided through interception of an error. D. This was calculated by multiplying the monthly savings of all intercepted errors by 0.07 (7%), which is the assumed percent of medication errors that will cause harm to the patient. E. This was calculated by multiplying the monthly cost savings of 7% of intercepted errors by 12. The number in this column is the annualized costs avoided by intercepting 7% of all medication errors. F. This cost is a fixed cost determined at the author s institution. G. This was calculated by subtracting the total annual investment from the annualized cost savings of 7% of intercepted errors. This is the projected net amount a hospital would save through implementation of the technology. H. This was calculated by dividing the total annual investment by the monthly cost savings of 7% of intercepted errors. This amount shows the amount of time it would take for a hospital to pay for the technology investment. 8

11 References 1. Brennan, TA, et al. Incidence of adverse events and negligence in hospitalized patientsresults of the Harvard medical practice study I. N Engl J Med 1991;324: Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human- building a safer health system. Institute of Medicine. Washington, DC: National Academy Press, Committee on Quality of Healthcare in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21 st century. Washington, DC: National Academy Press, Leape LL, et al. The nature of adverse events in hospitalized patients- results of the Harvard medical practice study II. N Engl J Med 1991;324: Barker KN, et al. Medication errors observed in 36 health care facilities. Arch Intern Med 2002;162: Santell JP, Cousins D. Medication errorsdocumenting and reducing medication errors. US Pharmacist 2003;Vol 28(No 7) w=article&page=8_1120.htm. Accessed Leape LL, et al. Systems analysis of adverse drug events. JAMA 1995;274: Reason J. Human error: models and management. BMJ 2000;320: Image downloaded from British Medical Journal Web site 7/768/Fu2 (Accessed January 28, 2008). Published in BMJ 2000;320: Schneider PJ. Opportunities for pharmacy. Am J Health-Syst Pharm 2007;64(Suppl 9):S10-S Neuschwander M, et al. Practical guide to bar coding for patient medication safety. Am J Health-Syst Pharm 2003;60: Cummings, et al. Bar-coding medication administration overview and consensus recommendation. Am J Health-Syst Pharm 2005;62: Brown T (ed). Handbook of institutional pharmacy practice. 4 th edition. Bethesda, MD. American Society of Health-System Pharmacists Barcode tool kit s/education/specialprograms/barcodeguide.asp x (accessed ) 15. Siv-Lee L, Morgan L. Implementation of wireless intelligent pump iv infusion technology in a not-for-profit academic hospital setting. Hospital Pharmacy 2007;42(9): Wilson K, Sullivan M. Preventing medication errors with smart infusion technology Am J Health-Syst Pharm 2004;61: Cassano AT. IV medication safety software implementation in a multihospital health system. Hospital Pharmacy 2006;41(2): Medical malpractice verdicts, settlement, and statistical analysis. Jury verdict research. Referenced by: Albert T, Liability insurance crisis: bigger awards just one factor. April 15, 2002; Kaushal R, Bates DW, Landigan C, et al. Medication errors and ADEs in pediatric inpatients. JAMA 2001;285: IOM preventing medication errors report in brief. 3/medication%20errors%20new.pdf (Accessed ) 21. Aspen P, Wolcott J, Bootman JL, et al. Preventing medication errors. Washington, DC. Institute of Medicine. National Academies Press,

12 Continuing Education Processing Continuing education for this activity is processed solely through the ProCE online CE Center. To receive CE credit, please go to: Click on Take Post- Test to enroll and complete the Post-Test and Evaluation. With a passing grade of 70% or greater on the Post-Test, you will be able to print your CE statement of credit online. Post-Test 1. are the most common types of adverse medical events. A. Surgical complications B. Drug complications C. Wound infections D. Technical complications 2. Which of the following statements is true? A. The further we move from the patient, it is less likely a potential error will be intercepted B. The closer we move to the patient, it is less likely a potential error will be intercepted C. The closer we move to the patient, it is more likely an error will be intercepted D. None of the above statements are true 3. At which point would an adverse drug event be least likely to be intercepted? A. Physician ordering B. Pharmacy dispensing C. Transcription/verification D. Nurse administration 4. Which of the following are examples of latent failures that could lead to a serious error? A. Increased nurse workload B. Increasing number of medications C. Increased patient acuity D. All of the above are examples of latent failures that could lead to a serious error 5. What are the patient s five rights? A. Right drug, right patient, right route, right circumstance, right time B. Right drug, right situation, right route, right dose, right time C. Right drug, right patient, right route, right dose, right time D. Right drug, right nurse, right route, right dose, right time 6. Which of the following bar codes is generally not scanned during medication administration? A. Nursing unit identification bar code B. Nurse s identification bar code C. Patient identification bar code D. Medication identification bar code 7. Which of the following is a potential disadvantage of bar code medication administration technology? A. Automated documentation B. Controlled substance tracking C. Cost D. Improved patient safety and accuracy 8. When building a drug library for an intelligent pump, which of the following documentation is not required for the building process? A. Standard drug concentrations B. IV preparation guidelines C. IV infusion administration guidelines D. Order sheets/protocols E. Minutes from P&T Committee meetings 9. Clinical care areas (CCAs) can be defined by A. Demographic unit B. Consolidated groupings C. A combination of both A & B D. A, B, or C are correct 10. For most intelligent pumps on the market, hard-limits cannot be overridden. A. True B. False 10

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