Pharmacy Technicians: Patient Safety Involvement
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1 Pharmacy Technicians: Patient Safety Invlvement Presented & Created By: Christen Schenkenfelder, CPhT Directr, Pharmacy Technician Prgram Sullivan University Dn Carpenter, CPhT III St. Claire Reginal Medical Center
2 Objectives After this presentatin the audience will; Be able t describe what patient safety encmpasses. Identify the relatinship between medicatin errrs and patient safety. Emply strategies at their facility t help reduce the number f medicatin errrs. Explain the imprtant rles they have in prviding the safest patient care pssible.
3 Disclsure The cmpany and brands discussed in this presentatin are prducts that are used at St. Claire Reginal Medical Center (SCR). I have nt received any gratuities r cmpensatin frm any utside entity.
4 What is Patient Safety ACPE Defines Medicatin Safety as- The preventin f healthcare errrs, and the eliminatin r mitigatin f patient injury caused by healthcare errrs (An unintended healthcare utcme caused by a defect in the delivery f care t a patient.) Healthcare errrs may be errrs f cmmissin (ding the wrng thing), missin (nt ding the right thing), r executin (ding the right thing incrrectly). Errrs may be made by any member f the healthcare team in any healthcare setting. (definitins apprved by the Natinal Patient Safety Fundatin Bard July 2003)
5 What is Patient Safety Wiki- Patient safety is a new healthcare discipline that emphasizes the reprting, analysis, and preventin f medical errr that ften leads t adverse healthcare events.
6 Key Definitins Medical errr- used t refer t all adverse health events Adverse Drug Event- an injury resulting frm the use f a drug. Under this definitin the term ADE includes harm caused by a drug (ADR and verdses) and harm frm the use f the drug (dse reductins and discntinuatin Medicatin errrs as defined by the Natinal Crdinating Cuncil fr Medicatin Errr Reprting and Preventin is any preventable event that may cause r lead t inapprpriate medicatin use r patient harm, while the medicatin is in cntrl f the health care prfessinal, patient, r cnsumer.
7 Medicatin Errrs Effects Lives: Emily Jerry & Eric Crpp Stry
8 Medicatin Errr Statistics Average errr rate in Cmmunity pharmacies is 1.7% Equal 30,000,000 dispensing errrs/year
9 Apprximately hw many peple are injured annually in the US frm medicatin errrs? A. 10,000 peple B. 100,000 peple C. 500,000 peple D. 1 millin peple ANSWER: 1.5 Millin (Accrding t the Institute f Medicine reprt n Preventing Medicatin Errrs)
10 Statistics Different Studies have shwn a range f data fr medicatin errrs. Sme shw 1 death per day due t a medicatin errr Other shw upwards f 19 deaths per day Serius preventable medicatin errrs ccur in: 3.8 millin inpatient admissins millin utpatient visits 3 Ntes 2. Massachusetts Technlgy Cllabrative (MTC) and NEHI, Saving Lives, Saving Mney: The Imperative fr CPOE in Massachusetts. Updated t 2008 figures. Cambridge, MA: NEHI, Available at: 3. Center f Infrmatin Technlgy Leadership (CITL), The Value f Cmputerized Prvider Order Entry in Ambulatry Settings. Updated t 2007 figures. Available at: Last accessed Octber 2011.
11 The Cst f Medicatin Errrs Annual Cst f Preventable Medicatin Errrs by Setting:
12 Wh is at Risk Senir citizens make up 40% f the fatalities related t a medicatin errr. Generally n 10 r mre prescriptins Pediatrics are the secnd highest categry.
13 Increasing Patient Safety What is the number ne way fr pharmacy staff t increase patient safety? Decrease the amunt f medicatin errrs
14 Hspital Statistics Estimates range frm 2-7 deaths per 100 admissins. Csting hspitals 3.5 t 5.6 billin dllars per year
15 St. Claire Reginal Medical Center (SCR)
16 St. Claire Reginal Medical Center SCR Facts Licensed fr 159 beds Apprximately 1400 staff members Half-millin annual patient encunters 31 Medical Specialties 5 Family Medicine Clinics 2 Specialty Clinics 1500 Admissins SCR Pharmacy 24/7 pharmacy services 9 Full-time/3 part-time Pharmacists 2 PGY1 Pharmacy Residency psitins 3 levels f Technicians 32 autmated dispensing cabinets 350,000 + Orders entered per year 1800 frmulary items
17 St. Claire Reginal Lking at the Math SCR has 1500 admissins per year Fatal medicatin errrs wuld range frm 30 t 105 deaths per year due t a medicatin errr.
18 Histric SCR Statistics Fiscal Year medicatin errrs 121 reached the patient 101 did n harm 18 increased mnitring w/n harm 2 treatment given t prevent harm 1873 rdering errrs 1855 errrs required pharmacist interventin Fiscal Year medicatin errrs 168 reached patients 146 did n harm 18 increased mnitring w/ n harm 1 treatment given t prevent harm 3 initial r prlnged hspitalizatin, temprary pt. harm 1410 rdering errrs 1383 errrs required pharmacist interventin
19 SCR Statistics
20 SCR Statistics
21 SCR Statistics
22 SCR Statistics
23 SCR Statistics
24 Cmmunity Pharmacy Errrs These are much mre difficult t track due t the administratin aspect. Track nly errrs and near misses discvered in the pharmacy. Can t track administratin errrs (frm patients r care givers)
25 Hw can Technicians Help Be Active & Be Aware!!!!!!!!!!!!!!!!!
26 2014 Natinal Pharmacy Technician Regulatin Screcards
27 Emily Jerry Fundatin Grading Scale: A % B % C % D % F %
28 Scring Scale: Educatin, Training, & CE
29 Scring Scale: Certificatin & Registratin/Licensure
30 Lk-alike & Sund-alike Drugs Institute f Safe Medicine Practices (ISMP) & Jint Cmmissin wrk t develp list and review names Examples include: Adacel vs Daptacel Advair vs Advicr buproin vs buspirne CeleBREX vs Cerebyx glipizide vs glyburide
31 TaLL Man LeTTering ISMP guidelines and recmmendatins Example hydralazine & hydroxyzine
32 High Alert Medicatins ISMP High alert medicatin list Separate list fr Hspitals and Cmmunity Examples: warfarin carbamazapine metformin EPINEPHrine ptassium phsphates
33 Abbreviatins ISMP errr prne list f abbreviatins Examples: µg mistaken fr mg MSO4 mistaken fr MgSO4 HCT mistaken fr HCTZ Nte: Similar list maintained by Natinal Assciatin f Chain Drug Stres website:
34 Wrkflw design Evaluate yur wrkflw and the pharmacies wrkflw: Lk fr breakdwns in efficiency Areas that are likely t be time sensitive Duties that can be perfrmed during lwvlume times Discuss this as a grup
35 Quality Imprvement Shuld be pen errr reprting withut FEAR f retaliatin If an errr ccurs it shuld be investigated and the rt cause shuld be fund and evaluated fr ptential future errrs.
36 Questins??
37 References Natinal Crdinating Cuncil fr Medicatin Errr Reprting and Preventin (NCCMERP). Website Abut Medicatin Errrs. Natinal Patient Safety Fundatin, Press Release, Octber Flynn EA, Barker KN, Carnahan, BJ. Natinal bservatinal study f prescriptin dispensing accuracy and safety in 50 pharmacies. J AM Pharm Assc. 2003;43: Wikipedia ACPE website Natinal Institute f Medicine. T Err is Human: Building a Safer Health System. Washingtn, DC. Natinal Academy f Sciences; ISMP FAQ Institute f Medicine, July 2006 Preventing Medicatin Errrs Strickland J, McCarthy K. Medicatin Errrs and Patient Safety: Lessn s Learned Frm Tragedy. The Emily Jerry Fundatin website Hspital Survey n Patient Safety Culture:2014 User Cmparative Database Reprt: Agency fr Healthcare Research and Quality, Rckville, MD.
38 Christen Schenkenfelder Sullivan University Cllege f Pharmacy Luisville, KY [email protected] Dn Carpenter, CPhT III St. Claire Reginal Medical Center Mrehead, KY [email protected]
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