Presentation on theme: "Risk Reduction Strategies for High-Alert Medications"— Presentation transcript:
1 Risk Reduction Strategies for High-Alert Medications Richard C. WallsAdvisor: Scott Ciarkowski
2 Learning Objectives Describe characteristics of high-alert medications Describe characteristics of effective risk-reduction strategies for high-alert medicationsReview the medication use process and identify possible sites for errorOutline the steps to developing a comprehensive risk-reduction programPresent and discuss examples of the implementation of risk-reduction programs
3 High-Alert Medication: Definition1 A high-alert medication is a medication that:has a high risk of causing patient harm when used in error.A high-alert medication is not necessarily a medication that has a higher risk of being used in error.Sakowski et. Al. evaluated perceived severity of medication errors saw high-alert medications as 5% more likely to have a moderate or severe adverse reaction21-http://www.ismp.org/tools/highalertmedicationLists.asp2 – PMID
4 High-Alert Medication: ISMP Examples3,4 InsulinParenteral nutritionAnticoagulantsDialysis solutionOpioidsLiposomal formulationsConcentrated electrolytesImmunosuppressantsAntineoplastic agentsPregnancy category X drugsAntiretroviral agentsPediatric liquid formulationsAnesthetic agentsOral hypoglycemic agentsAntiarrhythmic agentsIV radiocontrast agentsEpidural/intrathecal formulationsHypertonic salineNeurommuscular Blocking AgentsAdrenergic agonistsAdrenergic antagonists3 -4 -Darkened medications considered by ISMP to be essential to any institution’s high-alert medication list.
5 High-Alert Medications Joint Commission standard MMInstitutions must:Have a list of high-alert medicationsDevelop a process for mitigating risk with high-alert medicationsImplement their process for managing high-alert medicationsAny list and any process meet minimum requirements65 -6 -However, to actually improve patient safety, it is necessary to carefully design an individualized high-alert medication, and now we will take a look at a few factors to consider when developing a high-alert medication list.
6 Developing a High-Alert Medication List ISMP’s lists a good starting point3,4Add or subtract drugs based on institutional needsDrugs new to formularyAppropriate criteria for therapy not establishedStaff less familiar with processes to manage adverse effects.Drugs locally identified to have caused patient harmDrugs of particular risk to an institution’s patient population
7 Developing a High-Alert Medication List Inclusion/Exclusion BalanceDo not want to leave out dangerous medicationsDo not want to expend undue resources monitoring generally safe medicationsINCLUDE: Concentrated IV Electrolytes7DO NOT INCLUDE: Unconcentrated PO Electrolytes87 – Micromedex – KCl injection8 – Micromedex – Calcium Carbonate
8 Developing a High-Alert Medication List List should be dynamic6List should be known to all practitionersList should be backed by processes that reduce errors, and which reduce the risk associated with errorsDynamic – Update the list. Add and subtract medications as patterns in use change. Having a high-alert list that has not been updated since its inception is suboptimal.
9 Low-Leverage Risk Reduction Strategies Staff Education ProgramsLabels & Manual Double ChecksBulletinsGiven these examples of strategies considered low-leverage, let’s discuss a few of the characteristics of these processes that limit their overall effectiveness.
10 Low-Leverage Risk Reduction Strategies PassiveInform agents that may prevent medication errors, but do not prevent errors themselvesIntermittentMay influence behaviors in short term9, with returns dissipating over timeFocus on IndividualsUtility limited by fatigue, time constraints, may create sense of punitive cultureDo improve awareness, but must be combined with a more comprehensive program to maximize effectiveness9 – PMIDA more comprehensive program will have to include high-leverage strategies. I have included a list of strategies from ISMP in your handout packet, and will outline a few strategies on the next slide
11 High-Leverage Risk Reduction Strategies Limit AccessSeparate/locked containersOnly certain meds in floor stockActive Sources of InformationElectronic notifications (labs, cultures, etc.)Deploy clinical pharmacistsUtilize smart pumps with drug librariesUtilize Fail SafesElectronic ‘hard stops’Oral syringes that cannot be connected to IV ports
12 High-Leverage Risk Reduction Strategies ActiveStrategies themselves play a role in making errors less likelyContinuousLess subject to waxing and waning effectivenessFocus on SystemsIndefatigable, high yield, pulls blame from individualsMore effective, but demand more resourcesSelect strategies relevant to likely errorsExamples of High-Leverage Risk Reduction strategies outlined in handoutIn order to implement effective and efficient strategies, programs must be designed to target likely errors. Next, I would like to review the medication use process and sites where errors may occur
13 Medication Use Process: Overview Prescribing-Selection of agent-Selection of doseTranscribing-Recording prescription in writing-Transferring records between systemsMonitoring-Signs of efficacy-Signs of adverse reactions-Reporting of resultsDispensing/Storage-Preparation of product-Delivery to storageAdministration-Retrieval of product-Administration to patient
14 Medication Use Process: Possible Errors Prescribing-Irrational dose-Drug-indication mismatchMonitoring-Failure to monitor-Failure to report monitored informationTranscribing-Record incorrect dose-Record incorrect agent-Transcription illegibleAdministration-Administer wrong drug-Administer to wrong patient-Administer at wrong time-Improper techniqueDispensing/Storage-Dispense wrong dose-Dispense wrong product-Confusable medications stored in proximity
15 Medication Use Process: Possible Appropriate Risk-Reduction Strategies Prescribing-Standardized dosing-CPOE Order SetsMonitoring-Standardized monitoring protocols-Electronic lab result notificationsTranscribing-Integrated CPOE-dispensing-administraton systemsAdministration-BCMA-Standardized administration protocols-Smart pumpsDispensing/Storage-Automated dispensing-Barcode verification-Separation of look-alike sound-alike medications
16 Role of Pharmacists in Reducing Error Be familiar with your institution’s high-alert medication listTake more care when verifying high-alert medicationsRecruit double checks on high-alert medicationsAlert downstream personnel of riskReport errors identifiedEncourage implementation of error reduction systems
17 Other Considerations for Error Reduction Want to utilize multiple risk-reduction strategies that target multiple pathwaysReducing medication errors is a multidisciplinary responsibilityReporting errors is critical for identifying areas for improvementTargeting multiple steps is key to success – an error that slips through one pathway is unlikely to be recognized downstream, and an error downstream in the pathway will nullify the most finely tuned upstream processes
18 Examples of Medication Errors Error: Patient prescribed IV acyclovir for possible meningitis and dosed on actual body weight rather than adjusted body weight resulted in dose 20% higher than recommended.Possible negative impact of error: Expose patient to higher risk of adverse effects.Possible strategy to reduce error: CPOE that automatically calculates dose based on patient’s height and weight.Error: Patient prescribed IV acyclovir for possible meningitis and dosed on actual body weight rather than adjusted body weight resulted in dose 20% higher than recommended.Possible negative impact of error: Expose patient to higher risk of adverse effects.Possible strategy to reduce error: CPOE that automatically calculates dose based on patient’s height and weight.Encourage audience to start thinking about medication errors they have seen in their practice and what sort of risk-reduction strategy could be used to prevent such an error in the future, or how an implemented strategy helped identify or manage the error
19 Examples of Medication Errors Error: Patient prescribed Medrol dose pack. Prescriber labeled “use as directed on package”. Dispensed with label “take two today, and then one daily until gone”.How error was detected: Detected during data entry double-check.How error was mitigated: Called the patient and told her to follow the instructions in the package, not the label we affixed to the product.
20 Examples of Medication Errors Error: Multiple instances of wrong drug product being selected for fill at a community pharmacy.How error was detected: Barcode NDC verification comparing bottle to product specified at data entry.How error was mitigated: Put the wrong bottle back on the shelf and selected the correct one.Open floor to other medication error reports
21 Putting it All Together Now that we’ve detailed the principles involved in selecting medications for a high-alert medication list and what strategies are likely to be effective at reducing risk associated with medications, I want to go through an example of how one might develop a comprehensive program to reduce risk associated with high-alert medicationsDeveloping a comprehensive risk-reduction program for high-alert medications
22 A General Stepwise Approach Build a list of high-alert medicationsIdentify likely causes of medication errorsDevelop multiple strategies to target possible sources of errorIdentify process and outcome measures to evaluate strategy effectivenessImplement strategies and collect effectiveness dataRegularly review effectiveness data and revise programs in accordance with results
23 A Comprehensive Institutional Program: Insulin Step 1: Build a list of high-alert medicationsWhy insulin10?Significant risk of hypoglycemiaunconsciousness, possibly comaRemember that the risk of patient harm is the primary factor in determining what medications are included in a high-alert medication list10 – micromedex insulin
24 A Comprehensive Institutional Program: Insulin Step 2: Identify likely causes of medication errors11PrescribingAdministrationIrrational DosagesNot associating dose w/mealsAdministering wrong doseTranscribingMistranscriptionMonitoringInadequate monitoringDispensing/StorageFailure to adjust doseU-100 vs. U-500Confusion with heparinPMID
25 A Comprehensive Institutional Program: Insulin Step 3: Develop multiple strategies to target possible sources of error.11PrescribingAdministrationIrrational DosagesNot associating dose w/mealsAdministering wrong doseTranscribingMistranscriptionMonitoringInadequate monitoringDispensing/StorageFailure to adjust doseU-100 vs. U-500Confusion with heparin
26 A Comprehensive Institutional Program: Insulin Step 3: Develop multiple strategies to target possible sources of error.11PrescribingAdministrationStandardized order setsCoordinate direct linkage between blood glucose monitoring, nutrition, and insulin administrationTranscribingCPOEDouble-check syringe dosesDispensing/StorageMonitoringStore only U-100 on floorsLink testing to administrationSegregate look-alike productsInclude dose adjustments in order set protocolsPrescribing – eliminate free text, instead use order sets flexible enough to tolerate complex insulin regimensTranscribing – Prefer CPOE to written, verbal, or phone orders
27 A Comprehensive Institutional Program: Insulin Step 4: Identify process and outcome measures to evaluate effectiveness of strategiesProcess MeasuresOutcome MeasuresRecord timing of dosesRates of hyperglycemiaRecord timing of mealsRates of hypoglycemiaRecord timing of glucose testsStep 5: Implement strategies and collect effectiveness data.Step 6: Regularly review effectiveness data and revise program in accordance with results.
28 A Comprehensive Community Program: Warfarin Step 1: Build a list of high-alert medicationsWhy warfarin12?Narrow therapeutic indexSignificant risks associated with both supratherapeutic (bleeding) and subtherapeutic (DVT, PE, stroke) dosagesRemember that the risk of patient harm is the primary factor in determining what medications are included in a high-alert medication list12 – micromedex warfarin
29 A Comprehensive Community Program: Warfarin Step 2: Identify likely causes of medication errorsWrong dose prescribedWrong dose at data entryPrescription entered in wrong patient profileWrong drug strength selectedPrescription labeled with wrong directionFilled prescription placed in wrong bagPMID
30 A Comprehensive Community Program: Warfarin Step 3: Develop multiple strategies to target possible sources of error.13Wrong dose prescribedWrong dose at data entryPrescription entered in wrong patient profileWrong drug strength selectedPrescription labeled with wrong directionFilled prescription placed in wrong bagPMID
31 A Comprehensive Community Program: Warfarin Step 3: Develop multiple strategies to target possible sources of error.13Increase patient counselingData verification double checksBarcode NDC verificationIncreased automation of fillingHard stop alert when irrational warfarin doses are enteredShow pill image at prescription verificationOpen bag at point-of-salePMID
32 A Comprehensive Community Program: Warfarin Step 4: Identify process and outcome measures to evaluate effectiveness of strategiesProcess MeasuresOutcome MeasuresFrequency of counselingNumber of products dispensed in errorPercentage of automated fillsStep 5: Implement strategies and collect effectiveness data.Step 6: Regularly review effectiveness data and revise program in accordance with results.
33 SummaryHigh-alert medications have increased risk of causing patient harm when used in errorCombining multiple low and high-leverage risk-reduction strategies are essential to improving outcomesRisk-reduction strategies need to be selected based on errors likely to occur with a particular drugMonitoring programs for effectiveness is essential to guaranteeing sustained success
34 ReferencesInstitute for Safe Medication Practices [Internet]. High-Alert Medications. Horsham, PA. (accessed 2013).Sakowski J, Newman JM, Dozier K. Severity of medication administration errors detected by a bar-code medication administration system. Am J Health Syst Pharm Sep 1;65(17):Institute for Safe Medication Practices [Internet]. Institutional High-Alert Medication List. Horsham, PA. (accessed 2013).Institute for Safe Medication Practices [Internet]. Institutional High-Alert Medication List. Horsham, PA. (accessed 2013).The Joint Commission [Internet]. Pre-Publiation Requirements. (accessed 2013).Institute for Safe Medication Practices [Internet]. Your High-Alert Medication List: Relatively Useless without Associated Risk-Reduction Strategies. (accessed 2013).
35 ReferencesPotassium chloride. In: Micromedex DRUGDEX [Internet Database]. Truven Health Analytics. Updated 2013, September.Calcium carbonate. In: Micromdex DRUGDEX [Internet Database]. Truven Health Analytics. Updated 2013, October.Abbasinazari M, Zareh-Toranposhti S, Hassani A, et al. The effect of information provision on reduction of errors in intravenous drug preparation and administration by nurses in ICU and surgical wards. Acta Med Iran Nov;50(11):771-7.Insulin. In: Micromedex DRUGDEX [Internet Database]. Truven Health Analytics. Updated 2013, August.Cobaugh DJ, Maynard G, Cooper L, et al. Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. Am J Health Syst Pharm Aug 15;70(16):Warfarin. In: Micromedex DRUGDEX [Internet Database]. Truven Health Analytics. Updated 2013, September.Cohen MR, Smetzer JL, Westphal JE, et al. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc Sep-Oct;52(5):