HOSPITAL FOCUS: TIPS TO REDUCE MEDICATION ERRORS IN THE HOSPITAL PHARMACY SATURDAY/4:30-5:30PM ACPE UAN: 0107-9999-16-040-L05-T 0.1 CEU/1 hr Activity Type: Application-Based Learning Objectives for Pharmacy Technician: Upon completion of this CPE activity participants should be able to: 1. Defi ne the various types of medication errors 2. Discuss the negative impact of medication errors on society 3. List high-risk medications that are prone to medication errors 4. Describe where medication errors may occur throughout the dispensing process 5. Identify strategies that may be employed to decrease the occurrence of medication errors in the hospital setting Speaker: Amanda Johnson, PharmD Amanda Johnson is a PGY2 Critical Care Pharmacy Resident at Avera McKennan Hospital & University Health Center in Sioux Falls, SD. She completed her undergraduate and graduate training at South Dakota State University in Brookings, SD. Her research project this year is focusing on outcomes of epinephrine during cardiac arrest and medication utilization in ACLS medication trays. Her interest areas include neurology, trauma, and cardiology. Speaker Disclosure: Amanda Johnson reports no actual or potential confl icts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation. FEBRUARY 13, 2016 IOWA EVENTS CENTER DES MOINES, IOWA
Tips to Reduce Med Errors in the Hospital Pharmacy Setting Amanda Johnson, PharmD PGY2 Critical Care Pharmacy Resident Avera McKennan Hospital & University Health Center Disclosure Amanda Johnson reports no actual or potential conflicts of interest associated with this presentation 1
Learning Objectives Upon successful completion of this activity, technicians should be able to: Classify the various types of medication errors. Discuss the negative impact of medication errors on society. List "high-risk" medications that are prone to medication errors. Describe where medication errors may occur throughout the dispensing process. Identify strategies that may be employed to decrease the occurrence of medication errors. Medication Errors 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 Nebeker JR. Ann Intern Med 2004. NCC MERP 2
Classifying Medication Errors Hartwig SC. Am J Hosp Pharm 1991. 3
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Impact on Society Cost Did not reach the patient (Categories A,B): $6.92 Reached the patient (Categories C-I): $147.96 Did not cause harm: $11.85 Caused harm: $1,473.40 Loss of trust in the health care system by patients Diminished satisfaction by both patients and health professionals Samp JC. Pharmacotherapy 2014. Kohn LT. 2000. High-Alert Medications All forms of insulin U-500 U-300 Epinephrine http://www.mediccast.com/blog/2014/12/23/long-termeffects-of-epinephrine-on-cardiac-arrest-patients/ http://thehealthscience.com/node/1211878 ISMP 2014. 5
High-Alert Medications Electrolytes (IV) Magnesium sulfate Potassium chloride Potassium phosphate Parenteral nutrition preparations Chemotherapeutic agents (parenteral and oral) Epidural or intrathecal medications ISMP 2014. Confused Drug Names Examples bupropion buspirone glipizide glyburide guanfacine guaifenesin hydroxyzine hydralazine LORazepam clonazepam NIFEdipine nimodipine diltiazem diazepam ISMP 2015. 6
Where do medication errors occur? Prescribing/Ordering: 49% to 56% Administration: 26% to 34% Dispensing: 14% Hughes RG. Am J Nurs 2005. Strategies for Prevention High-alert medications Confused drug names Health information technologies Computerized provider order entry (CPOE) Unit dose dispensing Bar coding Automated dispensing cabinets Assertive communication methods ISMP 2014. ISMP 2015. Hughes RG. Am J Nurs 2005. 7
Computerized Provider Order Entry (CPOE) Recommended by Institute of Medicine May reduce errors from poor handwriting or incorrect transcription 2013 review Estimated 17.4 million medication errors per year avoided due to CPOE (12.5% reduction) Processing a drug order through CPOE decreases the likelihood of error on that order by 48% User errors Radley DC. J Am Med Inform Assoc 2013. CPOE at Avera McKennan Meditech Order sets, saved favorites Reduced errors due to poor handwriting/incorrect transcription Pyxis Connect User errors Not using order sets Continuation of home medications Alert fatigue Education on updates 8
Bar Coding Bar code-assisted dispensing Incidence of target dispensing errors All doses scanned: 93-96% relative reduction 1 dose scanned: 60% relative reduction Implementation may result in unintended consequences and new types of errors Bar coded medication administration (BCMA) Reportedly produce 54-87% reductions in errors during administration Poon EG. Ann Intern Med 2006. Agrawal A. Br J Clin Pharmacol 2009. Bar Coding at Avera McKennan Replacing & Updating Inventory Dispensing Pyxis Restock Bar Coded Medication Administration (BCMA) 9
Bar Coding at Avera McKennan Bar code refill and dispensing Increased patient safety All medications to be scanned prior to final dispensing/distribution Required scanning prior to Pyxis refill Bar coded medication administration (BCMA) >95% bar code scan rate since implementation Reduction in errors Automated Dispensing Cabinets (ADCs) Replaced individual patient unit-dose cassettes Benefits After ADC implementation Lower rates of dispensing errors in filling ADCs compared with manual filling of unit-dose cassettes Fewer errors in drug administration and fewer missing doses An increase in errors (by more than 30%) in 6 of 7 nursing units evaluated Crucial to use ADC systems with minimal bypasses Grissinger M. P T 2012. ISMP 2008. 10
ADC Tips and Recommendations ISMP 2008 guidance document Store each medication and strength in an individual lidded ADC compartment that opens only when the specific medication is selected Limit medications stored in matrix drawers to non-opiate analgesics and antacids Select one medication at a time for ADC distribution Use bar code scanning to confirm that the medication selected for distribution to the ADC matches the medication listed on ADC fill report Develop a check process prior to dispensing Organize medications by patient care unit, drawer, and bin Use bar code scanning to identify the correct drawer and pocket and to scan the drug being delivered ISMP 2008. ADCs ADC utilization at Avera McKennan How does your institution utilize ADCs? 11
Assertive Communication Methods Speak up! Make an opening State the concern State the problem (real or perceived) Offer a solution Reach agreement on next steps AHRQ 2015. Two-Challenge Rule Your responsibility to assertively voice concern at least 2 times to ensure that it has been heard Team member being challenged must acknowledge that concern has been heard If safety issue still hasn t been addressed Take stronger course of action Utilize supervisor or chain of command AHRQ 2015. 12
CUS AHRQ 2015. 13
Reporting Medication Errors Institute of Medicine (IOM) report emphasized the importance of reporting errors Use systems to hold providers accountable for performance and provide information that leads to improved safety Reporting potentially harmful errors that were intercepted before harm was done, errors that did not cause harm, and near-miss errors is as important as reporting the ones that do harm patients Patient safety initiatives target systems-related failures Efforts may fail because errors are not reported voluntarily or captured through other mechanisms Wolf ZR. Patient Safety and Quality: An Evidence-Based Handbook for Nurses 2008. Reporting Medication Errors Voluntary reporting systems more successful than mandatory systems National reporting program: Medication Errors Reporting Program (MERP) Pass information to FDA s MedWatch Voluntary reporting systems at individual institutions Avera McKennan: reporting system within Meditech Examples of system changes due to error reports Heparin drips Medication reconciliation How does your institution report medication errors? Barron WM. Jt Comm J Qual Saf 2003. 14
Conclusion Medication errors are a preventable event with a negative impact on society High-alert medications and confused drug names lists are created by ISMP Medication errors occur most frequently during drug administration Technology including CPOE, ADCs, and bar coding have been shown to decrease medication errors Assertive communication methods should be used if a concern or problem arises References Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: a clinician s guide to terminology, documentation, and reporting. Ann Intern Med 2004;140:795-801. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Consumer information for safe medication use. 2015. Available at: http://www.nccmerp.org/consumer-information Hartwig SC. Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm 1991;48(12):2611-6. Samp JC, Touchette DR, Marinac JS, et al. Economic evaluation of the impact of medication errors reported by U.S. clinical pharmacists. Pharmacotherapy 2014;34(4):350-7. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. 1 st ed. Washington, DC: National Academy Press;c2000. Institute for Safe Medication Practices (ISMP). ISMP list of high-alert medications in acute care settings. 2014. Available at: https://www.ismp.org/tools/highalertmedications.pdf Institute for Safe Medication Practices (ISMP). ISMP s list of confused drug names. 2015. Available at: https://www.ismp.org/tools/confuseddrugnames.pdf Hughes RG, Ortiz E. Medication errors: why they happen, and how they can be prevented. Am J Nurs 2005;105(3) Supplement:14-24. Radley DC, Wasserman MR, Olsho LEW, et al. 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. Agrawal A. Medication errors: prevention using information technology systems. Br J Clin Pharmacol 2009;67(6):681-6. Poon EG, Cina JL, Churchill W, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med 2006;145:426-34. Grissinger M. Safeguards for using and designing automated dispensing cabinets. P T 2012;37(9):490-1,530. Institute for Safe Medication Practices (ISMP) guidance on the interdisciplinary safe use of automated dispensing cabinets. 2008. Available at: http://www.ismp.org/tools/guidelines/adc_guidelines_final.pdf TeamSTEPPS 2.0. September 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.html Wolf ZR, Hughes RG. Error Reporting and Disclosure. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 35. Available from: http://www.ncbi.nlm.nih.gov/books/nbk2652/ Barron WM, Kuczewski MG. Unanticipated harm to patients: deciding when to disclose outcomes. Jt Comm J Qual Saf. 2003;29:551 5. 15