The document discusses the 2012 Joint Commission National Patient Safety Goals. It provides 3 goals: 1) improve patient identification, 2) improve communication among caregivers, and 3) improve safety of medication use. It also presents several case studies on medication errors and discusses root causes, prevention strategies, and recommendations to reduce errors.

1. 2012 Joint Commission National Patient Safety Goals Goal 1: Improve the accuracy of patient identification A. Use at least two patient identifiers (neither to be the patients room number) when providing care, treatment or services

2. Joint Commission Patient Safety 2012 Eliminate Transfusion Errors when administering blood and blood products Nurses must adhere to a strict patient identification protocol when administering blood

3. 2012 National Patient Safety Goals Goal 2- Improve the effectiveness of communication among caregivers

4. 2012 National Patient Safety Goals For verbal or telephone orders or for telephonic reporting of critical test results, verify “read -back” of the complete order or test result by the person receiving the order or test result

5. 2012 National Patient Safety Goals Standardize a list of abbreviations, acronyms and symbols that are NOT to be used throughout the organization. The use of certain abbreviations has been associated with errors.

6. Case Study An 81 year old female with a history of chronic Atrial Fibrillation who was receiving warfarin (Coumadin) developed asymptomatic runs of ventricular tachycardia http://www.ahrq.gov

7. Case Study Unit RN contacted MD who was involved in a sterile procedure and gave a verbal order to the procedure nurse who relayed the message to the RN Someone in the verbal order(by phone) said “ 40 of K”. The unit RN wrote the order as “ Give 40mg of Vit K IV now”

8. Case Study The hospital pharmacist contacted The MD concerning The high dose and the Route for the medication order Clarification of order Was obtained and correct order was “ 40 mEq of KCL (Potassium Chloride) PO( by mouth)” Simultaneously the unit RN had obtained the Vit K on over ride From the Pyxis system( cabinet where medications are kept) and gave the IV dose of Vit K instead of KCL.

9. Case Study The RN attempted to contact the MD but was told he was busy. The MD was not notified until the next day. Heparin was started and warfarin was retitrated. No long term consequences were suffered. Abbreviations were used in this case study which was identified as one of the root causes for the error. What are other possible root causes?

10. Do Not Use Abbreviations

13. How Important is Communication and Patient Safety? 70-80% of health care errors are caused by human factors associated with interpersonal interactions (Schaefer,1994)

14. Behaviors That Impede Patient Safety Reluctance or refusal to answer questions- avoidance Rude or condescending comments Threatening body language Verbal abuse “ I am in charge. Just do it” Threats to reputation

15. Behaviors That Support A Culture of Safety Collaboration Respect Interdisciplinary rounds/conferences Open, honest and direct communication Supportive non-punitive reporting Goal directed interactions

16. Reporting Incidents: SBAR A method of communication used to report a critical situation to a physician or other health care provider is S = Situation- What happened B = Background- Patient information A = Assessment- What you found R = Recommendation- What needs to be done

17. 2012 National Patient Safety Goals Goal 3 Improve the safety of using medications Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs

18. Case Study A woman with chronic renal failure & diabetes was transferred from a nursing home to the hospital for treatment of an infection. Bicitra (citric acid)30ml four times a day was ordered on admission. The pharmacist filled the order with Polycitra instead ( contains citric acid & Potassium citrate). The patient drank the entire dose.

19. Case Study The nurse on the next shift noted the empty container. The MD was notified and a potassium blood level was > 8mEq/L. (Normal is 3.5-5) and her blood glucose was 600mg/dl( normal < 129) The patient was Treated with Kayexalate and insulin without complications. What happened? Reference: http://www.ahrq.gov

20. Near Miss The wrong drug was administered to the patient. This is an example of a sound alike drug error. Nurses are responsible to know what medications they are administering and question all inconsistencies. Sound alike/look alike drugs should be stored in different areas and contain special labeling/alerts.

21. 2012 National Patient Safety Goals - Label all medications, medication containers(syringes, medicine cups,etc) or other solutions on & off the sterile field( Area where instruments and solutions are placed during procedures)

22. Case Study A woman was injected with Chlorhexidine (topical anti microbial solution) instead of the Intended contrast media during a cerebral angiogram procedure. The clear pink tinged Chlorhexidine solution was placed in a basin identical to that used to hold clear colored contrast media. Neither basin was labeled so both solutions looked very similar. ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

23. Case Study The patient experienced an acute severe chemical injury to the blood vessels in her leg. Within two weeks her leg was amputated. She then suffered a stroke and organ failure leading to her death. ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

24. What Happened ? Is this an example of an active or latent failure?

25. What Happened ? It is an example of both. The lack of labeling on the basins is an active failure. The change in cleaning solutions is a latent failure. Administration neglected to notify staff regarding the change. Blunt End Sharp End

26. Additional Medication Safety Issues The National Coordinating Council for Medication Error Reporting & Prevention defines a medication error as follows: “ A medication error is 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. Such events may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling, packing, and nomenclature; compounding; dispensing; distribution, administration; education;monitoring;and use.”

27. TYPES OF ERRORS Unauthorized drug Improper dose Omission Prescribing Wrong time Wrong Patient Extra dose Wrong administration technique Wrong method of preparation Wrong dosage form Wrong route Failure to monitor

28. How Often Do Medication Errors Really Occur ? According to the IOM study more than 7000 deaths occur each year related to medication errors. Another study found that as many as 1 in every 5 medications reach the patient in error.

29. Medication Errors Keep in mind that the reporting of medication errors is thought to be grossly under reported ! Reporting agencies include the FDA, US Pharmacopeia via Medmarx , ISMP and Joint Commission.

30. Where in the Process do Medication Errors Occur? Reference: http://www.ahrq.gov

31. Where in the Process do Medication Errors Occur? Most errors occur during the prescribing /ordering process. About 50% of those prescribing errors are caught prior to reaching the patient. Greater than one third of errors occur during administration but only 2% of these errors are caught prior to reaching the patient. ISMP Medication Safety Alert, November 2005

32. Patient is the Last Line of Defense Errors made during the administration process are much more likely to reach the patient and are associated with those errors that cause harm. Encourage patient and families to ask questions. ISMP Medication Safety Alert, November 2005

33. Do All Medication Errors Result in Harm to Patient? According to MEDMARX 2002 Data report (USP) out of 192,477 reported med errors-82 % were classified as non-harmful. However, a reported 3,193 were classified as harmful and 20 as fatal errors.

34. Key Points Written orders must be clear and legible ! Clarify any order that is questionable including sound alike/ look alike drugs. Patients age, sex,current medications, diagnosis, co morbidities, concurrent conditions, laboratory values, allergies and past sensitivities must be available to prescriber

35. Case Study A patient was admitted to a teaching hospital with suspected vasculitis. During rounds the senior resident instructed the intern to “give the patient one gram of steroids.” Following rounds the interns ordered ” Prednisone 20mg tabs 50 pills PO x 1 now”. The pharmacist contacted the intern to clarify the order. She suggested to the intern that the order should probably be given in an IV form. The intern refused to change the Order despite the pharmacists suggestion to contact the senior resident for clarification. The intern added to give Maalox with the steroids. The patient reluctantly took the fifty 20 mg pills and developed mild nausea and heartburn. The following day the senior resident found the error and changed the order to the IV form. Reference: http://www.ahrq.gov

36. What Happened? The intern did not seek clarification as suggested by the pharmacist, who is an expert in pharmacology. Lack of interdisciplinary approach to patient care. The intern may have been fearful of the senior residences reaction to seeking clarification. The pharmacist did not follow the chain of command by calling the senior resident when the discrepancy was not addressed by the intern. Asking a person to take 50 pills is NOT appropriate. QUESTION INCONSISTENCIES-YOUR PATIENT’S SAFETY IS IN YOUR HANDS

37. Medication Errors : Prevention Strategies Adhere to standards of medication administration -“8 Rights” Right Patient Right Drug Right Dose Right Route Right Time Right Documentation Right to refuse Right Reason

38. Medication Errors: Prevention Strategies Communicate with the patient /family They are a line of defense. Example: If you inform them of their medications prior to administration and they question a particular drug, don’t ignore them. Red flag ! Identify medications with high risk for error and institute specific protocols- High risk drugs include insulin, heparin, coumadin, chemotherapy- Additional labeling, verification and double check systems should be instituted

39. Medication Errors : Prevention Strategies Training & competency assessment Orientation process, personal responsibility for education, in-services, ongoing competency evaluations. Decrease distractions Computerized order entry the prescriber generates a medication order via the computer decreases med errors at the ordering and prescribing stages. Systems check the drugs indication against a diagnosis, patient allergies, drug interactions, lab tests, acceptable doses etc. In order to be effective these systems must interface with the pharmacies system. Overall these systems effectively reduce errors relating to the prescribing and transcribing process

40. Medication Errors : Prevention Strategies Automated dispensing devices can effectively decrease med errors by eliminating multi-dose concentrations of drugs and the need for reconstitution. They can decrease errors of omission by increasing the availability of meds. Good for stat & first doses. They are not fail proof. Example: If the sleeve where a specific drug should be was filled with the wrong drug and the nurse does not check it an error can occur. NOTE: Ideally all medication orders will be checked by a pharmacist before the drug can be removed from the Pyxis system.

41. Medication Errors: Prevention Strategies Bar coding-decreases errors in administration When the patient is admitted they are assigned a bar code. The staff has a scanner and any deviations sound alarm. This can decrease some types of medication errors such as the wrong patient. The VA hospital system was one of the first to use this system. Multiple studies have shown a significant decrease in medication errors. Increased clinical Pharmacists

42. 2012 Patient Safety Goals Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

43. Case Study Three neonates died at a hospital as a result of accidental heparin overdoses. A pharmacy technician inadvertently filled the automated dispensing cabinet with 1ml vials of heparin containing 10,000 units/ml instead of the1ml vials of heparin10 units/ml. The nurses did not notice the discrepancy and the heparin was administered to the neonates. ISMP Medication Safety Alert Oct 2006 4/10

44. Recommendations In order to prevent this tragedy from happening again the following recommendations have been made: Eliminate 10, 000 units/ml concentration vials stocked in the hospital. If this concentration remains in the pharmacy, keep the vials separate from other concentrations. Require an independent double check of drug. Reduce look alike/ sound alike drug packaging The vials of heparin had similarities that may have contributed to the error. For all recommendations see reference

45. Unintended Medication Discrepancies at the Time of Hospital Admission 6% Severe harm potential 61% No harm potential 33% Moderate harm potential More than half of patient have  1 unintended medication discrepancy at hospital admission Reference: http://www.ahrq.gov

46. Unintended Medication Discrepancies at the Time of Hospital Admission Cornish,Knowles & Marchensano(2005)found greater than 50% of patients had at least 1 medication discrepancy upon hospital admission. The most common error was omission of a regularly used medication. Obtaining an accurate medication history at the time of admission is critical to prevent such errors. Reference: http://www.ahrq.gov

47. 2012 National Patient Safety Goals Goal 8- Accurately and completely Reconcile Medications across the continuum of care