Incorporating Pediatric Medication Safety into your Health System

Transcription

1 Incorporating Pediatric Medication Safety into your Health System Julie Kasap, Pharm.D. Margaret CHOI Heger, Pharmacy PharmD, Supervisor BCPS January 2015 Pediatric Antimicrobial Stewardship Conference June 7 th, 2013 Objectives Identify factors that place pediatric patients at risk for medication errors. List possible interventions to reduce the likelihood of a medication error for a pediatric inpatient. I have no actual or potential conflict of interest in relation to this activity. OSF Saint Francis Medical Center and Children's Hospital of Illinois Peoria, IL 4 th largest Medical Center in IL University of IL College of Medicine at Peoria Level 1 trauma center and tertiary care medical center Children s Hospital of Illinois St. Jude Midwest Affiliate clinic 2010 Milestone Building PGY1 & PGY2 Pediatric Residency Program Mission: To serve with the greatest care and love. Factors Placing Pediatric Patients at Risk Changing pharmacokinetic parameters Ages and stages of maturation Calculations! Lack of commercially available preparations Need precise dose measurement And appropriate delivery system Lack of published data/ FDA labeled dosing J Pediatr Pharmacol Ther 2001;6: Common Pediatric Medication Errors Improper dose/quantity Omission error Wrong drug Prescribing error Hospital survey shows much more needs to be done to protect pediatric patients from medication errors ISMP and the Pediatric Pharmacy Advocacy Group (PPAG) survey to newsletter subscribers Feb 2000 Most prevalent safety practices (312 responses) Patient's age entered Pediatric training for nurses Pharmacist double checks all parenteral solutions 1

2 Hospital survey shows much more needs to be done to protect pediatric patients from medication errors Least prevalent safety practices Including the mg/kg dose within order Lack of clinical pharmacists on units Pti Patient's t' weight ihtis always entered Prescribing CPOE with CDS reports a 36% to 87% reduction in errors* Enable dose alerts Use mg/kg dosing Order sets / preprinted orders Pediatric representation on formulary committees Education and training Ten fold dosing errors Pediatrics 2014;134: CHOI Order Completeness Pediatric Antimicrobial Stewardship Go Live EMR! The Pediatric ASP team Meet twice weekly to review all pediatric patients on anti infectives Education of house staff Order sets CDS for CPOE Chemotherapy Orders in the Era of the EMR CPOE of Chemotherapy What kind of errors are made? Upfront pharmacy involvement Documented triple check for safety Chemotherapy Orders in the Era of the EMR Significant decrease in the % of orders with errors Reduction in most types of errors post intervention 2

3 Dispensing Pediatric Preparations as Unit of Use Dispensing Pediatric satellite pharmacies Clearly differentiate adult vs. pediatric products Standardize pediatric preparations p Parenteral and enteral Barcode scanning Bedside Pharmacy ADCs Parenteral preparations within the IV room Administration Limit override choices in ADCs Access to resources for dose checking Preprinted code sheets with calculations Bedside barcode scanning Dose rounding Smart pumps Patient / Caregiver Education Safe Care Transitions Over 70,000 emergency department visits annually unintentional medication overdoses among children Over 80% of ED visits are due to children taking medications on their own 10% of these ED visits are due to medication errors Prevention of Overdoses and Treatment Errors in Children Taskforce (PROTECT) Initiative Am J Prev Med 2009;37:181 7 Discharge Medication Reconciliation Some pediatric challenges Weight based dosing Compounded suspensions SFMC Discharge Medication Reconciliation Review (Adult and Pediatric) Common errors pharmacists have caught Oral syringes vs. household measuring spoons Communicating the correct volume to administer 24.7% of pharmacy labels did not match volumetric measure of original prescription* J Pediatr 2014;164:

4 Using Teach-Back for Safe Transitions Active process Learner can Demonstrate healthcare skills Verbalize home care instructions Teacher can Verify understanding Correct inaccurate information Reinforce new home care skills Team Approach to Safety Quality Safety Committee Medication Safety Officers Safety Coaches Be creative J Pediatr Nursing 2013:28: Which of the following are factors that place a pediatric patient at risk of a medication error? a. Need for weight based dosing b. Lack of commercially available appropriate dosage forms c. Changing pharmacokinetic parameters as patient ages Which of the following are factors that place a pediatric patient at risk of a medication error? a. Need for weight based dosing b. Lack of commercially available appropriate dosage forms c. Changing pharmacokinetic parameters as patient ages Which of the following interventions can be utilized within the pharmacy to prevent pediatric medication errors? a. Standardize pediatric concentrations of medications b. Provide medications in unit of use packaging c. Separate pediatric and adult batch report dispensing functions Which of the following interventions can be utilized within the pharmacy to prevent pediatric medication errors? a. Standardize pediatric concentrations of medications b. Provide medications in unit of use packaging c. Separate pediatric and adult batch report dispensing functions 4

5 References Levine SR, Cohen MR, et al. Guidelines for preventing medication errors in pediatrics. J Pediatr Pharmacol Ther 2001;6: The Joint Commission : Preventing pediatric medication errors. Sentinel Event Alert #39, April 11, Available online: Institute for Safe Medication Practices: Hospital survey shows much more needs to be done to protect pediatric patients from medication errors. Acute Care ISMP Medication Safety Alert, April 19, Available online: Rinke ML, Bundy DG, et al. Interventions to Reduce Pediatric Medication Errors: A Systematic Review. Pediatrics 2014;134: Schillie SF, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med 2009;37: Shah R, Blustein L, et al. Communicating doses of pediatric liquid medicines to parents/caregivers: A comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy. J Pediatr 2014;164: Kornburger C, Gibson C, et al. Using Teach back to promote a safe transition from hospital to home: An evidence based approach to improving the discharge process. J Pediatr Nursing 2013:28: