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Risk Reduction Strategies for High-Alert Medications

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Presentation on theme: "Risk Reduction Strategies for High-Alert Medications"— Presentation transcript:

1 Risk Reduction Strategies for High-Alert Medications
Richard C. Walls Advisor: Scott Ciarkowski

2 Learning Objectives Describe characteristics of high-alert medications
Describe characteristics of effective risk-reduction strategies for high-alert medications Review the medication use process and identify possible sites for error Outline the steps to developing a comprehensive risk-reduction program Present 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 reaction2 1-http://www.ismp.org/tools/highalertmedicationLists.asp 2 – PMID

4 High-Alert Medication: ISMP Examples3,4
Insulin Parenteral nutrition Anticoagulants Dialysis solution Opioids Liposomal formulations Concentrated electrolytes Immunosuppressants Antineoplastic agents Pregnancy category X drugs Antiretroviral agents Pediatric liquid formulations Anesthetic agents Oral hypoglycemic agents Antiarrhythmic agents IV radiocontrast agents Epidural/intrathecal formulations Hypertonic saline Neurommuscular Blocking Agents Adrenergic agonists Adrenergic antagonists 3 - 4 - Darkened medications considered by ISMP to be essential to any institution’s high-alert medication list.

5 High-Alert Medications
Joint Commission standard MM Institutions must: Have a list of high-alert medications Develop a process for mitigating risk with high-alert medications Implement their process for managing high-alert medications Any list and any process meet minimum requirements6 5 - 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 point3,4 Add or subtract drugs based on institutional needs Drugs new to formulary Appropriate criteria for therapy not established Staff less familiar with processes to manage adverse effects. Drugs locally identified to have caused patient harm Drugs of particular risk to an institution’s patient population

7 Developing a High-Alert Medication List
Inclusion/Exclusion Balance Do not want to leave out dangerous medications Do not want to expend undue resources monitoring generally safe medications INCLUDE: Concentrated IV Electrolytes7 DO NOT INCLUDE: Unconcentrated PO Electrolytes8 7 – Micromedex – KCl injection 8 – Micromedex – Calcium Carbonate

8 Developing a High-Alert Medication List
List should be dynamic6 List should be known to all practitioners List should be backed by processes that reduce errors, and which reduce the risk associated with errors Dynamic – 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 Programs Labels & Manual Double Checks Bulletins Given 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
Passive Inform agents that may prevent medication errors, but do not prevent errors themselves Intermittent May influence behaviors in short term9, with returns dissipating over time Focus on Individuals Utility limited by fatigue, time constraints, may create sense of punitive culture Do improve awareness, but must be combined with a more comprehensive program to maximize effectiveness 9 – PMID A 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 Access Separate/locked containers Only certain meds in floor stock Active Sources of Information Electronic notifications (labs, cultures, etc.) Deploy clinical pharmacists Utilize smart pumps with drug libraries Utilize Fail Safes Electronic ‘hard stops’ Oral syringes that cannot be connected to IV ports

12 High-Leverage Risk Reduction Strategies
Active Strategies themselves play a role in making errors less likely Continuous Less subject to waxing and waning effectiveness Focus on Systems Indefatigable, high yield, pulls blame from individuals More effective, but demand more resources Select strategies relevant to likely errors Examples of High-Leverage Risk Reduction strategies outlined in handout In 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 dose Transcribing -Recording prescription in writing -Transferring records between systems Monitoring -Signs of efficacy -Signs of adverse reactions -Reporting of results Dispensing/Storage -Preparation of product -Delivery to storage Administration -Retrieval of product -Administration to patient

14 Medication Use Process: Possible Errors
Prescribing -Irrational dose -Drug-indication mismatch Monitoring -Failure to monitor -Failure to report monitored information Transcribing -Record incorrect dose -Record incorrect agent -Transcription illegible Administration -Administer wrong drug -Administer to wrong patient -Administer at wrong time -Improper technique Dispensing/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 Sets Monitoring -Standardized monitoring protocols -Electronic lab result notifications Transcribing -Integrated CPOE-dispensing-administraton systems Administration -BCMA -Standardized administration protocols -Smart pumps Dispensing/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 list Take more care when verifying high-alert medications Recruit double checks on high-alert medications Alert downstream personnel of risk Report errors identified Encourage implementation of error reduction systems

17 Other Considerations for Error Reduction
Want to utilize multiple risk-reduction strategies that target multiple pathways Reducing medication errors is a multidisciplinary responsibility Reporting errors is critical for identifying areas for improvement Targeting 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 medications Developing a comprehensive risk-reduction program for high-alert medications

22 A General Stepwise Approach
Build a list of high-alert medications Identify likely causes of medication errors Develop multiple strategies to target possible sources of error Identify process and outcome measures to evaluate strategy effectiveness Implement strategies and collect effectiveness data Regularly review effectiveness data and revise programs in accordance with results

23 A Comprehensive Institutional Program: Insulin
Step 1: Build a list of high-alert medications Why insulin10? Significant risk of hypoglycemiaunconsciousness, possibly coma Remember that the risk of patient harm is the primary factor in determining what medications are included in a high-alert medication list 10 – micromedex insulin

24 A Comprehensive Institutional Program: Insulin
Step 2: Identify likely causes of medication errors11 Prescribing Administration Irrational Dosages Not associating dose w/meals Administering wrong dose Transcribing Mistranscription Monitoring Inadequate monitoring Dispensing/Storage Failure to adjust dose U-100 vs. U-500 Confusion with heparin PMID

25 A Comprehensive Institutional Program: Insulin
Step 3: Develop multiple strategies to target possible sources of error.11 Prescribing Administration Irrational Dosages Not associating dose w/meals Administering wrong dose Transcribing Mistranscription Monitoring Inadequate monitoring Dispensing/Storage Failure to adjust dose U-100 vs. U-500 Confusion with heparin

26 A Comprehensive Institutional Program: Insulin
Step 3: Develop multiple strategies to target possible sources of error.11 Prescribing Administration Standardized order sets Coordinate direct linkage between blood glucose monitoring, nutrition, and insulin administration Transcribing CPOE Double-check syringe doses Dispensing/Storage Monitoring Store only U-100 on floors Link testing to administration Segregate look-alike products Include dose adjustments in order set protocols Prescribing – eliminate free text, instead use order sets flexible enough to tolerate complex insulin regimens Transcribing – 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 strategies Process Measures Outcome Measures Record timing of doses Rates of hyperglycemia Record timing of meals Rates of hypoglycemia Record timing of glucose tests Step 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 medications Why warfarin12? Narrow therapeutic index Significant risks associated with both supratherapeutic (bleeding) and subtherapeutic (DVT, PE, stroke) dosages Remember that the risk of patient harm is the primary factor in determining what medications are included in a high-alert medication list 12 – micromedex warfarin

29 A Comprehensive Community Program: Warfarin
Step 2: Identify likely causes of medication errors Wrong dose prescribed Wrong dose at data entry Prescription entered in wrong patient profile Wrong drug strength selected Prescription labeled with wrong direction Filled prescription placed in wrong bag PMID

30 A Comprehensive Community Program: Warfarin
Step 3: Develop multiple strategies to target possible sources of error.13 Wrong dose prescribed Wrong dose at data entry Prescription entered in wrong patient profile Wrong drug strength selected Prescription labeled with wrong direction Filled prescription placed in wrong bag PMID

31 A Comprehensive Community Program: Warfarin
Step 3: Develop multiple strategies to target possible sources of error.13 Increase patient counseling Data verification double checks Barcode NDC verification Increased automation of filling Hard stop alert when irrational warfarin doses are entered Show pill image at prescription verification Open bag at point-of-sale PMID

32 A Comprehensive Community Program: Warfarin
Step 4: Identify process and outcome measures to evaluate effectiveness of strategies Process Measures Outcome Measures Frequency of counseling Number of products dispensed in error Percentage of automated fills Step 5: Implement strategies and collect effectiveness data. Step 6: Regularly review effectiveness data and revise program in accordance with results.

33 Summary High-alert medications have increased risk of causing patient harm when used in error Combining multiple low and high-leverage risk-reduction strategies are essential to improving outcomes Risk-reduction strategies need to be selected based on errors likely to occur with a particular drug Monitoring programs for effectiveness is essential to guaranteeing sustained success

34 References Institute 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 References Potassium 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):


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