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 21 st Century (2001) Medication Errors Adverse Drug Events Adverse Drug Reactions Assessing the Culture Teamwork Patient Involvement Systems Openness/Transparency Accountability
Types of Med Errors Prescribing error Omission error Wrong time error Unauthorized drug error Improper dose error Wrong dosage-form error American Society of Hospital Pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993; 50:305–14.
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, and Monitoring: not noting the effects of the given medication
Med Error Discussion Think about medication administration As a student have you experienced A near miss? A medication error Witnessing a near miss Witness a medication error From http://www.psqh.com/sepoct05/barcodingrfid1.html
Beyond the 5 Rights. Preventing Medication Errors: Technology and Equipment
Medication Administration Technology ORDERING/TRANSCRIBING: eMARs ePrescriptions CPOE (Computerized Provider Order Entry) CDSS (Clinical Decision Support Systems)
EMR and Human Error Elements in the EMR that reduce human error: CPOE Bar Code systems CDSS High Alert Medication Documentation Point of Care Documentation Mandatory Fields Communication Tool Med. Recon.
Potential for errors with technology Errors with BMCA: Medication does not come packaged as bar-coded unit-dose product Pharmacy does not scan products arriving in pharmacy for readability Pharmacy applies correct label with bar code to wrong product Drugs not available in ready-to-use unit- doses for nurse (e.g., tablets not broken in half) Nurse fails to scan patient Nurse fails to scan medication Bar code on patient and/or medication is unreadable Patient wristbands are not on patients but other locations (e.g., clipboards, med rooms) Nurse overlooks alert displayed on computer screen Nurse overrides alert without investigating its cause
ERRORS WITH CPOE/EMR/eMAR/ePrescribing: Mostly user interface issues: o Wrong patient chosen o Drop down menu issues (too many choices!) Software issues In 2010 computers at a major Midwest hospital chain : o EMR would switch to another patient record without the user directing it to do so o electronic pharmacy orders weren't being delivered to nurses for dispensing to patients http://www.huffingtonpost.com/2010/08/04/fda-obama-digital-medical_n_670036.html Potential for errors with technology
Emerging Patient Safety Technologies The present and the future
Other patient safety technologies What is patient safety technology? 1. Used in direct hands-on care of the patient 2. Documentation tools 3. Meeting the needs of patients and families 4. Supporting the staff caring for the patient and the family SOME EXAMPLES: o Bedside monitoring o CDSS o Communication Tools o Educational o Smart rooms
Potential for errors OTHER TECHNOLOGIES: DISCUSS What are some other areas that might have potential for error CDSS Automated medication dispensing devices Smart Pumps Smart Rooms Others?
The Nurses Role Participate or organize equipment fairs to evaluate technology and equipment before it is purchased at your facility Practice and learn to use new technology on challenging scenarios in a simulated setting Mentor and oversee temporary (agency) nurses and other personnel as they use your facilitys technology Become critical users of technology by identifying problems early and communicating them to vendors and in-house biomedical engineering staff Ensure that adverse events associated with medical devices are reported to the Food and Drug Administration MAUDE reporting system and/or ECRIs Problem Reporting System Serve as a resource person on your unit for new technologies by being a SuperUser! From: http://www.ncbi.nlm.nih.gov/books/NBK2686/ Culture of safety Technology The future