Presentation on theme: "N101Y Health Information Technology Module"— Presentation transcript:
1 N101Y Health Information Technology Module Medication SafetyPatient SafetyError Prevention
2 What is a culture of safety? Patient SafetyWhat is a culture of safety?
3 A Culture of Safety IOM: To Err is Human: Building a Safer Health System (19919)Crossing the Quality Chasm – A New Health System for the 21st Century (2001)Medication ErrorsAdverse Drug EventsAdverse Drug ReactionsSix elements:Assessing the CultureTeamworkPatient InvolvementSystemsOpenness/TransparencyAccountabilityIOM 1 definitions: 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, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.Some of the factors associated with medication errors include the following:Medications with similar names or similar packagingMedications that are not commonly used or prescribedCommonly used medications to which many patients are allergic (e.g., antibiotics, opiates, and nonsteroidal anti-inflammatory drugs)Medications that require testing to ensure proper (i.e., nontoxic) therapeutic levels are maintained (e.g., lithium, warfarin, theophylline, and digoxin)Adverse drug events are defined as injuries that result from medication use, although the causality of this relationship may not be proven.Some are preventable errorIf not, preventable often the result of adverse drug reactions (ADRs), which are :any response to a drug which is noxious and unintended and which occurs at doses normally used for prophylaxis, diagnosis or therapy of disease, or the modification of physiological function, given that this noxious response is not due to medication error.adverse drug reaction also: an undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or both.Assessing the CultureTeamworkPatient InvolvementSystemsOpenness/TransparencyAccountability
4 Types and when they occur Medication ErrorsTypes and when they occur
5 Types of Med Errors Prescribing error Omission error Wrong time error Wrong drug-preparation errorWrong administration- technique errorDeteriorated drug errorMonitoring errorCompliance errorOther medication errorPrescribing errorOmission errorWrong time errorUnauthorized drug errorImproper dose errorWrong dosage-form errorPrescribing error Incorrect drug selection (based on indications, contraindications, known allergies, existingdrug therapy, and other factors), dose, dosage form, quantity, route, concentration, rate ofadministration, or instructions for use of a drug product ordered or authorized by physician (orother legitimate prescriber); illegible prescriptions or medication orders that lead to errors thatreach the patientOmission error The failure to administer an ordered dose to a patient before the next scheduled dose, if anyWrong time error Administration of medication outside a predefined time interval from its scheduled administrationtime (this interval should be established by each individual health care facility)Unauthorized drug error Administration to the patient of medication not authorized by a legitimate prescriber for the patientImproper dose error Administration to the patient of a dose that is greater than or less than the amount ordered by theprescriber or administration of duplicate doses to the patient, i.e., one or more dosage units inaddition to those that were orderedWrong dosage-form error Administration to the patient of a drug product in a different dosage form than ordered by the prescriberWrong drug-preparation error Drug product incorrectly formulated or manipulated before administrationWrong administration-technique error Inappropriate procedure or improper technique in the administration of a drugDeteriorated drug error Administration of a drug that has expired or for which the physical or chemical dosage-formintegrity has been compromisedMonitoring error Failure to review a prescribed regimen for appropriateness and detection of problems, or failureto use appropriate clinical or laboratory data for adequate assessment of patient response toprescribed therapyCompliance error Inappropriate patient behavior regarding adherence to a prescribed medication regimenOther medication error Any medication error that does not fall into one of above predefined categoriesAmerican Society of Hospital Pharmacists. ASHP guidelineson preventing medication errors in hospitals. Am J HospPharm. 1993; 50:305–14.
6 When Med Errors Occur Ordering: wrong dose, wrong choice of drug, Transcribing: wrong frequency of drug administration, missed dose because medication is not transcribed,Dispensing: drug not sent in time to be administered at the time ordered, wrong drug, wrong dose,Administering: wrong dose of drug administered, wrong technique used to administer the drug, andMonitoring: not noting the effects of the given medicationFrom IOM 1 also.
7 Med Error Discussion Think about medication administration As a student have you experiencedA near miss?A medication errorWitnessing a near missWitness a medication errorDiscuss and refer back to previous slides:what type was it and when did it occur and?FromFrom
8 Preventing Medication Errors: Technology and Equipment Beyond the 5 Rights.
9 Medication Administration Technology ORDERING/TRANSCRIBING:eMARsePrescriptionsCPOE (Computerized Provider Order Entry)CDSS (Clinical Decision Support Systems)When the technology is used and how it prevents errorsEmars- fields, tracking, links with BCMACpoe- order sets, protocols, automatic populated data (weight, age, labs) - standard prescription guidelines, doses, etc. spelling errors prevented. No abbrev. necessary, self populating protocols and fields (ei- weight based info pulled from weight input) Allergy alerts, etc.CDSS- provides information, prompts
10 Medication Administration Technology DISPENSING:Automated medication dispensing devices (“Pyxis®”)ADMINISTERING:BCMA (Bar Code Medication Administration)RFIDSmart PumpsMONITORING:Smart RoomsEMRHow it is used and how it prevents errorsAMDD- inventories, controls, tracks users/meds,BCMARFID- confirms IDSmart Pumps- identifies 5 rights of med admin, safety “guard rails”Smart RoomsEMR(see next slide)
11 EMR and Human Error Elements in the EMR that reduce human error: CPOE Bar Code systemsCDSSHigh Alert Medication DocumentationPoint of Care DocumentationMandatory FieldsCommunication ToolMed. Recon.CPOE systems have many safeguards - standard prescription guidelines, doses, etc. spelling errors prevented. No abbrev. necessary, self populating protocols and fields (ei- weight based info pulled from weight input) Allergy alerts, etc.Bar Coding- pt has unique ID, which accesses pt’s eMar or chart and confirms med orders, labs etc. Labels can match pt. for labsHigh Risk med- forced to document that another nurse has double checked high risk med adminPOC documentation- accurate time, able to record results IE- vital signs , lab results (fingersticks) etcMandatory fields- prevent errors of omission, required data is recorded so others can make decisions about pt careSmart pumps- medication libraries used to safety dose, run IV infusions“Guard Rails”Communication tool - accessible by all of the care team, information is integrated so it can be used for clinical decision making and accurate transmission of info for pt care.
12 Potential for errors with technology Errors with BMCA:Medication does not come packaged as bar-coded unit-dose productNurse fails to scan medicationBar code on patient and/or medication is unreadablePharmacy does not scan products arriving in pharmacy for readabilityPatient wristbands are not on patients but other locations (e.g., clipboards, med rooms)Pharmacy applies correct label with bar code to wrong productDrugs not available in ready-to-use unit-doses for nurse (e.g., tablets not broken in half)Nurse overlooks alert displayed on computer screenNurse overrides alert without investigating its causeNurse fails to scan patientDiscuss-what phase in med admin do these happen?Ordering, transcribing, dispensing, administering, or monitoring?
13 Potential for errors with technology ERRORS WITH CPOE/EMR/eMAR/ePrescribing:Mostly user interface issues:Wrong patient chosenDrop down menu issues (too many choices!)Software issuesIn 2010 computers at a major Midwest hospital chain :EMR would switch to another patient record without the user directing it to do soelectronic pharmacy orders weren't being delivered to nurses for dispensing to patientsDiscuss-what phase in med admin do these happen?Ordering, transcribing, dispensing, administering, or monitoring?What about computer/software/hardware malfunctions?Discuss
14 Emerging Patient Safety Technologies The present and the future
15 Other patient safety technologies What is patient safety technology?1. Used in direct hands-on care of the patient2. Documentation tools3. Meeting the needs of patients and families4. Supporting the staff caring for the patient and the familySOME EXAMPLES:Bedside monitoringCDSSCommunication ToolsEducationalSmart roomsOften technology that helps in one area may conflict in another. Especially #Monitoring- +integrated into EMR, interprets, - false alarms, alarm fatigue, still require nursing judgementCDSS +educational, falls scales, Braden or CIWA scales, prompts and alerts, - prompts and alertsCommunication tools (Vocera, , text paging) + staff and patients can be connected to providers, documents contacts (for example outpatient setting, labs, alert to MD in inbox, MD follows up with patient via or phone and documents follow up, patient as access to PHR and info about the lab and reminders on what the MD said, esp if contact was electronic, patient can review later)Educational- + outpatient : patients can look up meds or symptoms for more info, contradictions, etc, staff can quickly find info about meds, conditions and provide consistent outpatient teaching, simulation; - info may not be current or up to date, may confuse or scare patients. Costs money for simulators/trained staffSmart rooms- integration of technologies, increase real time delivery of care, information, etc
17 Educational Technology ExemplarUniversity of Texas, Arlington video of their simulation smart hospital
18 Potential for errors OTHER TECHNOLOGIES: DISCUSS What are some other areas that might have potential for errorCDSSAutomated medication dispensing devicesSmart PumpsSmart RoomsOthers?CDSS- delays in care, incorrect info, interface issuesAMDD- improperly stocked, delays in care if not stocked or inventoried correctlySmart Pumps work arounds, improper soft stops programmedSmart RoomsOthers?
19 The Nurse’s Role Culture of safety Technology The future Participate or organize equipment fairs to evaluate technology and equipment before it is purchased at your facilityPractice and learn to use new technology on challenging scenarios in a simulated settingMentor and oversee temporary (agency) nurses and other personnel as they use your facility’s technologyBecome critical users of technology by identifying problems early and communicating them to vendors and in-house biomedical engineering staffEnsure that adverse events associated with medical devices are reported to the Food and Drug Administration MAUDE reporting system and/or ECRI’s Problem Reporting SystemServe as a resource person on your unit for new technologies by being a SuperUser!From: