Med safety nj ph a 10 10 11 final 3 (97-2003)


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  • This chart shows the breakdown of medication error types for the 594 reports in which a patient died. Improper dose was the most common type, with a majority being overdoses (36.4%) Wrong drug (inadvertant administration of one drug product for another, e.g. potassium chloride injection instead of sodium chloride) Wrong route was the other major type of error (intrathecal instead of IV most common) Wrong patient fairly uncommon Other is comprised of wrong technique/rate/strength/dosage form/time, as well as monitoring and deteriorated drug errors (aggregate of many small things)
  • In order to reduce the number of medication errors occurring, we need to recognize the behaviors that are causing the errors to occur. By far, human factors are the biggest cause. Includes: Performance deficits (gave drug IV instead of IM) Knowledge deficits (reasonable practice standards of education/CE) Dose miscalculations Preparation errors (wrong diluent, drug, active ingredient, or quantity) Incorrect selection of drug from computer/transcription errors Communication Order misinterpretation Oral/written miscommunication Name confusion Sound alike/look alike
  • Something we’re all very familiar with (common question for RPh from techs “What does this say?) An’t go ONE day w/out saying this-preprnted/electronic froms rxs Can be tricky  sometimes our assumptions are not correct Absolutely critical to double check on handwriting problems! Combinations of bad handwriting and similar drug names create perfect conditions for errors Example  report of fatal bleeding in a patient prescribed Cogentin 0.5mg and given Coumadin 5 mg
  • Errors of communication are an all too common cause of medication errors, particularly wrong drug and dose/frequency errors. Can be significantly reduced through double checks and following best practices for taking verbal orders and writing prescriptions
  • This hospital order is difficult to interpret. Drug name looks like Plendil (wrong dose/frequency), or Zestril (right dose, wrong frequency), but may be something else based on the dose/directions.
  • This is an order for HCTZ 50 mg PO daily; however, the lack of spacing between the drug name and strength could be misinterpreted as 250 mg of HCTZ per day
  • Abbreviation misinterpretation is a frequent cause of mix-ups, and the ISMP/FDA are leading a campaign to eliminate the use of certain error-prone abbreviations Recommended that these abbreviations be written out QD/QOD/QID may be mistaken for one another if handwriting is not clear  simply write out direction Do not abbreviate drug names (e.g. MS for “morphine sulfate” may be mistaken for magnesium sulfate) Eye/ear directions may look similar if handwriting is poor, leading to route of administration errors Source:
  • An order for regular insulin. As written, it could be interpreted as 6 U (six units) now, or as 60 units now. A 60 unit dose is improbable, but may be overlooked or not questioned, which could easily cause a patient’s glucose to bottom out
  • Those of us that work on order forms know how prevalent these abbreviations still are Units of weights and measures also leave plenty of room for error U may be mistaken for a 0 or 6 IU may be mistaken for IV, leading to fatal IV administration errors µg may be misread as milligram instead of microgram, a thousandfold dose error Apothecary units are often unfamiliar to practitioners Use of fractions of a grain (e.g. 1/100 grain) can lead to fraction errors or conversions to metric Use of symbols for teaspoon/tablespoon/ounce can be confusing
  • Decimal errors are of particular importance because an error in a decimal can result in a ten or more-fold dose error! The problem with decimals is that they always leave a space for error if missed. Avoid whenever possible. Always place a zero in FRONT of a decimal to avoid misinterpretation (Risperdal .5 may be read as “5 mg”, a ten fold overdose) Avoid trailing zeros whenever possible
  • Seeing it in actual writing makes it easier to recall how easily decimal errors can occur. Simply missing the decimal would expose a patient to a ten-fold overdose of colchicine or levothyroxine, both of which would have serious consequences
  • A number of drugs have names that look similar enough to cause confusion These names may be misread when in a hurry or not paying close attention to work Compounding the problem is the fact that some of these drugs have similar strengths and indications These are just a few examples. A complete list is available from the ISMPs website Not JUST names but PACKAGING too
  • Just as look alike drugs can lead to errors in prescription reading and dispensing, sound alike drugs are a pitfall of verbal orders for medication
  • Verbal prescription orders add an extra risk of error in several ways Communication issues foreign/local accents or dialects may be misunderstood Background noise in the pharmacy/MD office, as well as interruptions Unfamiliarity with the drug name, terminology for directions may generate an error Despite convenience of verbal orders, they do add an additional step for an error to be made, a risk which must be mitigated
  • So what behaviors can we change to reduce the number of verbal order errors that occur? Having a set read-back procedure is a easy way to immediately double check what was just ordered Read back patient name, DOB, drug name, strength, dose, frequency, quantity Double checking protects everyone  patients from drug errors, and health care professionals/hospitals from liability resulting from errors
  • Study published in 2010 NEJM this year found that the use of bar coding technology coupled with electronic medication administration records (eMARs) significantly reduced the rate of error in the hospital setting Technology cross-checks bar codes on a patient’s wrist with the drug about to be administered to ensure the correct patient, drug, strength/dose, and time.
  • This diagram gives a visual of the relationship between ADE, adverse drug reactions, and medication errors for perspective. The intent is to illustrate several points: Not all MEs result in ADE, and fewer result in ADR (only about 1% result in ADE) Approximately 25% of ADEs are caused by medication errors, and are often serious in nature That the small percent of ADEs resulting from errors costs the patients and the healthcare system such an enormous amount drives the need to reduce errors wherever possible Source: Nebecker et al. Clarifying Adverse Drug Events. Ann Intern Med 2004; 140: 795-801.
  • This slide is intended to visually highlight the impact of ADEs across the spectrum of severity Minor ADEs may cause simple inconveniences like GI upset or drowsiness Moderate ADEs may require medical attention or hospitalization, leading to greater financial burdens Severe ADEs lead to serious consequences, which in addition to creating a financial burden for patients, also tend to greatly impact a patients quality of life, particularly if full recovery is impossible (e.g. aminoglycoside hearing loss)
  • Process at Shore. Helps ID problems
  • These are some non-punitive approaches to error reduction By fostering an environment where practitioners do not need to fear being publicly or professionally “crucified”, we can encourage the reporting of errors and provide constructive feedback on how to make changes from the blunt end. Community/media education about error prevention efforts is important People need to know the healthcare field is made of other people who genuinely care about their safety The media tends to sensationalize medication errors, so making knowledge of error prevention efforts public may be a good way to mitigate this
  • It is important to focus on the human factors involved in medication errors due to the inherent limitations of the human brain Past research has shown us that humans can store at the most around 7 items in short term memory, which in reality may be a generous limit Number is limited in practice due to other things pulling our attention away This has happened to all of us  focused on multiple things and end up forgetting something important Humans have a limited capacity to remember things, as well as to observe events going on around us We aren’t very good at estimating probability, possibly due to other factors that influence our predictions of events (e.g. whether we want an event to happen or not or whether we have all the details)
  • So how do we reduce human error in the health care system? We use computers to perform tasks that are tedious, or which may involve significant human error. Computers have their own limitations, chief of which is that they are only as good as the person using them  computers don’t make mistakes, the people using them do Computers are unable (right now) to show common sense or true clinical judgement They can only generate results based on set parameters (for example, listing all possible drug interactions for a given drug pair, rather than decided which ones to question and which ones to let go)
  • Simply double checking key information while entering a script can prevent errors
  • Coach your staff into the habit of multi-checking everything Checks of
  • Route of administration errors carry a greater potential to cause fatal medication errors due to inadvertent IV/IT administration Constant vigilance and questioning is required to prevent Labeling of products not intended for a particular route of administration is critical Examples Nonsterile/non-pH balanced ear preps used in the eye can cause irritation and other problems FDA reports of deaths linked to accidental administration of nimodipine oral capsules intravenously (nimodipine is used for control of vasospasm s/p cerebral hemorrhage) Liquid in capsule withdrawn using IV syringe and 18 gauge needle for use with nasogastric tube  syringe not labeled and later given IV push, leading to death Reports of deaths when vinca alkaloids used for chemotherapy were given intrathecally instead of IV
  • Find a way to differentiate products that look similar Often an issue with a generic brand that uses identical packaging for many drugs (Mylan in particular) “ Tall Boy” lettering style – highlights portions of drug name that are dissimilar Be creative in coming up with a way to effectively differentiate between similar drug products. Shelf separators should be a part of any system, as they prevent drugs/strengths from getting mixed together
  • Med safety nj ph a 10 10 11 final 3 (97-2003)

    1. 1. Medication Safety & Error Prevention Shaukat Patel MS R.Ph. Clinical Pharmacist. Shore Medical Center
    2. 2. Learning Objectives <ul><li>Pharmacist and Pharmacy Technician </li></ul><ul><ul><li>Identify the most common types of medication errors & factors leading up to them </li></ul></ul><ul><ul><li>List systems/programs currently in practice to prevent/minimize medication errors </li></ul></ul><ul><ul><li>Define medication error versus adverse drug event (ADE) </li></ul></ul><ul><ul><li>Explain resources/educational tools available to pharmacists on ADE & medication errors </li></ul></ul>
    3. 3. Seriousness of Medication Errors <ul><ul><li>To Err Is Human: Building a Safer Health System </li></ul></ul><ul><ul><ul><li>Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals </li></ul></ul></ul><ul><ul><ul><ul><li>That's more deaths than from: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>motor vehicle accidents </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>breast cancer </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>AIDS </li></ul></ul></ul></ul></ul>
    4. 4. Seriousness of Medication Errors <ul><li>2005 FDA study </li></ul><ul><ul><li>1 death per day </li></ul></ul><ul><ul><li>1.3 million injuries per year </li></ul></ul><ul><ul><li>Length of stay increased 12 days </li></ul></ul>
    5. 5. Medication Error <ul><li>Definition </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>May be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use </li></ul></ul>
    6. 6. Definitions <ul><li>Medication Error: </li></ul><ul><li>Any error in the process of ordering, transcribing, dispensing, administering and monitoring a medication. A medication error may or may not result in an actual or potential adverse drug event. </li></ul>
    7. 7. Definitions <ul><li>Adverse Drug Event: </li></ul><ul><li>Any injury caused by the use (or nonuse) of a drug. </li></ul><ul><li>Potential Adverse Drug Event: </li></ul><ul><li>An error that had the potential to cause an adverse drug event, but did not, either by interception or ‘luck.’ </li></ul>
    8. 8. What Classifies as a Med Error? <ul><li>At any step in the medication process </li></ul><ul><li>Omissions </li></ul><ul><li>Commissions </li></ul><ul><li>Documentation </li></ul><ul><li>Even if there is no consequence </li></ul><ul><li>Near Misses </li></ul>
    9. 9. Guess the Med Error <ul><li>Patient receives IV piggyback (same drug and dose) belonging to another patient </li></ul><ul><li>Patient receives 20 units of insulin instead of 10 units </li></ul><ul><li>Nurse notices patient allergic to medication ordered and notifies doctor to change order </li></ul><ul><li>Technician charts heart rate in blood sugar column- nurse corrects the entry </li></ul>
    10. 10. Definitions of Medication errors <ul><li>Mistaken diagnoses and errors in treatment are examples of errors of commission; </li></ul><ul><li>Missed diagnoses, and needed treatments not given are errors of omission. </li></ul><ul><li>A mistake that has not caused harm is a near miss . </li></ul>
    11. 11. Definitions of Medication errors <ul><li>When harm is caused by a mistake, it is termed a Preventable Adverse Event. </li></ul><ul><li>Adverse drug events that cause harm but have not resulted from an error and could not have been prevented (for example, a drug rash when a medication is correctly prescribed to a patient without a history of allergic reaction) are Adverse Drug Reactions. </li></ul>
    12. 12. Types of medication Error <ul><li>Prescribing Error; Incorrect drug . Illegible prescriptions or medication orders that lead to errors that reach the patient. </li></ul><ul><li>Omission Error ; The failure to administer an ordered dose to a patient before the next scheduled dose, if any. Also missed diagnoses, and needed treatments not given are errors of omission. </li></ul>
    13. 13. Types of medication Error <ul><li>Wrong time error; Administration of medication outside a predefined time interval from its scheduled administration time. </li></ul><ul><li>Unauthorized drug error; Administration to the patient of medication not authorized by a legitimate prescriber for the patient. </li></ul>
    14. 14. Types of medication Error <ul><li>Improper dose error; </li></ul><ul><li>Administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber. </li></ul>
    15. 15. Types of medication Error <ul><li>Wrong route of administration: </li></ul><ul><li>Vinca alkaloids must only be administered intravenously . Some times given intrathecaly and can be fatal. </li></ul><ul><li>  </li></ul>
    16. 16. Types of medication Error <ul><li>Wrong dosage-form error; Administration to the patient of a drug product in a different dosage form than ordered by the prescriber </li></ul><ul><li>Wrong drug-preparation error; Drug product incorrectly formulated or manipulated before administration. </li></ul>
    17. 17. Types of medication Error <ul><li>Wrong administration-technique error ; Inappropriate procedure or improper technique in the administration of a drug </li></ul><ul><li>Deteriorated drug error; Expired drugs Administration of a drug that has expired or for which the physical or chemical dosage-form integrity has been compromised </li></ul>
    18. 18. Types of medication Error <ul><li>Monitoring error; Failure to review a prescribed regimen for appropriateness and detection of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy </li></ul><ul><li>Compliance error; Inappropriate patient behavior regarding adherence to a prescribed medication regimen </li></ul>
    19. 19. Philips J et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. 2001 Oct 1;58(19):1835-41
    20. 20. Philips J et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. 2001 Oct 1;58(19):1835-41
    21. 21. What Causes Med Errors? <ul><li>Human vs. System factors </li></ul><ul><li>Lack of or poor communication </li></ul><ul><li>Making assumptions </li></ul><ul><li>Complicated or high-risk processes </li></ul><ul><li>Not following policies/procedures </li></ul><ul><li>Not updating policies/procedures </li></ul><ul><li>Environment </li></ul>
    22. 22. Common causes of medication errors <ul><li>Human factors </li></ul><ul><li>Systems </li></ul><ul><li>Abbreviations </li></ul><ul><li>Oral orders </li></ul><ul><li>Look-alike and sound-alike drugs </li></ul><ul><li>Dosage calculation </li></ul><ul><li>At-risk population </li></ul><ul><li>At-risk drugs </li></ul>
    23. 23. Handwriting Misinterpretation <ul><li>Illegibility </li></ul><ul><li>Drug name look-alike </li></ul><ul><li>Blurring of drug name with other info </li></ul><ul><li>Omissions of information </li></ul><ul><li>Reports </li></ul><ul><ul><ul><li>Coumadin 5 mg dispensed for Cogentin 0.5 mg </li></ul></ul></ul>
    24. 24. Handwriting
    25. 25. Communication Errors <ul><li>Handwriting </li></ul><ul><li>Transcription </li></ul><ul><li>Decimals </li></ul><ul><li>Look-alike/sound-alike </li></ul><ul><li>Sig abbreviations </li></ul><ul><li>Verbal orders </li></ul>
    26. 26. Unclear Handwriting
    27. 27. Unclear Handwriting
    28. 28. Written Rx Best Practices - Abbreviations <ul><li>“ Do Not Use” abbreviations list </li></ul><ul><ul><li>QD/QOD/QID  write out direction </li></ul></ul><ul><ul><li>Drug name  write out drug name </li></ul></ul><ul><ul><li>UD  write “as directed” </li></ul></ul><ul><ul><li>Eye/ear directions </li></ul></ul>
    29. 29. Written Rx Best Practices – Weights, Volumes, Measures
    30. 30. Written Rx Best Practices – Weights, Volumes, Measures <ul><li>U  write “unit” </li></ul><ul><li>IU  write “international unit” </li></ul><ul><li>CC  write mL or milliliter </li></ul><ul><li>µg  write “mcg” </li></ul><ul><li>Apothecary units </li></ul><ul><ul><li>Grains/drams </li></ul></ul><ul><ul><li>ʒ, ℥, etc </li></ul></ul><ul><li>Space between drug name and strength </li></ul>
    31. 31. Written Rx Best Practices - Decimals <ul><li>Avoid whenever possible </li></ul><ul><ul><li>Use 500 mg for 0.5 g </li></ul></ul><ul><ul><li>Use 125 mcg for 0.125 mg </li></ul></ul><ul><li>Avoid “naked” decimals </li></ul><ul><ul><li>Risperdal 0.5 mg instead of Risperdal .5 mg </li></ul></ul><ul><li>Avoid trailing zeros </li></ul><ul><ul><li>Colchicine 1 mg instead of 1.0 mg </li></ul></ul>
    32. 32. Written Rx Best Practices - Decimals
    33. 33. What’s the Error? <ul><li>Patient is on oral vancomycin. Doctor orders vancomycin IV. Patient is given IV vancomycin, but not oral vancomycin for 2 days </li></ul><ul><ul><li>Need for communication </li></ul></ul><ul><ul><li>No room for assumption (you know what happens when you assume) </li></ul></ul>
    34. 34. “ Look-Alike” Drugs Amiodarone Amrinone Amlodipine Amiloride Hydroxyzine Hydralazine Prednisone Prednisolone Celexa Celebrex
    35. 35. “ Sound-alike” Drugs Mellaril Elavil Paxil Taxol Prilosec Prozac Cerebyx Celebrex OxyContin Oxycodone
    36. 36. Problems With Verbal Orders <ul><li>Verbal orders leave extra room for errors to occur </li></ul><ul><li>Communication issues </li></ul><ul><ul><li>Accents, dialects </li></ul></ul><ul><ul><li>Background noise/interruptions </li></ul></ul><ul><ul><li>Unfamiliar drug names/terms </li></ul></ul><ul><li>More steps = more risk of error </li></ul>
    37. 37. Types of Verbal Order Errors <ul><li>Wrong Drug </li></ul><ul><ul><ul><li>Clonidine misheard as Klonopin </li></ul></ul></ul><ul><ul><ul><li>Amiodarone misheard as amrinone </li></ul></ul></ul><ul><li>Wrong Dose </li></ul><ul><ul><ul><li>Toradol 15 mg misheard as 50 mg </li></ul></ul></ul><ul><li>Wrong Labs </li></ul><ul><ul><ul><li>Blood glucose misheard as 257 instead of 157  patient received 6 units of insulin instead of 2 </li></ul></ul></ul>
    38. 38. Preventing Verbal Order Errors <ul><li>Read back procedure </li></ul><ul><li>Cincinnati Children’s Hospital reduced verbal order errors from 9% to ZERO by simply using read-back </li></ul>Source: Vossmeyer MT. Improving patient safety using a verbal order read back process. Pediatric Academic Societies Annual Meeting; 2006 Apr 29; San Fransisco, CA.
    39. 39. The Response to a Med Error <ul><li>Always notify the physician and take immediate corrective action for the patient </li></ul><ul><li>Management must be involved </li></ul><ul><li>Document, document, document </li></ul><ul><li>Never try to hide an error </li></ul><ul><li>Report the error </li></ul>
    40. 40. The “Other” Victim <ul><li>No one feels worse than the person who made the mistake </li></ul><ul><li>Involve that person in the post-error process </li></ul><ul><li>Make sure the person knows the process that failed and that the process needs attention, not the person </li></ul>
    41. 41. The “Other” Victim <ul><li>ISMP Safety Alert July 14 th , 2011 </li></ul><ul><ul><li>Too many abandon the “second victims” of medical errors </li></ul></ul><ul><ul><ul><li>Just 7 months after making a mathematical error that led to an overdose of calcium chloride and the subsequent death of a critically ill infant, a veteran nurse took her own life </li></ul></ul></ul><ul><ul><ul><li>The healthcare industry as a whole has not widely communicated or implemented effective support mechanisms to address the deeply personal, social, spiritual, and professional crisis often experienced by the “second victims” of fatal errors </li></ul></ul></ul>
    42. 42. The “Other” Victim <ul><li>ISMP Safety Alert July 14 th , 2011 </li></ul><ul><ul><li>The second victims of errors have the right to: </li></ul></ul><ul><ul><ul><li>Be treated with respect </li></ul></ul></ul><ul><ul><ul><li>Participate in the process of learning from the error </li></ul></ul></ul><ul><ul><ul><li>Be held accountable in a fair and just culture </li></ul></ul></ul><ul><ul><ul><li>Not to be abandoned by the healthcare organization, and to be supported by their peers and organizational leaders. </li></ul></ul></ul>
    43. 43. Prevention <ul><li>Simplicity </li></ul><ul><li>Standardization </li></ul><ul><li>Education and training </li></ul><ul><li>Automation </li></ul><ul><li>Multidisciplinary communication </li></ul><ul><li>Layers of security / double checks </li></ul><ul><li>Reporting </li></ul>
    44. 44. Reducing medication errors through technology <ul><li>Computerized Physician Order Entry (CPOE) </li></ul><ul><li>Digital Assistants (PDAs) </li></ul><ul><li>Internet </li></ul>
    45. 45. Medical Administration Record
    46. 46. CPOE can <ul><li>Reduce errors / adverse drug events 55-80%; </li></ul><ul><li>Produce legible and complete orders; </li></ul><ul><li>Flag laboratory results that affect prescribing; </li></ul><ul><li>Inform ordering MDs of drug interactions, allergies, and duplication; </li></ul>
    47. 47. Allergy Screen
    48. 48. CPOE can <ul><li>Transmit orders to pharmacy when written; </li></ul><ul><li>Minimize dosing errors; and </li></ul><ul><li>Automatically calculate total doses </li></ul>
    49. 49. Bar Code Point of Care <ul><li>Health Care Technology </li></ul>
    50. 50. BPOC Bedside Device Wireless Laptop computer with a touch screen and bar code scanner
    51. 51. Barcode Technology Nurse barcode scans name tag Nurse barcode scans patient identification bracelet Patient MAR appears on bedside laptop Scheduled and prn meds are scanned Warnings/alerts are issued when indicated
    52. 52. Bar Coding/eMAR <ul><li>Report from Brigham and Women’s Hospital </li></ul><ul><ul><li>Reduced patient mix-up by 57% </li></ul></ul><ul><ul><li>Reduced wrong dose by 42% </li></ul></ul><ul><ul><li>Reduced risk of getting a drug without an order by 61% </li></ul></ul><ul><ul><li>Cut transcription errors from 6% to zero </li></ul></ul>
    53. 53. Patient Scanning <ul><li>Durability </li></ul><ul><li>Reliability </li></ul><ul><li>Is the wrist band on the wrist? </li></ul><ul><li>Addressing patient concerns </li></ul>
    54. 54. Medication Scanning <ul><li>Manufacturer bar codes </li></ul><ul><li>Repackaging </li></ul><ul><li>Adding barcodes to existing package </li></ul><ul><li>Quality control </li></ul>
    55. 55. ADE, ADR, & Medication Errors Adverse Drug Events
    56. 56. Adverse Drug Events <ul><li>Impact </li></ul><ul><ul><li>7000 deaths/year due to medication errors </li></ul></ul><ul><ul><li>2 out of every 100 admissions experience preventable ADE </li></ul></ul><ul><ul><li>Average increased hospital cost of preventable ADE: $4,700 per admission or $2 billion nationwide </li></ul></ul>
    57. 57. Consequences of ADEs Anaphylaxis – penicillin Deafness – gentimycin Pseudo. colitis –clindamycin Thrombocytopenia –heparin GI upset –erythromycin Urticaria – phenytoin Death $$$$ Permanent disability $$$$ Threat to Life $$$ Hospitalization $$$ ER visit $$$ Inconvenience $
    58. 58. ADR Trigger Report <ul><li>Steroids </li></ul><ul><li>Vitamin K </li></ul><ul><li>Romazicon </li></ul><ul><li>Naloxone </li></ul><ul><li>Protamine </li></ul>
    59. 59. Reporting Errors <ul><li>Institution should encourage non-punitive reporting in a database that’s easy to access and use </li></ul><ul><li>Report ASAP </li></ul><ul><ul><li>Details fresh </li></ul></ul><ul><ul><li>No editorializing </li></ul></ul><ul><ul><li>Option to remain anonymous </li></ul></ul><ul><li>Pharmacists are in an ideal situation to report </li></ul>
    60. 60. Pharmacist: “The backbone” of Reporting Errors .
    61. 61. Reporting System <ul><li>What makes for an effective reporting system? </li></ul><ul><li>Easy to access and use </li></ul><ul><ul><li>Web </li></ul></ul><ul><ul><li>Phone </li></ul></ul><ul><ul><li>Paper </li></ul></ul><ul><li>Ability to stay anonymous </li></ul><ul><ul><li>Comfort </li></ul></ul><ul><li>Follow up </li></ul><ul><li>Ability to trend </li></ul><ul><ul><li>Find patterns </li></ul></ul><ul><ul><li>Reduce reoccurrence </li></ul></ul><ul><ul><li>Reduce risk </li></ul></ul>
    62. 62. Effective Approach (“New Look”) <ul><li>Non-punitive environment </li></ul><ul><li>Emphasis on multifactorial nature of error </li></ul><ul><li>Assumption that errors will occur </li></ul><ul><li>Emphasis on caregiver interaction </li></ul><ul><li>Sharp end, blunt end </li></ul><ul><ul><ul><li>Emphasis on systems , not people </li></ul></ul></ul>Reference: Cook et al. A tale of two stories. Contrasting views of patient safety
    63. 63. Non-Punitive Approaches to Error Reduction <ul><li>Reward practitioners for reporting </li></ul><ul><li>Provide feedback about medication errors and system-based improvements </li></ul><ul><li>Maintain confidentiality of individuals involved in an error </li></ul><ul><li>Educate the community about error prevention efforts </li></ul>
    64. 64. Human Error <ul><li>Human Limits </li></ul><ul><li>Human brain can store 7+/- 2 items at a time </li></ul><ul><ul><ul><li>Miller GA. The magical number seven, plus or minus two: some limits on our capacity for processing information. 1956. </li></ul></ul></ul><ul><ul><ul><li>Cowan N. The magical number 4 in short-term memory: a reconsideration of mental storage capacity. Behav Brain Sci 2001. </li></ul></ul></ul><ul><li>Limited memory </li></ul><ul><li>Limited ability to observe events </li></ul><ul><li>Bad at estimating probabilities </li></ul>
    65. 65. Computer Error <ul><li>Computer Limits </li></ul><ul><li>Can only do things correctly with the correct input from a user </li></ul><ul><li>Lack common sense </li></ul><ul><li>Can only mimic an expert’s way of working </li></ul>
    66. 66. Check the Profile! <ul><li>Review of key patient information during script entering helps prevent mistakes </li></ul><ul><ul><li>Name </li></ul></ul><ul><ul><li>Gender </li></ul></ul><ul><ul><li>Contact info </li></ul></ul><ul><ul><li>Date of Birth </li></ul></ul><ul><ul><li>Allergies/Previous idiosyncratic rxns </li></ul></ul><ul><ul><li>Conditions </li></ul></ul>
    67. 67. Multi-Point Checks <ul><li>Multipoint checks on a prescription help to ensure accuracy in Rx entering </li></ul><ul><li>Read the label 3 times </li></ul><ul><ul><li>When obtaining package </li></ul></ul><ul><ul><li>When using the package </li></ul></ul><ul><ul><li>When discarding or returning to stock </li></ul></ul><ul><ul><li>Don’t rely on shelf tags! Rely on what’s in your hands! </li></ul></ul>
    68. 68. Check the Route! <ul><li>Significant contribution to fatal errors </li></ul><ul><li>Requires vigilance and clarity of communication to prevent </li></ul><ul><li>Labeling </li></ul><ul><li>Examples </li></ul><ul><ul><ul><li>Eye/ear preparations  irritation </li></ul></ul></ul><ul><ul><ul><li>Vinca alkaloids given intrathecally </li></ul></ul></ul>
    69. 69. Preventing Drug Mix-Ups <ul><li>Find a way to differentiate items that look similar but may be confused </li></ul><ul><ul><li>Purchase one product from a different source </li></ul></ul><ul><ul><li>“ Tall Boy” lettering style </li></ul></ul><ul><ul><ul><li>hydOXYzine vs. hydALAzine </li></ul></ul></ul><ul><ul><ul><li>vinBLASTine vs. vinCRISTine </li></ul></ul></ul><ul><ul><li>Use other means to make drug products look different </li></ul></ul><ul><ul><ul><li>Stickers, labels, etc </li></ul></ul></ul>
    70. 70. Preventing Drug Mix-Ups <ul><li>Separate problem products </li></ul><ul><ul><li>Store look-alike drugs separately whenever possible </li></ul></ul><ul><ul><li>Use red shelf separators to distance the products </li></ul></ul><ul><ul><li>Cisplatin/carboplatin and vincristine/vinblastine not listed in order on preprinted chemo forms </li></ul></ul>
    71. 71. Training/Education <ul><li>All pharmacists and support staff should complete some type Quality Assurance training/CE at least annually </li></ul><ul><li>Utilize multiple CE opportunities to learn about medication errors & patient safety </li></ul>
    72. 72. Workflow <ul><li>Validate patient using DOB, MAR#, FIN# </li></ul><ul><li>Verify patient allergies on every visit </li></ul><ul><li>Contact the prescriber if further clarification is necessary </li></ul><ul><ul><li>drug name, strength, quantity </li></ul></ul><ul><ul><li>directions or any aspect of the prescription </li></ul></ul><ul><li>Document discussion </li></ul><ul><li>Review High Risk Medication Alerts in the computer system and verify correct selection of medication </li></ul><ul><ul><li>Reduce “alert fatigue” </li></ul></ul><ul><li>Work area free of clutter and distractions </li></ul>
    73. 73. Key Points <ul><li>It is human to err, but it is also human to react and create solutions </li></ul><ul><li>Errors happen every day, but don’t always cause harm </li></ul><ul><li>Prevention is multi-factorial </li></ul><ul><li>Response to an error is paramount </li></ul><ul><li>Reporting is the foundation for improvement </li></ul>
    74. 74. Case Exercise <ul><li>A 91-year-old female </li></ul><ul><ul><li>transferred to a hospital-based skilled nursing unit from the acute care hospital for continued wound care </li></ul></ul><ul><ul><li>intravenous (IV) antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis of the heel </li></ul></ul><ul><ul><li>She was on IV vancomycin and began to have frequent, large stools </li></ul></ul>
    75. 75. Case Exercise <ul><li>The attending physician ordered a test for Clostridium difficile on Friday, and was then off for the weekend. </li></ul><ul><li>That night the test result came back positive </li></ul><ul><li>The lab called infection control, who in turn notified the float nurse caring for the patient </li></ul><ul><li>RN did not notify physician on call or the regular nursing staff. Isolation signs were posted on the patient's door and chart and the result was noted in the patient's nursing record. </li></ul><ul><li>Each RN who subsequently cared for this patient assumed that the physician had been notified, in large part because the patient was receiving vancomycin. However, the patient required oral vancomycin to treat C.difficile, not IV vancomycin </li></ul>
    76. 76. Case Exercise <ul><li>What are the systems/processes involved in this incident? </li></ul><ul><li>What were the failure points? </li></ul>
    77. 77. Analysis <ul><li>MD failed to check the result of an ordered test </li></ul><ul><li>Float RN wrongly assumed that MD had been notified of the result </li></ul><ul><li>RN incorrectly assumed that IV vancomycin was adequate therapy </li></ul><ul><li>Pharmacist responsibility? </li></ul>
    78. 78. Failure Points <ul><li>Laboratory system for reporting critical results </li></ul><ul><ul><ul><li>Is a positive C. difficile culture considered a panic result? </li></ul></ul></ul><ul><ul><ul><li>To whom are panic values reported? </li></ul></ul></ul><ul><li>RN/MD communication </li></ul><ul><ul><ul><li>Does the institution foster an environment where RNs can comfortably question MD orders? </li></ul></ul></ul><ul><li>Pharmacist </li></ul><ul><ul><li>Antibiotic stewardship </li></ul></ul>
    79. 79. Resources <ul><li>Institute of Safe Medicine Practice (ISMP) </li></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Newsletter </li></ul></ul><ul><li>American Society of Hospital Pharmacists </li></ul><ul><ul><li>Report to ISMP </li></ul></ul><ul><ul><li>Report to Medwatch </li></ul></ul><ul><ul><li>Safety Alerts, Warnings and Recalls </li></ul></ul><ul><li>National Patient Safety Foundation </li></ul><ul><ul><li>Healthcare Providers </li></ul></ul><ul><ul><li>Patients and Families </li></ul></ul>
    80. 80. References <ul><li>To Err Is Human: Building a Safer Health System. Kohn, et al. </li></ul><ul><li>Poon, E et al. Effect of Bar-Code Technology on the Safety of Medication Administration. N Engl J Med 2010; 362:1698-1707.May 6, 2010 </li></ul><ul><li>Philips J et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. 2001 Oct 1;58(19):1835-41 </li></ul><ul><li>CDC. National Vital Statistics Reports. Deaths: Final Data for 2007. </li></ul><ul><li>ISMP. ISMP Homepage (and other links from this page). . </li></ul>
    81. 81. Thank You