Medication Errors 1022 - Cdn.ymaws
10/19/2017DISCLOSUREPREVENTING MEDICATION ERRORS IN PHARMACY PRACTICEThe speakers have nothing to disclose concerning possible financial orpersonal relationships with commercial entities (or their competitors) that maybe referenced in this presentation.Pamela Schauben, R.Ph., M.S.Bill Renfro, Pharm. D.Ly Nguyen, Pharm. D., BCPSLEARNING OBJECTIVESAt the conclusion of this activity, participants should be able to: Discuss the national medication error data and trends Understand the medication error analysis process Explain the importance of transitions of care in improving patient safety andreducing medication errors. Describe the role of the pharmacist and technician in transitions of careLEARNING OBJECTIVESAt the conclusion of this activity, participants should be able to: Discuss the national medication error data and trends Understand the medication error analysis process Explain the importance of transitions of care in improving patient safety andreducing medication errors. Describe the role of the pharmacist and technician in transitions of careDEFINITION"A medication error is any preventable event that may cause or lead toinappropriate medication use or patient harm while the medication is in the controlof the health care professional, patient, or consumer. Such events may be related toprofessional practice, health care products, procedures, and systems, includingprescribing, order communication, product labeling, packaging, and nomenclature,compounding, dispensing, distribution, administration, education, monitoring, anduse."NCCMERP. About Medication Errors 20151
10/19/2017The Joint Commission. Sentinel Event Data Root Causes by Event Type2004 –3Q 2015.The Joint Commission. Sentinel Event Data ‐ Event Type by Year 2017“THE MAJORITY OF EVENTS HAVE MULTIPLE ROOT CAUSES”“KEY ELEMENTS” OF THE MEDICATION-USE SYSTEMPatient informationCase 1: Patient not responding to amiodarone, lidocaine loading dose/infusion ordered. Physician’s previous facility uses bolus from the premixed bag Nurse questions the order, physician affirms. Nurse sets the pump to run the loading dose, but forgets to set a time limitPatient receives very high dose of lidocaineDrug informationCommunication of drug informationDrug labeling, packaging and nomenclatureDrug storage, stock, standardization, and distributionDrug device acquisition, use and monitoringEnvironmental factorsStaff competency and educationPatient educationQuality processes and risk managementInstitute for Safe Medication Practices. Frequently Asked Questions (FAQ) 2015HIGH-ALERT MEDICATIONS – ACUTE CAREHIGH-ALERT MEDICATIONS – ACUTE CARE (CONT)adrenergic agonists, IVchemotherapeutic agentsinsulin, subcutaneous and IVneuromuscular blocking agentsadrenergic antagonists, IVdextrose, hypertonicliposomal forms of drugsparenteral nutrition preparationsanesthetic agents, general, inhaled and IVdialysis solutionsmoderate sedation agents, IVradiocontrast agents, IVantiarrhythmics, IVepidural or intrathecal medicationsmoderate sedation agents, oral, for childrenantithrombotic agentshypoglycemics, oralnarcotics/opioids IV, transdermal, oralsterile water for injection, inhalation, andirrigationcardioplegic solutionsinotropic medications, IVInstitute for Safe Medication Practices. List of High‐Alert Medications in Acute Care Settings 2014sodium chloride for injection, hypertonicInstitute for Safe Medication Practices. List of High‐Alert Medications in Acute Care Settings 20142
10/19/2017PACKAGING AND L ABELINGHIGH-ALERT MEDICATIONS – AMBULATORYInstitute for Safe Medication Practices. List of High‐Alert Medications in Community/AmbulatoryHealthcare.MEDICATION SHORTAGESPage 1 of 9SALAD creation (similar packaging)Unfamiliarity with substitute productSubstitute is less effectiveSubstitute not in BCMA database, warningsnot built, etc. Treatment delays No alternative treatment available Institute for Safe Medication Practices. ISMP’s List of Confused Drug Names. 2015WHY DON’ T SAFETY MECHANISMS WORK?DISTRACTIONCase 2 56 yo male admitted for replacement of PEG tube, on warfarin PTA 5mg/day forintracardiac mural thrombus. Admission INR 1.4 - dose increased to 10mg perday. Day 2, decision to stop the warfarin and do an echo to confirm anticoagulationstill needed. Resident started to d/c the order via smartphone, but in theinterim received a text about a party. Warfarin was not d/c’d, but the team thought it was, so they didn’t check INR. Most of the time, they doHuman natureConfirmation biasSafety mechanisms defeated due to time priorityIntimidationAlert fatigueGIGO (garbage in, garbage out)Day 4, pt developed SOB, tachycardia and hypotension. Echo revealedcardiac tamponade; INR found to be 8.5Halamaka J. AHRQ Patient Safety Network. WebM&M. December 2011.3
10/19/2017Case 3: 16 yo male with NEMO deficiency syndrome for an elective colonoscopy. Patient taking Septra DS 1 tablet BID Order entered for Septra DS 38 ½ tablets The full dose was administeredThe patient had a grand mal seizure, stopped breathing andrequired 8#.4kkbryhfaALERT FATIGUEMethodsPrescribers were observed for 102 hours in situ as they ordered medications for patientsand resolved alerts, then interviewed.ResultsPrescribers: n 30 Patients: n 146Alerts: n 320 (2.2/pt)Alert fatigue: 37/320 (11.6%)Problems:Lack of specificityNo indication of level of riskPoor credibilityRedundancyRuss AL, et al. International Journal of Medical Informatics. April 2012; 81(4):232‐243.INTIMIDATIONSurvey: 4,884 respondents.Nurses (68%) pharmacists (14%), 200 physicians.Most (66%) staff-level practitioners.At LeastOnce (%)Often (%)Assume order is safe because of the stellar reputation of theprescriber302Felt pressure to accept an order, dispense a product, oradminister a drug despite concerns about safety393HUMANS VS. TECHNOLOGYExpectations:Reality:“If I’m not supposed to, the systemwill stop me”Systems are programmed andmaintained by humans.“Computers are infallible”Settings often have unexpectedoutcomesMedicationSafetyAlert! Acute Care Volume 18 Issue 20. ISMP October 3, 20134
10/19/2017FAILURE MODES IN THE BCMA PROCESS Medication does not come packaged as bar-coded unit-dose product Pharmacy does not scan products arriving in pharmacy for readability Pharmacy applies correct label with bar code to wrong product Drugs not available in ready-to-use unit-doses for nurse (e.g., tablets not broken in half)“ missing special characters such as decimal point, forward slash, orpercentage in some records”Ex: the strength of a drug previously dispensed may be reported as“ramipril 25 mg capsules,” when it should have been reported as“ramipril 2.5 mg capsules.” Nurse fails to scan patient Nurse fails to scan medication Bar code on patient and/or medication is unreadable Patient wristbands are not on patients but other locations (e.g., clipboards, med rooms) Nurse overlooks alert displayed on computer screen Nurse overrides alert without investigating its causeNational Alert Network (NAN), National Coordinating Council for Medication ErReporting and Prevention (NCC MERP) February2014Pennsylvania Patient Safety Advisory. Pa Patient Saf Advis 2008 Dec;5(4):122‐6.DEVICE USECase 4Patient weighed 95 lb, but 95 kg entered into the “smart pump”Order for heparin infusion 15 units/kg/hrPatient received 1425 units/hr instead of 648 units/hrPump is programmed to detect doses over 20 units/kg/hrBUT it doesn’t know how much the patient weighs Electronic medical recordTallman lettering/SALAD warningsBar coded medication administration (BCMA)Bar coded/RFI medication dispensingAutomated sterile product prep/check“Smart” infusion pumpsMedication ReconciliationStandardizing concentrationsError reportingSAFETY MEASURESJOINT COMMISSION NATIONAL PATIENT SAFETY GOALSRELATED TO 1/6/NPSG Chapter HAP Jan2017.pdf5
10/19/2017SUMMARY – MEDICATION ERROR TRENDSMEDICATION SAFETY RESOURCESInstitute for Safe Medication Practices (ISMP)www.ismp.orgAmerican Society of Medication Safety Officerswww.asmso.orgThe Joint Commissionwww.jointcommission.orgHospital quality of carewww.hospitalcompare.hhs.govUnited States Food and Drug Administrationwww.fda.govNational Guideline Clearinghousewww.guidelines.govInstitute for Healthcare Improvement (IHI)www.ihi.orgThe Cochrane Collaborationwww.cochrane.orgAgency for Healthcare Research and Quality (AHRQ)Centers for Disease Control and Prevention (CDC)www.psnet.ahrq.govwww.cdc.govASSESSMENT QUESTION 1Which of the following statements is FALSE?A. The majority of events have multiple root causesB. Known causes of medication errors include: confusing labeling andnomenclature, human and environmental factors and medication shortagesC. Medication safety measures include barcoding, smart pumps, medicationreconciliation and pharmacistsD. Medication errors are the most common sentinel event reported.E. None of the aboveMedication use process: complex and many opportunities for errorsThe majority of events have multiple root causesMedication safety tips: Double check as much as possibleDo not rely on the computer system to catch all errorsAsk questions, and encourage others to ask questionsAssist with workflow/alert improvement effortsReport near misses and errorsLEARNING OBJECTIVESAt the conclusion of this activity, participants should be able to: Discuss the national medication error data and trends Understand the medication error analysis process Explain the importance of transitions of care in improving patient safety andreducing medication errors. Describe the role of the pharmacist and technician in transitions of careREPORTING SYSTEMSINCIDENT REPORTING SYSTEMS Automated reporting system built for ADRs, errors, falls, quality incidents Needs to provide “a big picture” of events reported with categories Needs to explain the event for tracking and trending, but most importantly toprevent recurrence6
10/19/2017REPORTINGIs not a tool for getting someone in troubleIs not a once and done choreFor medication errors include quantity if known, exactly where occurred (whichdispensing cabinet etc.), and any other medications associated with errorDoes not have to include a specific patientCan be anonymous, but hard to follow up with if neededREPORTINGADR vs errorERRORADRREPORTING Initial review and assessment by Risk DepartmentTask assigned to individual reviewers (usually more than one)Inpatient vs outpatient vs North campus vs Oncology satellitesTasks are different levels or responseRisk can amend some elementsREPORTING Where do issues ”go” based on HIPPA regulations?If needed- ManagerIf applicable- to pharmacist reporting or managing the patientIf applicable to prescriber’s service reviewer, Nursing, Radiology, etc.Department QI meetingsMedication Safety TeamAPIT and IPITMUAP&TREPORTING Departments may look for trends or just a singular event for resolutionMany events have a “rest of the story” that require analysisDifficult to make comparisons for trendingSome issues have too many moving partsMay trigger a RCAMay involve the institution’s SIPNEW RCARCsA2Root Cause(s) Analysis and Action7
10/19/2017RCSA2COMPONENTS OF RCSA2Should occur as soon as possible after discoveryStaff directly involved may or may not be includedRisk staff and reviewersLegalAdministration of departments involvedSometimes an unattached observer may be utilized Managers gather statements from all parties with corroboration if possibleReview of how event occurred in time-line fashion based on statementsReview procedures for correct processLook for gaps in what actually occurred and what should have occurredRCSA2 Gaps may involve communication problem-human error (SALADS) Gaps may involve procedure not followed-risk (BCMA override or Epic overrideof significant allergy) Gaps don’t usually involve frank disregard-recklessRCSA2 Human errors are coached to correct Procedures are examined for completeness and accuracy Procedures may be modified based on review with other departments topromote cohesive action Expectations of follow through for each department are set with time limitRCSA2RCSA2 December 24, 2014 Significant Decline in ADEs Bolsters Safety in Hospitals; 50,000 Deaths Averted Washington, D.C.—An estimated 50,000 fewer patients died in U.S. hospitals and about 12 billion inhealthcare costs was saved due to the reduction in hospital-acquired conditions from 2010 to 2013,according to a report released by the Department of Health and Human Services (HHS).8
10/19/2017CHANGE IN HACS, 2011-2015 (TOTAL 3,097,400)JUST CULTURE Idea fostered by Dr. Lucian Leape in the late 1990’s Designed after other accident conscious businesses-airlines for example “To make no mistakes is not in the power of man; but from their errors andmistakes the wise and good learn wisdom for the future”PlutarchAgency for Healthcare Research and Quality. December 2016.JUST CULTURE Where does “Just Culture” fit into medication safety? Blame game-who is at fault Nobody’s fault- It’s the system at fault Action taken is commensurate with outcome Nobody was hurt vs. poor patient responseJUST CULTURE Just Culture is none of these System to evaluate whether the error was a result of human error vs. riskybehavior vs. reckless behavior and apply corrective action to match type of error Designed to encourage safety by reporting related event regardless of outcomeTHREE HUMAN BEHAVIORSHuman errorRiskyRecklessHUMAN ERROR Inadvertent action- slip, lapse, mistakeDelayMisplaced decimal pointForgot to renal adjust doseMinimize through training, systems, processes Console offender9
10/19/2017AT RISK BEHAVIORAT RISK BEHAVIOR? Choice of action when risk is not recognized or is considered justified Procedural rules not followed Incentivize following rules/increase redundancy Coach offenderAT RISK BEHAVIOR At risk is usually a result of “drift” from usual processToo busy, too comfortable, or find a short cutHappens with more experienced staffMulti-taskingWhat if there is no procedure to follow?There is a “Reasonable Person “ StandardJUST CULTURE Evaluation follows an algorithm of yes/no questionsDuty to produce outcomeDuty to follow procedureDuty to not act with reckless disregard10
10/19/2017DUTY TO PRODUCE AN OUTCOME Duty to get to work on time (produce an outcome)If outcome not met and yes/no algorithm finds event as human error-ConsoleEvaluate system and employee for opportunity to correctIf repetitive and no system improvement possible-consider punishmentDUTY TO FOLLOW PROCEDURAL RULE Is there a rule to keep children away while feeding a crocodile? What if Steve didn’t know procedural rule human error Reasonable person standardRECKLESS BEHAVIOR Did the offender’s behavior put a patient or the institution in harm’s way? Two key questions- Was the behavior justified and was it the choice of theoffender to make? Action includes-support, console, coach If reasonable answers. May require corrective/punitive action if reckless disregard.ASSESSMENT QUESTION 2Just Culture is?A. A series of analytical questions and steps to determine degree of punishmentfor perpetrator of a medical error.B. A term that describes formal attempts for prevention of medical errors byfocusing on as many opportunities as possible, including misses and nearmisses in a case‐by case algorithm to find and remedy the ultimate cause.C. A process in which attempts to blame the human responsible for a medicalerror.D. A system that attempts to prevent errors by providing “just‐in‐time” educationto health care workers.11
10/19/2017TOC DEFINITION:THE NATIONAL TRANSITIONS OF CARE COALITIONLEARNING OBJECTIVESAt the conclusion of this activity, participants should be able to: Discuss the national medication error data and trends Understand the medication error analysis process Explain the importance of transitions of care (TOC) in improving patient safety andreducing medication errors. Describe the role of the pharmacist and technician in transitions of care“The movement of patients between health care locations, providers, or differentlevels of care within the same location as their conditions and care needs change,and frequently involves multiple persons, including the patient, the family memberor other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s),physician(s), and other sources/ntoccissuebriefs.pdf.CAN YOU COUNT HOW MANY?An 84 yo M is transferred from the LTCF to the ED for AMS. After initialassessment, he is admitted to the ICU. Three days later, he leaves the ICU andspends 4 days in IM unit. Pt is discharged back to the LTCF today.A.B.C.D.TwoThreeFourFiveMEDICATION ERRORS Inadequate TOC– 60% of all med errors happen during TOC– Increased readmissions, increased costs, poor patient outcomes Poor communication during TOC– 50% of all med errors in hospitals– 20% of all ADEs Medication reconciliation– TOC and med errorsSteeb, et al. J Am Pharm Assoc. 2012;52(4):e43–52.Levenson et al. J Am Med Dir Assoc. 2007;8(1):55–64.Kirwin et al. Pharmacotherapy. hot topics transitions of care.pdf.NATIONAL PATIENT SAFETY GOALS Provided by The Joint Commission Identify health care issues, provide solutions patient safety Medication reconciliation declared a NPSG in 7 NPSG HAP ER.pdf2015 National Patient Safety Goals pg. 32 Copyright The Joint CommissionNATIONAL PATIENT SAFETY GOALSHospital Correctly identify patientsUse medicines safelyPrevent infectionPrevent surgery mistakesImprove staff communicationUse alarms safelyIdentify patient safety risksAmbulatory Correctly identify patientsUse medicines safelyPrevent infectionPrevent surgery /2017 NPSG HAP 2017 NPSG AHC ER.pdf.12
10/19/2017USE MEDICINES SAFELYMEDICATION RECONCILIATION- APHA AND ASHP NPSG.03.06.01“Record and pass along correct information about a patient’s medicines. Find outwhat medicines the patient is taking. Compare those medicines to new medicinesgiven to the patient. Make sure the patient knows which medicines to take whenthey are at home. Tell the patient it is important to bring their up-to-date list ofmedicines every time they visit a doctor.”“Comprehensive evaluation of a patient’s medication regimen any time there isa change in therapy in an effort to avoid medication errors such as omissions,duplications, dosing errors, or drug interactions, as well as to observecompliance and adherence patterns. This process should include a comparisonof the existing and previous medication regimens and should occur at everytransition of care in which new medications are ordered, existing orders arerewritten or adjusted, or if the patient has added nonprescription medication tohis or her self-care.”APhA: American Pharmacists AssociationASHP: American Society of Health‐System 1/18/SEA 2017 NPSG HAP 2017 NPSG AHC ER.pdf.MEDICATION RECONCILIATIONJOINT COMMISSION- FIVE STEP PROCESS“Process of comparing a patient's medication orders to all of the medicationsthat the patient has been taking” Fernandes OA. Pharmacy Practice. 2009;25:26.UNINTENDED DISCREPANCIES ON ADMISSION Study Design– Prospective study– 1000-bed teaching hospital– Internal med unit admission over 3month period Primary Outcome– Unintended discrep
B.Known causes of medication errors include: confusing labeling and nomenclature, human and environmental factors and medication shortages C.Medication safety measures include barcoding, smart pumps, medication reconciliation and pharmacists D.Medication errors are the most common sentinel event reported. E.None of the above LEARNINGOBJECTIVES
BBG1022FS-OM (V1.3) BBG-1022-FS PRODUCT MANUAL 1-5 Introduction BBG-1022-FS Functional Description BBG-1022-FS Functional Description Figure 1-1 shows a functional block diagram of the BBG-1022-FS. The BBG-1022-FS frame sync also includes AES/analog audio support and CVBS video I/O. In addition to a basic signal presence input failover
!Additionally, ME were categorized according to „Good practice guide on recording, coding, reporting and assessment of medication errors”: !!medication errors associated with adverse reaction(s), !!medication errors without harm, !!intercepted medication
List some common medication errors and associated regulatory deficiencies. Identifying administrative supports for a successful medication pass. Describe the pharmacist role in reducing medication errors. Discuss medication administration processes to prevent errors.
Errors and Data Analysis Types of errors: 1) Precision errors - these are random errors. These could also be called repeatability errors. They are caused by fluctuations in some part (or parts) of the data acquisition. These errors can be treated by statistical analysis. 2) Bias errors - These are systematic errors. Zero offset, scale .
We can overcome these medication errors by educating physicians, nurses regarding the areas where medication errors are more prone to occur. Key words: Medication error, Prescribing error, Dispensing error, Administration error, Documentation error, Transcribing error, EPA (Electronic prior authorization), Near miss, Missed dose. INTRODUCTION
to safe medication practice 57 8.1.2 Practical methods to minimize harm from medication errors 58 8.1.3 Preventing medication errors 58 8.1.4 Making them visible 58 8.1.5 Mitigating their effect when they occur 59 8.1.6 Raising awareness, education and training 59 8.2 Prevention strategies for medicine regulators and industry 61
reporting errors including the US Food and Drug Administration's . MedWatch Reporting Program and . ISMP Medication Errors Reporting Program (MERP). Prior Committee Discussions . As part of its evaluation of medication errors and workforce issues, the Committee has discussed reporting requirements for medication errors and research available.
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