MEDICATION MANAGEMENT ASSESSMENT

Transcription

1 MEDICATION MANAGEMENT ASSESSMENT The Mediation Management Assessment provides evidene-based reommendations/standards for Minnesota hospitals in the development of a omprehensive mediation safety program. The assessment and aompanying tool kit were developed by the Minnesota Hospital Assoiation (MHA) Adverse Drug Event (ADE) Advisory Group as the Road Map to a Mediation Safety Program, with funding through the Centers for Mediare & Mediaid Servies Partnership for Patients (P4P) Initiative. The assessment reflets published literature and guidelines by relevant professional organizations and regulatory agenies as well as best praties identified by the MHA Adverse Drug Event Advisory Group. The assessment and tool kit will be reviewed regularly and updated as indiated through published literature. This Material was adapted by Health Servies Advisory Group, the Mediare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under ontrat with the Centers for Mediare & Mediaid Servies (CMS), an ageny of the U.S. Department of Health and Human Servies, from material originally prepared by Minnesota Hospital Assoiation. 2012/2013 Minnesota Hospital Assoiation. Used with permission. The ontents presented do not neessarily reflet CMS poliy. Publiation No. AZ-11SOW-C Minnesota Hospital Assoiation. Used with permission.

2 Mediation Management Assessment Safe from ADE* Speifi Ation(s) Audit Questions Yes No 1) Seure endorsements and resoures for Mediation Safety. 1a) The faility s leadership endorses implementation and sustainment of the Mediation Safety road map praties. SSafety Teams and Organizational Struture 2) Promote Mediation Safety representation and hampions throughout the faility. 1b) Senior leadership has learly ommuniated overall goals for Mediation Safety. 1) Senior leadership regularly reviews progress toward goals and supports adding resoures as appropriate. 1d) The faility has a designated senior leadership sponsor for Mediation Safety. 2a) The faility has an interdisiplinary team involved in addressing Mediation Safety with representation from aross the faility. Mediation Safety hampions/team members/liaisons with lear roles and expetations have been designated from: 2b) Physiian/liensed independent provider knowledgeable in mediation safety. 2) Nursing. 2d) Safety/Quality. 2e) Pharmay. 2f) The faility has a proess in plae to engage other team members as regular or ad-ho members as appropriate (e.g., dietary, laboratory, surgery, purhasing, eduation, risk management, human resoures). AAess to Information 3) Identify gaps and develop ation plans. 1) Trak progress on proess and outome measures. 2g) The faility has a designated oordinator(s) for Mediation Safety. 2h) The oordinator(s) has designated time to serve in this oordination funtion. The interdisiplinary team: 3a) Reviews the Mediation Safety plan throughout the year, and updates the plan as needed, to prioritize and address newly identified improvement opportunities. 3b) Reviews data results at least quarterly and identifies strengths and opportunities. 3) Commissions subgroups as needed to address priority issues requiring subjet matter experts (e.g., IV team, respiratory, pain team). Data Colletion A proess is in plae to ollet Mediation Safety bundle/proess data for the following as appliable: 1a) Hypoglyemi agent gap analysis 1b) Antioagulant gap analysis 1) Opioid agent gap analysis *ADE: Adverse Drug Event Page 1 Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.

3 Safe from ADE Speifi Ation(s) Audit Questions Yes No 2) Review and analyze the data for improvement opportunities. A proess is in plae to trak the following ADE measures, at a minimum: 1d) Number of patients with international normalized ratio (INR) >5 (or outside of established therapeuti range.) 1e) Number of patients with blood gluose < 40 (or outside of established therapeuti range.) 1f) Number of naloxone administrations (or established opioid ADE measure) 1g) A proess is in plae to affirm the reliability of both the proess and outome data obtained through audits. 1h) Standard riteria exist for onduting audits. (e.g. hart audits) when needed. 1i) The faility s doumentation system (eletroni or paper) is designed to apture suffiient detail about adverse drug events that our to allow for adequate event analysis. Data Analysis A proess is in plae to: 2a) Routinely review and analyze data for proess improvement opportunities/defets. 2b) Analyze data related to possible mediation-related readmissions to identify gaps and opportunities for improvement. 2) Trak progress against established targets (e.g., run harts, ontrol harts, dashboards, soreards.) 2d) Prioritize and at upon identified issues. 3) Mediation Safety Program data is shared within and aross units on a regular basis to identify improvement strategies. Data and Information Sharing Mediation Safety Program Event and Adverse Drug Event data and learnings are shared on a regular basis: 3a) Within units. 3b) Aross units. 3) With leadership. 3d) With medial staff. 3e) With the board(s). 4) Report test results in a timely manner. 5) Condut patient sreening and identify potential risks. 3f) Mediation Safety Program/Adverse Drug Event learnings are routinely shared through stories as well as through data (e.g., inlude in daily briefings, unit staff meetings, safety ommittees, newsletters.) 4a) A proess is in plae to provide stat laboratory test results 24 hours a day and 7 days per week to ensure safe and timely monitoring of high risk mediations. 5a) The faility s eletroni health reord diretly interfaes with the laboratory system to automatially alert pratitioners to abnormal values, indiating a potential need to modify high-alert mediation therapy. N/A: The faility s eletroni health reord and/or pharmay omputer system: 5b) Sreens mediation therapy against the patient s linial profile for ontraindiations, interations, and dose appropriateness before drugs are administered. N/A: 5) Alerts health are pratitioners to dupliate lass orders for mediations. N/A: 5d) Performs dose range heks. N/A: 5e) A proess is in plae for pratitioners to sreen for and doument existing diseases or onditions that ould affet the dosing of mediation therapy prior to initiating antithromboti, hypoglyemi, or opioid therapy. Page 2 Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.

4 Safe from ADE Speifi Ation(s) Audit Questions Yes No FFaility Expetations 6) Use prospetive analysis methods to identify risks and/or potential failures in are. 1) Follow standardized praties. 2) Leadership establishes and ommuniates lear expetations. 6a) Prospetive risk analysis methods (e.g., drug monograph, failure modes and effets analysis [FMEA]) are used to proatively identify potential risks assoiated with introdution of new mediations and mediation modalities (e.g., fentanyl patient-ontrolled analgesia [PCA] or liposomal bupiviaine) and new devies (e.g., smart pumps). 6b) A proess is in plae to prioritize and at upon issues identified through the analysis. 1a) The faility follows standardized linial pratie guidelines when developing order sets, poliies, and proedures. 1b) There is standard proess in plae to promptly retrieve outdated protools, pathways, guidelines, nomograms, order sets, flow sheets, and/or heklists throughout the faility and to replae with updated versions. 1) There is a standard proess in plae to ommuniate hanges to staff members. In failities with key or multiple teams addressing mediation safety (e.g., antioagulation therapy group, pain ommittee, or diabetes management team): 1d) Key teams lead and develop institutional poliies and proedures related to speifi high-alert mediations (e.g., the antioagulation therapy team leads antioagulation praties; pain team leads opioid praties; diabetes management team leads hypoglyemi agent praties). 1e) There is a proess in plae to ensure ommuniation and information sharing within teams and aross teams. 2a) Diret patient are staff members (e.g., nurses, physiians, pharmaists, pharmay tehniians) is informed of expetations and performane standards regarding their role in the Mediation Safety Program. 2b) Support staff members (e.g., laboratory, supply hain, operations) are informed of expetations and performane standards regarding their role in mediation safety. 2) The faility has a well defined proess to support a ulture that enourages staff to speak up and stop the line regarding any onern related to mediation safety. The stop the line proess learly outlines: 2d) When to stop the line. 2e) How to stop the line (e.g., I need larity ). 2f) The hain of ommand to follow if not supported in stopping the line. 3) Provide eduation for diret are and support staff members. 2g) Clear ommuniation to staff members from managers and leadership that staff will be supported if they speak up. Expetations and supporting Mediation Safety Program eduation have been inorporated into new employee orientation for: 3a) Diret patient are staff members. 3b) Support staff members. 3) Expetations and supporting Mediation Safety Program eduation have been inorporated into employee orientation for personnel employed by outside agenies and ontrated personnel. 3d) Mediation Safety Program eduation is provided to diret are staff members at least annually. 3e) Mediation Safety Program eduation is provided to support staff members when new relevant information is available. 3f) Expetations and supporting Mediation Safety Program eduation have been inorporated in new physiian orientation. Page 3 Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.

5 Safe from ADE Speifi Ation(s) Audit Questions Yes No 4) Establish a strutured ommuniation proess. The faility has a proess in plae whih evaluates staff ompetenies related to high-risk mediations inluding: 3g) Eduation on high-risk mediations in provider, presriber, pharmay, and nursing staff member orientation and ongoing ompeteny assessment. 3h) Development of poliies whih learly delineate the roles and responsibilities of physiians, presribers, pharmaists, and nurses for high-risk mediation use. 3i) Eduation on how to ondut effetive independent double heks for high risk mediations. 4a) The faility has strutured ommuniation tools (e.g., Situation, Bakground, Assessment, Reommendation [SBAR]) for ommuniation related to high-risk mediations at all levels of the organization. A strutured hand-off proess is in plae throughout the organization with speifi elements outlined that must be inluded for hand-offs: 4b) During shift-hange 4) Between departments/units 4d) To other failities 5) Establish an effetive mediation reoniliation proess. The faility s admission mediation reoniliation proess inludes, at a minimum: 5a) A good faith effort at verifiation of patient home mediation list. 5b) Identifiation and resolution of potential drug interations. 5) Identifiation and resolution of onomitant therapies. The faility s disharge mediation reoniliation proess inludes, at a minimum: 5e) Verifiation of patient mediations and dosages. 5f) Flag potential for mediation-related readmissions (e.g., polypharmay, high-alert mediations, multiple disease states, et.). 6) Dislose unantiipated outomes. A proess is in plae to promptly inform families when an Adverse Drug Event ours and inludes, at a minimum: 6a) Diretion on who should disuss the unantiipated outome with the patient/ family, and how that disussion should our. 6b) Individuals designated to provide dislosure to patients reeive training on effetive dislosure strategies. 6) A proess for dislosing to, and updating, patient/family as the event is reviewed and analyzed. 6d) A designated person is available to provide support and just-in-time training to staff members who are about to dislose an unantiipated outome to a patient/family. 1) Eduate and empower patients and families. 1a) A proess is in plae to assess and address any barriers to patient/ family ability to understand their role in adverse drug event prevention (e.g., ultural, language, hearing impairment, and health literay). EEngagement of Patient, Client, Resident, and Family 1b) Patients/families are eduated on their role in preventing adverse drug events and prevention measures they an expet to see from staff and providers aring for them in the hospital (e.g., bedside baroding, explaining purpose of mediations, identifying potential side effets of mediations, asking name and birthdate before mediation administration). 1) A proess is in plae to assess patient /families level of understanding of the eduation provided (e.g., teah bak.) 1d) The faility has a proess in plae to enourage patients and families to speak up if they have onerns about diret are/support staff/provider praties or other issues that may inrease the risk of a mediation error. 1e) A proess is in plae to report bak to patients/families that have shared a onern. Page 4 Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.