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Strategies to Reduce Errors


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Strategies to Reduce Errors

  1. 1. Strategies to Reduce Medication Errors
  2. 2. Strategic Overview <ul><li>Increase awareness </li></ul><ul><li>of at-risk populations. </li></ul><ul><li>Avoid abbreviations </li></ul><ul><li>and nomenclature. </li></ul><ul><li>Recognize prescription look-alike/sound-alike medications. </li></ul><ul><li>Beware of OTC family extensions and standardized labeling. </li></ul><ul><li>Focus on high-alert medications. </li></ul><ul><li>Look for duplicate therapies & interactions. </li></ul>
  3. 3. Strategic Overview continued <ul><li>Do not take shortcuts around technology safeguards. </li></ul><ul><li>Report errors to improve process. </li></ul><ul><li>Control the environment </li></ul><ul><li>Educate the patient. </li></ul>
  4. 4. 1. Increase Awareness of At-Risk Populations <ul><li>Two groups of patients at increased risk for the most harm from medication errors </li></ul><ul><li>Pediatric and Geriatric patients </li></ul><ul><ul><li>Risk is due to altered pharmacokinetic parameters </li></ul></ul><ul><ul><li>Lack of published information regarding the use of medications </li></ul></ul><ul><ul><li>Calculation of doses based on age & weight </li></ul></ul><ul><ul><li>Lack of available dosage forms and concentrations for smaller people </li></ul></ul>
  5. 5. Increase Awareness of At-Risk Populations continued <ul><li>33% of medication errors reaching the patient involved a patient aged 65 years or older </li></ul><ul><ul><li>Omission errors </li></ul></ul><ul><ul><li>Improper dose </li></ul></ul><ul><ul><li>Amount errors </li></ul></ul><ul><ul><li>Unauthorized medication </li></ul></ul><ul><li>> 55% of fatal hospital medication errors involved seniors </li></ul><ul><ul><li>Of these errors 9.6% of medication errors were classified as harmful </li></ul></ul>
  6. 6. At-Risk Populations continued <ul><li>Establish double-check systems for doses </li></ul><ul><li>Utilized reference books </li></ul><ul><li>Programmed Computer Alerts </li></ul><ul><ul><li>Recommended weight-based dose for a specific medication </li></ul></ul><ul><ul><li>Computer program can calculate dose based on age and weight </li></ul></ul><ul><ul><li>Adjust for renal function </li></ul></ul><ul><ul><li>Patient's Adherence </li></ul></ul><ul><ul><ul><li>Confusion about the indication or directions. </li></ul></ul></ul><ul><ul><ul><li>Dosing reminders & pill boxes </li></ul></ul></ul>
  7. 7. 2. Avoid Abbreviations & Nomenclature <ul><li>Shorthand causes confusion & misinterpretation. </li></ul><ul><ul><li>MTX (methotrexate) </li></ul></ul><ul><ul><li>Dosing abbreviations, such as QD (once a day) </li></ul></ul><ul><ul><li>Do not use trailing zeros </li></ul></ul><ul><ul><ul><li>Write &quot;55 mg,&quot; rather than &quot;55.0 mg”. </li></ul></ul></ul><ul><ul><li>Always have a zero preceding the decimal point </li></ul></ul><ul><ul><ul><li>Write &quot;0.55 mg,&quot; rather than &quot;.55 mg.&quot; </li></ul></ul></ul><ul><li>The Joint Commission Requires </li></ul><ul><ul><li>Accredited facilities to develop & publish a list of approved abbreviations, in conjunction with a list of &quot;do not use&quot; abbreviations, acronyms, and symbols. </li></ul></ul>
  8. 8. 3. Recognize Prescription Look-Alike/Sound Alike Medications <ul><li>Joint Commission has developed a list of look-alike/sound-alike medication </li></ul><ul><ul><li>Actonel/Actos </li></ul></ul><ul><ul><li>Celebrex/Celexa </li></ul></ul><ul><ul><li>Lamictal/Lamisil </li></ul></ul><ul><li>Look-Alike Packaging </li></ul><ul><ul><li>Concentrated Heparin </li></ul></ul><ul><ul><li>Avoid using color to recognize a product </li></ul></ul><ul><ul><li>Ask another person to double-check anything! </li></ul></ul>
  9. 9. 4. Beware of OTC Family Labeling <ul><li>Manufacturers of OTC products take advantage of recognizable trade names. </li></ul><ul><ul><li>Families of products with differing active ingredients </li></ul></ul><ul><ul><li>Trade names can confuse as to the actual ingredients. </li></ul></ul><ul><li>Drug Facts Labeling </li></ul><ul><ul><li>FDA regulations require a standardized OTC label </li></ul></ul><ul><ul><li>Uses, warnings, dosage, directions, and other information. </li></ul></ul><ul><ul><li>Educate </li></ul></ul>
  10. 10. 5. High-ALERT Medications <ul><li>Focus on High Risk Medications </li></ul><ul><ul><li>All of them are associated with significant consequences if an error occurs </li></ul></ul><ul><ul><li>Adrenergic Agonists IV </li></ul></ul><ul><ul><ul><li>Norepinephrine, epinephrine </li></ul></ul></ul><ul><ul><li>Adrenergic Antagonist IV </li></ul></ul><ul><ul><ul><li>Metoprolol, Labetalol </li></ul></ul></ul><ul><ul><li>Anticoagulatants </li></ul></ul><ul><ul><ul><li>Heparin, Warfarin, Alteplase </li></ul></ul></ul>
  11. 11. High-Alert Medications continued <ul><li>Multiple Formulation Medications </li></ul><ul><li>Development of standardized orders </li></ul><ul><li>Offer Safeguard Training </li></ul><ul><li>Automated Attention Alerts </li></ul><ul><li>Limit Access </li></ul><ul><li>Product Storage </li></ul><ul><ul><li>High-Alert Auxiliary Labels </li></ul></ul>
  12. 12. 6. Look for Duplicate Therapies & Interactions <ul><li>Drug interactions </li></ul><ul><ul><li>Alter the metabolism or excretion </li></ul></ul><ul><ul><li>Reduced effectiveness or toxic accumulation. </li></ul></ul><ul><li>Obtain Complete list of RX, OTC, & herbal products </li></ul><ul><li>Multiple formulations </li></ul><ul><li>Immediate-release & sustained-release </li></ul><ul><li>Therapeutic Duplications </li></ul><ul><ul><li>Different ingredients in the same drug class </li></ul></ul><ul><ul><li>Products containing more than one active ingredient </li></ul></ul><ul><li>Clarify before dispensing the new prescription. </li></ul>
  13. 13. 7. Do Not Take Shortcuts Around Technology Safeguards <ul><li>Safeguards were developed to prevent medication errors or in response to them. </li></ul><ul><li>These safeguards may viewed as time-intensive, they exist for a purpose. </li></ul><ul><li>Bypassing such systems, including computer alerts and bar coding, increases the risk of medication errors. </li></ul>
  14. 14. What Can You Do? <ul><li>Recognize It </li></ul><ul><li>Listen Up </li></ul><ul><li>Speak Up </li></ul><ul><li>Report It </li></ul>
  15. 15. 8. Report Errors to Improve Process <ul><li>Reporting Errors Intent </li></ul><ul><ul><li>Identify system failures </li></ul></ul><ul><li>Error Occurrence </li></ul><ul><ul><li>Notify patient or caregivers </li></ul></ul><ul><ul><li>Disclosing the error </li></ul></ul><ul><ul><ul><li>Preserve the patient– pharmacist trust </li></ul></ul></ul><ul><ul><li>Pharmacist acknowledgement that the event occurred </li></ul></ul><ul><ul><ul><li>Provide the patient with available facts about the incident. </li></ul></ul></ul><ul><li>Apologize </li></ul><ul><ul><li>Show commitment & concern to finding out why the error occurred </li></ul></ul><ul><ul><li>Inform patient of impact </li></ul></ul><ul><ul><ul><li>Now or in the future </li></ul></ul></ul><ul><ul><ul><li>Steps being taken to mitigate the effects </li></ul></ul></ul>
  16. 16. 9. Control the Environment <ul><li>Health Care Settings can be high-stress </li></ul><ul><li>Health Care Staff are trained to expect perfection </li></ul><ul><li>Medication errors attribute to </li></ul><ul><ul><li>Workplace distractions </li></ul></ul><ul><ul><li>Staffing issues </li></ul></ul><ul><ul><ul><li>Shift changes and floating staff </li></ul></ul></ul><ul><ul><li>Workload increases </li></ul></ul><ul><li>Controllable </li></ul><ul><ul><li>Lighting </li></ul></ul><ul><ul><li>Uncluttered Workspace </li></ul></ul><ul><ul><li>Answer Phones quickly to reduce noise </li></ul></ul><ul><ul><li>Reduce Interruptions </li></ul></ul>
  17. 17. 10. Educate the Patient <ul><li>Patients can prevent & detect errors. </li></ul><ul><li>Patients to consider the &quot;5 Rights&quot; for medication safety. </li></ul><ul><ul><li>Right Patient </li></ul></ul><ul><ul><li>Right Medication </li></ul></ul><ul><ul><li>Right Dose </li></ul></ul><ul><ul><li>Right Time </li></ul></ul><ul><ul><li>Right Route </li></ul></ul>
  18. 18. The Challenge of Champions
  19. 19. Technology Enhanced Safety <ul><li>One of the biggest barriers to enhanced safety is the reluctance of staff to embrace technology. </li></ul>W H Y ???
  20. 20. Pride and Prejudice <ul><li>Clinicians worry about </li></ul><ul><ul><li>caring for patients using a “cookbook” approach rather than individualizing care </li></ul></ul><ul><ul><li>want to resist the use of computerized decision support systems. </li></ul></ul>
  21. 21. Pride and Prejudice continued <ul><li>Evidence based artificial intelligence a guide thinking </li></ul><ul><ul><li>Prompt, suggest and remind – not demand can improve both clinical and financial outcomes. </li></ul></ul><ul><li>Regional and/or cultural bias is minimized </li></ul><ul><li>Published evidence suggests that patients will significantly benefit when computerized decision support systems are used, with a better chance of survival. </li></ul>
  22. 22. How We Lead <ul><li>Physicians and other prescribing practitioners understand that hand written prescriptions may be misinterpreted with sometimes disastrous results. </li></ul><ul><li>CPOE offers a clearly legible order that can be processed efficiently. </li></ul><ul><li>Combined with sophisticated programmed alerts, CPOE has demonstrated significant contributions to error reduction. </li></ul>
  23. 23. How We Lead continued <ul><li>Documentation of Care Delivery is Important </li></ul><ul><li>Eliminate Barriers </li></ul><ul><li>Technology </li></ul><ul><ul><li>Voice recognition software </li></ul></ul><ul><ul><li>Bar coding devices </li></ul></ul><ul><li>Real Time Data </li></ul>
  24. 24. So What Is NEXT? <ul><li>Continuous Quality Improvement Programs </li></ul><ul><li>Ways to improve complex systems </li></ul><ul><li>JCAHO mandated standards </li></ul><ul><li>Continuous Quality Improvement programs. </li></ul><ul><ul><li>FOCUS-PDCA, Six Sigma, Quality Related Events </li></ul></ul><ul><li>SIX-Sigma ~~ </li></ul><ul><ul><li>Define, Measure, Analyze, Improve, Control </li></ul></ul>
  25. 25. Medicare Decision <ul><li>Effective October 2008 Beginning with hospital discharges on or after October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) will no longer pay the extra costs of treating patients who develop eleven serious, preventable conditions after they have been. </li></ul>
  26. 26. Summary <ul><li>Culture of Safety </li></ul><ul><ul><li>Not afraid to identify errors and learn </li></ul></ul><ul><ul><li>No retribution for reporting errors or “near misses”. </li></ul></ul><ul><li>Team approach </li></ul><ul><li>Best practices </li></ul><ul><li>Organizational guidelines </li></ul><ul><li>Technical Support Strategies </li></ul>