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Medication Error Prevention in 2014 Wendy Perry, Pharm.D. September 28, 2013.

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Presentation on theme: "Medication Error Prevention in 2014 Wendy Perry, Pharm.D. September 28, 2013."— Presentation transcript:

1 Medication Error Prevention in 2014 Wendy Perry, Pharm.D. September 28, 2013

2 Objectives Describe a Medication Safety Officers responsibilities. List new safety challenges that are a result of technological advances. Discuss the mechanisms for obtaining medication error data. Describe a data analysis process and appropriate follow up. Define Just Culture. Discuss methods to reduce medication errors.

3 3 Why Medication Error Prevention in 2014?

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7 Medication Safety Officer Job Description –Guide and coordinate the organizations medication safety activities –Analyze data to identify trends and recommend priorities –Examine entire medication use system –Engage key stakeholders –Knowledge expert on committees –Present educational sessions Larson CM, Saine D. Medication Safety Officers Handbook. ASHP;2013 7

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9 Computerized Provider Order Entry (CPOE) and Clinical Decision Support (CDS) Pros –Decreased number of steps in the medication process, pre-populated fields, etc. improves safety –Provision of clinical info related to allergy, dose, duplicate therapy, etc. improves safety Cons –Complicated screens –Easier to make incorrect choice in patient, drug sentence –Alert fatigue 9

10 Post – CPOE 1 st PSE received: Wrong Patient Order for insulin received by pharmacist who was familiar with patient and recognized not appropriate Wrong patient was selected by MD Prevention methods: Only one patient MR open at once Create patient list 10

11 Bar Code Medication Administration (BCMA) Background –34% of all med errors occur in administration –50% of hospitals in 2011 –25% of nursing time spent on med-related activities Prospective before and after observational study –386 bed academic teaching hospital –2 medical-surgical units, 2 ICUs –Med admin errors assessed by comparing observed med administered to med intended for that patient Helmons PJ. Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. Am J Health-Syst Pharm. 2009;66:

12 Results Error rate = # of errors total opportunities for error Separated wrong time errors from other errors Med-surg: overall 8% to 3.5% (p<0.0001) omissions 4% to 1% (p<0.0001) ICUs: NS, charting compliance improved 12

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14 Raising the Bar for BCMA: Addressing Pharmacy Challenges, Nursing Engagement, and Data Analysis to Improve Practice; Beaumont Hospital; ISMP Webinar

15 BCMA Safety Opportunities Scanning omissions Bypass alert Work-arounds –Barcode copies –Wrong time Front or back scanning for convenience, patient availability To complete documentation –Wrong reason chosen 15

16 Automated Dispensing Cabinets (ADC) Non-profile units Override medications Incorrect medication fill – decreased with bar codes –Spill over –LASA medications –Replacement by nurses –Quantity to be scanned Alert fatigue 16

17 Smart IV Pumps Override functionality – drug libraries are the core safety feature Alert fatigue Lack of interface 17

18 Tools to Identify Safety Needs Voluntary reporting data Trigger tools Culture surveys Published literature and reporting sources Walk around Pharmacist clinical interventions Med administration BCMA scan failures Bypassed alerts and overrides Failure mode and effects analysis (FMEA) 18

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20 Voluntary Reporting Reported medication error rates are simply a measure of the ability of the organization to recognize and report medication-related problems. Therefore, an organization with a large number of error reports may actually (and in many cases is likely to) have a lower true underlying medication error rate than an organization where few reports are received, analyzed, and acted on. Larson CM, Saine D. Medication Safety Officers Handbook. ASHP;


22 Specific Event Type Mandatory: Yes Pick List Values (Single-pick) Adverse Drug Reaction Administration Technique Incorrect Dose Incorrect Drug With Known Allergy Medication Administered Not Ordered Narcotic Count Incorrect Illegible Order Time Incorrect/Delayed Outdated/Unusable Medication Drug Incorrect Monitoring Issue Patient Incorrect Omission Route Incorrect Storage Incorrect Drug Preparation Issue Pump Programming Issue Documentation Error Other (please specify) 22

23 Contributing Factors Mandatory: No Pick List Values (Multi-pick): Communication/Handoff Failure Competency of Staff Lack of Training/Education Insufficient Staff Action by Family Member/Caregiver Action by Patient Policy/Procedure Issue Physical Environment Condition/Design Insufficient Monitoring/Supervision Work Environment-Fatigue Language Barrier Administration Issue/Calculation Error Drug Name Confusion(e.g. Look Alike & Sound Alike) Medication Not Available Distractions/Interruptions Monitoring – Vital Signs Not Checked Patient Unavailable Incomplete/Ambiguous Order Preparation – Delayed Delivery Preparation – Wrong Drug/Dose/Strength Transcription Issue – Incorrect Computer Order Entry Transcription – Order Not Entered In Computer System Drug Info Missing – Inadequate Medication Reconciliation Process Patient Info Missing – Allergies Patient Info Missing – Lab Values Patient Info Missing – Weight Other (please specify) 23

24 ADR vs ADE Medication Error A preventable error occurring in any step of the medication process Adverse Drug Event An undesirable occurrence associated with a medication Adverse Drug Reaction An idiosyncratic reaction or other adverse effect of a medication that is not preventable 24

25 Med Errors ADE ADR Near Miss 25

26 Interpretation Near Misses are Med Errors –Caught by chance –Caught by following a safety process ADRs are not Med Errors –All ADRs are ADEs –Not all ADEs are ADRs –Focus and follow up is different Involves patient management Future prevention and education Reporting if necessary 26


28 C, D Med Errors ADE ADR Near Miss B 28 E - I

29 Purpose of Nomenclature and Definitions Communication within institutions and corporations Regulatory self-assessment Trending and consolidation Monitoring performance Benchmarking 29

30 Dont get overwhelmed with data collection and/or analysis The most important aspect of medication safety is to apply what has been learned to implement changes in the organization to decrease the potential for harm to patients. 30

31 How to Set Priorities National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP) – Categories A – I Causes of a level where harm occurred often also seen in near misses 31

32 Data Analysis Departmental Event Type: Pump Programming Contributing Factor: Hand-off Failure Severity: E-I Medication: Insulin Location: 5NE Interdisciplinary Committee Medication Management: Nursing and Pharmacy, monthly Hospital Committee E-I Patient Safety Event Review: Multidisciplinary, biweekly Quality Department Root Cause Analysis (RCA) 32

33 Tools from Highly Reliable Industries 1.Failure Mode and Effects Analysis (FMEA) FMEA is an ongoing quality improvement process that is carried out in healthcare organizations by a multidisciplinary team. It can be employed to examine the use of new products and the design of new services and processes to determine points of potential failure and what their effect would be – before any error actually happens. FMEA is a proactive process used to look more carefully and systematically at vulnerable areas or processes. In this regard, FMEA differs from Root Cause Analysis (RCA). 33

34 2. Root Cause Analysis (RCA) Usually RCA is a reactive process, employed after an error occurs, to identify its underlying causes. Required by The Joint Commission for sentinel events, defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Includes an action plan, and monitoring the effectiveness of the plan. 34

35 Just Culture Whack-a-Mole by David Marx, J.D This book argues that our Whack-a-Mole approach to inevitable and often predictable human error is ineffective, inefficient, and unjust; it does nothing to enable us to learn what we might do differently next time, or what systems we might put in place to minimize the chances of causing the same adverse outcome again. 35

36 Just Culture We spend far too much time looking at the severity of the adverse outcome (how bad was it?) and who was the unfortunate soul to be closest to the harm. In turn, we spend far too little time addressing the system design that got us there and the behavioral choices of the humans in those systems that might have ultimately contributed to the adverse outcome. 36

37 Just Culture The Behaviors We Can Expect: Human error -inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. At-risk behavior –behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. Reckless behavior -behavioral choice to consciously disregard a substantial and unjustifiable risk. 37

38 Just Culture Console the human error. Coach the at-risk behavior. Punish the reckless behavior. Independent of the outcome. 38

39 Its About Changing Staff Expectations (from Just Culture literature) 39 Looking for the risks around me Reporting errors and hazards Helping to design safe systems Making safe choices –Following procedure –Making choices that align with organizational values –Never signing for something that was not done

40 Error Prevention Strategies Improve communication and handoff Situation, Background, Assessment, Recommendation (SBAR) Handoff Checklist Catch phrases Multidisciplinary or team safety meetings Technology Catch of the Month Double Checks 40

41 Double Check The virtues of independent double checks – they really are worth your time! ISMP December 17, 2009 The average checking error rate (errors missed during a double-check) is about 5%. In studies where artificial errors were introduced into medication carts and sample pharmacy orders, 93% to 97% of such mistakes were identified during an independent double- check. 41

42 Double-checks work best when they are conducted independently. The person checking has to form an independent judgment without cues from the person doing the initial work (why ISMP encourages independent double-checks). It would be more effective, for example, to have two people calculate a dose separately and then compare their answers, than to have them perform the calculation together or to have one share his answer with the other before the double-check occurs. People may be swayed by the opinions of others, even more so if the other person holds a position of authority or has more experience. 42

43 Heparin 25,000 units/500 ml standard solution Store in high risk section; boxes placed below Tech places HEPARIN sticker on bag; pharmacist initials when checks Tech ran out of bags, placed HEPARIN sticker on additional bags that were not checked by pharmacist Additional bags were actually Lidocaine 43

44 Limit checks to high-risk situations While its true that independent double-checks are not as effective as system changes that make it hard for people to make mistakes, if performed properly, they can reduce the risk of an error reaching the patient Challenge: when does technology suffice 44

45 Learn from captured errors. –Document mistakes discovered during double checks –Analyze to understand the reasons behind them –Identify precautions that need to be taken –Not doing so has resulted in fatal errors 45

46 What is your action plan? 46

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