Presentation on theme: "Good Hospital Practice 2012"— Presentation transcript:
1Good Hospital Practice 2012 Medication safetyGood Hospital Practice 2012
2Objectives of this presentation To highlight the importance of ensuring the safe use of medications in Medical CityTo present the roles of the Medical City staff in promoting medication safetyTo discuss how to report, monitor and prevent adverse drug reactions
3What is a medication error? "A 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. “ National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) definition of a medication error. Specifically, a 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."
4Incidence of preventable adverse drug events Each year380,000 – 450,000 in hospitals800,000 in long-term care facilities530,000 among outpatientsInstitute of Medicine Report Brief, July 2006 at
5What factors are related to medication errors? professional practice,health care products, procedures, and systems ofprescribing;order communication;product labeling, packaging, and nomenclature;compounding;dispensing;distribution;administration;education;monitoring; and use."
6We have about 2,000 admissions every month We give about 3 to 5 medications per patientEven if our correct medication rate is 99% we would still expect 60 to 100 medication errors per month.
7Some reasons for medication errors verbal orderspoor communications within healthcare teampoor handwritingimproper drug selectionmissing medicationpoor teamworkpolypharmacydrug interactionsavailability of floor stock (no second check)look alike / sound alike drugshectic work environmentlack of computer decision support
8Relationship between ADEs, potential ADEs, and medication errors Relationship between ADEs, potential ADEs, and medication errors. (Reproduced with permission from Morimoto T, Gandhi T, Seger A, Hsieh T, Bates D. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care 2004; 13:306–14.)
9Mistakes may be defined as errors in the planning of an action and may be knowledge-based (e.g. giving amedication without having established whether thepatient is allergic to that medication) or rule-based. Rulebasederrors can further be classified as either themisapplication of a good rule (e.g. injecting a medicationinto the non-preferred site) or the application of a badrule or the failure to apply a good rule (e.g. usingexcessive doses of a drug). Slips and lapses are errors inthe performance of an action – a slip through anerroneous performance (e.g. writing the more familiar‘chlorpropramide’ instead of ‘chlorpromazine’) and a lapsethrough an erroneous memory (giving a drug that apatient is already known to be allergic to). Technicalerrors are the result of a failure of a particular skill (e.g. inthe insertion of a cannula) and are therefore a subset ofslips (skill-based errors).The classification of medication errors based on a psychological approach. (Reproduced with permission from Ferner RE,Aronson J. Clarification of terminology in medication errors. Definitions and classification. Drug Saf 2006; 29:1011–22.)
10Prescribing errorsLack of knowledge of the prescribed drug, its recommended dose, interactions with food and drugsLack of knowledge of patient detailsIllegible handwriting.Inaccurate medication history taking.Confusion with the drug name.Inappropriate use of decimal points. A zero should always precede a decimal point (e.g. 0·1). Similarly, tenfold errors in dose have occurred as a result of the use of a trailing zero (e.g. 1·0).Use of abbreviations (e.g. AZT has led to confusion between zidovudine and azathioprine).Use of verbal orders.
11Administration errors Dispensing errorsDrug interchange due to look alike / sound alike drugsWrong patient, wrong doseAdministration errorsDrug interchange due to look alike / sound alike drugsWrong patient, wrong dose
12Common errors resulting in ADRs 1. Math error when calculating dose.2. Nurse uses wrong patient weight.3. Nurse does not check patient’s armband.4. Nurse draws up wrong amount in syringe.5. Nurse administers wrong strength bolus.6. No double check of pump completed.7. Uses estimated patient weight.8. Uses inaccurate patient weight.9. Double check of dose is only cursory.
13The role of ALL doctorsChoose medications wisely. Limit the number of medications to avoid adverse drug events.Check for drug allergies and interactions always.Write all prescriptions and medication orders legibly.Ask your nurse to READ BACK your written orders to avoid medication errors.Order medications that are in the formulary. Formulary drugs are reviewed for efficacy and safety. They are cheaper than non-formulary brands.Use the generic name of the drug AND write it in FULL.Allow generic substitution of ordered medications. Do not insist on your brand. Do not make your patients pay more and wait longer for emergency drug purchases.
14The role of ALL doctorsWrite the clinical indication for the drug, e.g., leurpolide to block testosterone. Writing the indication helps reduce wrong drug administration and educates patients and the care team.Compare the patient’s list of meds being taken at home with the list of meds to be ordered on admission and reconcile the two lists. Communicate the finalized list to healthcare team members and the patient. Repeat the process whenever meds are added or removed. .Respond to pharmacists’ queries promptly. Pharmacists are required to review every new drug order for therapeutic appropriateness, correct dosing, interactions with food and drugs, etc
15The role of ALL doctorsDo not use Forbidden Abbreviations. Residents and nurses will ask you to replace all Forbidden Abbreviations.Avoid phone orders save for extreme emergency and sign the orders within 24 hours.Write and reconcile all drugs after a procedure. “Resume all meds” is an illegal order and will not be followed.Do not allow brought in medications to be taken during confinement, except for a few exempted drugs (mostly topicals). “Meds care of patient” is an illegal order and will not be followed.Report all adverse drug events to the Therapeutics Committee.
179 reasons why you should watch out for ADRs in older patients Smaller bodies and different body compositionDecreased ability of the liver to process drugsDecreased ability of the kidneys to clear drugs out of the bodyIncreased sensitivity to many drugsDecreased blood pressure-maintaining abilityDecreased temperature regulation.More diseases than affect response to drugsMore drugs being taken, thus more ADRs and interactionsInadequate testing of drugs in elderly before regulatory approval
18The role of nursesRead back all written and verbal drug orders, clearly repeating the generic name of the drug, the dosage ordered, and indication. Request for confirmation from the prescriber.Refer to the head nurse and pharmacist when faced with conflicting information from prescribers and published drug literature.When administering medications, confirm with the patient his or her identity AND the generic and brand name of the medication you are administering to him or her.
19The role of nurses4. Follow all procedures on drug calculations, drug preparation and drug administration to the letter. No shortcuts.5. Ensure that the medications are given on a timely basis and as prescribed.6. Store all medications according to policy.7. Be particularly careful in preparing, administering and storing drugs in the DrugWatch list.8. Monitor all first dose effects.9. Ensure medication reconciliation at all critical points during confinement.10. Verify and replace all forbidden abbreviations.
20The role of nurses11. Report all adverse drug events to the Therapeutics Committee.12. Report all medications errors and near misses to your head nurse.13. Educate patients about their medications and about medication safety.
21What are adverse drug reactions (ADRs)? An adverse drug reaction is any unexpected, unintended, undesired, or excessive response experienced following the administration of a drug or combination of drugs that is associated with ANY ONE of the following:A. Requires discontinuing the drug, or changing the drug therapy,B. Requires significant dose modification,C. Necessitates admission (for ambulatory patients) or significantly prolongs the length of stay (for inpatients)D. Necessitates supportive treatment,E. Significantly complicates diagnosis or negatively effects prognosisF. Results in temporary or permanent harm, disability, or deathG. Is a therapeutic failure.
22You must report suspected ADRs ADRs may or may not be related or caused by drug intake and this may be difficult to determine.The important thing is to alert the Medical City that a patient on a particular set of drugs has experienced an adverse event so that appropriate study can be carried out.
23What should you do if you suspect an ADR? Stop the medication immediately.Report the ADR by filling out the ADR Reporting Form and hand it over to the Clinical Pharmacist. Any hospital staff member, even if unsure, may report a potential ADR preferably while the patient involved is still confined. Reporting may be done anonymously.Coordinate with the Clinical Pharmacist in managing the patient’s ADR.
24How will your report be handled? The Clinical Pharmacists, through evaluative questions and professional judgment, initially screens and assesses your ADR report. Once verified, they will advise you on how to manage the patient’s ADR.Your report goes into the Medical City ADR database maintained by central pharmacy.ADR reports are monitored and analyzed and provide the basis for educational programs to help the hospital staff in avoiding ADR occurrence and improving patient careADR reports are also sent to the manufacturer and/or BFAD.
25The role of pharmacists Follow all procedures on drug storage, labelling, dispensing, recall and disposal.Be particularly careful in the dispensing and storing of drugs in the DrugWatch list.Ensure medication reconciliation at all critical points during confinement.Regularly conduct random sampling of charts in their units and check forTimeliness of nurses’ accomplishment of physicians’ medication ordersLegibility of physician’s orders,Completeness of medication ordersCompleteness of prescriptions.
26The 2012 DrugWatch List Look-alike and sound-alike drugs Drugs with narrow therapeutic indexInotropic agentsInsulin preparationsChemotherapeutic agentsDangerous DrugsConcentrated electrolytesNon-steroidal anti-inflammatory drugs (NSAIDs)AnticoagulantsTotal parenteral nutrition given through the central line
27The role of pharmacists 5. Alert the Therapeutics Committee when look-alike and sound-alike drugs are admitted into the formulary in order to take steps to identify these drugs as “high risk” for potential errors.6. When look-alike and sound-alike drugs are allowed on the formulary, or are ordered on a non-formulary basis, they should be identified as being medications at "high risk" for potential error and extra steps should be taken to assure safety in ordering, dispensing and administering such products.7. If a forbidden abbreviation is used, verify the prescription order with the prescriber prior to its being filled..
28The role of pharmacists 8. Review all new drug orders and prescriptions in terms ofa) the appropriateness of the drug, dose, frequency, and route of administration;b) therapeutic duplication;c) real or potential allergies or sensitivities;d) real or potential interactions between the medication and other medications or food;e) variation from organization criteria for use;f ) patient’s weight and other physiological information; andg) other contraindications.
29The role of pharmacists 9.Report all medication errors and near misses10. Report all adverse drug events11. Educate staff and patients about medications safety
30Examples of best practices in combating medication errors Standardization/simplification of drug handlingEliminate look-alike/sound-alike drugsForcing functions (lock-outs/time-outs)ChecklistsStructured communication (read back orders to patients or to doctors)
31Hierarchy of Barriers for Error Reduction Most EffectivePhysical (Forcing Functions)Natural (Distance, Time)Information (Labels, Signs)Measures (Tests, Inspections)Knowledge (Training, Coaching)Administrative (Checklists, Policies)Least Effective
33Reducing medication errors Prescribers:use sound med reconciliation techniquesavoid verbal orders except in emergenciesavoid abbreviations (U for units seen as a 0)inform patients of indications for all medicationswork as a team with pharmacists and nursesuse special caution with DrugWatch medicationsreport errors and ADEs
34Reducing medication errors Pharmacists:monitor the medication safety literaturein conjunction with doctors and nurses, develop, implement, and follow medication reconciliationverify the accurate entry of data on new prescriptions (clarify all abbreviations);report errors and near misses to MQIO
35Reducing medication errors Nurses:foster a commitment to patients’ rights (YOU are the patient’s advocate)be prepared and confident in questioning prescribers about their medication ordersparticipate in, or lead, medication safety projectssupport a culture that values accurate reporting of medication errors
36The Science of Safety The key to improving safety lies not in changing the humancondition, but inchanging the conditions under which humans workReason J. Human Error. Cambridge, UK: Cambridge University Press; 1990
37Are you a safe medication practitioner? Which of the following are in the Medical City Drugwatch list?Potassium chlorideInsulinMagnesium sulfateAll of the aboveAnswer: ?DWhich of the following practice/s promote/s medication safety?a. Writing orders and prescriptions legiblyb. Insisting that the pharmacy stock up your brand of antibioticc. Arranging drugs alphabetically by brand namesd. All of the aboveA. Choices b and c lead to mixing up sound-alike drugs.
38Are you a safe medication practitioner? 3. Which of the following will lead you to report a possible ADR?a. The drug needed to be stopped or changed.b. A significant dose modification is required.c. The patient suffered temporary or permanent harm.d. All of the aboveAnswer: ?D4. When reporting a possible ADRa. You must be absolutely sure that it was caused by a drug.b. You must always sign the report with your name.c. You must immediately file the report while patient is confined.d. all of the aboveAnswer:?C. You don’t have to be sure of drug causation and you can file the report anonymously.
39Are you a safe medication practitioner? 5. Which of the following is an inexpensive but effective intervention to help the pharmacist screen for medication errors?a. Write the side effects on the prescriptionb. Write the drug indication on the prescriptionc. Avoid the forbidden abbreviations.d. all of the aboveAnswer: ?B6. Which among the following is a/are good way/s to prevent ADRs?a. Have nurses read back orders to MDsb. Reprimand nurses who make erroneous computations.c. Suspend residents who write illegibly.A
40Are you a safe medication practitioner? 7. Which strategy is the LEAST effective way for preventing ADRs?a. Physical (Forcing Functions)b. Natural (Distance, Time)c. Information (Labels, Signs)d. Administrative (Checklists, Policies)Answer: ?D. Forcing functions are the most effective. Policies can be broken.8. The following is/are reason/s why elderly are more prone to ADRs:a. Old people have trouble remembering their drugs.b. Old people have poor liver and kidney drug handling capacities.c. Old people have lower fat deposits in which drugs are stored.d. All of the aboveD
41Are you a safe medication practitioner? 8 out of 8 – your patients are safe from medication errors!6 or 7 out of 8 – your patients safety level is above average4 or 5 out of 8 – your patients safety level is just about barely adequate2 or 3 out of 8 – you can improve the safety of your medication practice!*0 or 1 out of 8 – let us try again; meanwhile try to keep your medication use on patients to the bare minimum!** Please go over the slides again.
42Summary of this presentation Our ability to ensure the safe use of medications can spell the difference between health and illness, even life and death, for many patients.Our staff have critical roles to play in promoting medication safetyWe must report, monitor and prevent adverse drug reactions to spare our patients from further harm.
43This SIM Card certifies that ______(please overwrite with your name, thank you)__, MD has successfully completed the Self Instructional Module on Medication Management and Use (Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose Acuin President and CEO Director, Medical Quality Improvement