Presentation on theme: "Medication Error Prevention"— Presentation transcript:
1 Medication Error Prevention M. Lisa Pagnucco, BS Pharm, PharmD, BCACP Assistant Professor, Pharmacy Practice University of New England, College of PharmacySeptember 8th, 2013
2 DisclosureI have no conflicts of interest to disclose.
3 ObjectivesDiscuss why a culture of safety is an important element to improve the medication use process in any practice setting.Describe one example of an error occurring at each stage in the medication use process.Explain one or more strategies used to reduce or eliminate errors identified at each stage in the medication use process.
4 Patient Safety – Adverse Events DHHS. Office of Inspector General. (2010) Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Retrieved from Last accessed July 2012.
5 The Problem: Scope and Cost Preventable Medication Errors:Occur in 3.8 million (inpatient admissions)Occur in 3.3 million (outpatient visits)$21 billion ($21,000,000,000)$16.4 billion (inpatient)$4.2 billion (outpatient)NEHI. (2011) Preventing Medication Errors: A $21 Billion Opportunity. Retrieved from Last accessed July 2012.
6 Estimates that 30 - 50% of $2.7 trillion annual US healthcare spending is…… wasteful.
7 What is a Medication Error? What is an Error?The failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning).An error may be an act of commission or an act of omission.Institute of Medicine, 2004What is a Medication Error?…. “any error occurring in the medication use process.”Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995;10(4): 100–205.
8 Error of Commission Error of Omission An act of doing something wrong that leads to an undesirable outcome or significant potential for such an outcome.Example:Ordering a medication for a patient with a documented allergy to that medication.An act of failing to do the right thing that leads to an undesirable outcome or significant potential for such an outcome.Example:Failing to prescribe VTE prophylaxis for a patient after hip replacement surgeryAHRQ, Patient Safety Network (PSNet), Glossary
9 Where Do Medication Errors Occur (%) Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
10 Where are errors caught? Stage of Medication UseErrors (%)Interception (%)Prescribing39%48%Transcription12%33%Dispensing11%34%Administration38%2%Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
11 Established by National Academy of Sciences in 1970 to examine policy issues related to the health of the publicThe Quality of Health Care in America project (1998)To develop a strategy for quality improvement in next ten yearsThe first report from the project was released in 1999: “To Err is Human: Building a Safer Health System”
12 “To Err is Human: Building a Safer Health System” Landmark report, 1999Examined impact of medical errorsIdentified errors are caused by faulty systemProcesses and conditions that lead people to make mistakes or fail to prevent themSuggested national strategy for improvementEstimated annually in US:44,000 to 98,000 patient deaths from patient care errors7,000 deaths from medication errorsInstitute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
13 “To Err is Human: …1999” Strategies for Improvement Establish a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety.Identify and learn from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems.Raise performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.Implement safety systems in health care organizations to ensure safe practices at the delivery level.Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
14 “Crossing the Quality Chasm: A New Health System for the 21st Century” Report released in 2001Health care harms patients frequentlyChasm:The divide between the current health care and what health care could be likeStudy how the health system can be reinvented to foster innovation and improve the delivery of careInstitute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
15 “Crossing the Quality Chasm:…2001” Strategies for Improvement Six Aims for Improvement:SafeEffectivePatient-centeredTimelyEfficientEquitableInstitute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
16 “Preventing Medication Errors” Report released in 2006Adverse drug event (ADE):Patient harm due to administration of a drug; may be preventable (related to any error in the medication use process) or non-preventable. Hospitalized patients:One medication error per patient per dayEstimated annually in US:At least 1.5 million preventable ADEsAt a cost of $3.5 billionInstitute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
17 “Preventing Medication Errors” 2006 Strategies for Improvement Improving the Patient-Provider PartnershipAllow and encourage patients to take a more active role in their careBetter communication with patients at all steps by all providersNew and Improved Drug Information ResourcesImprove consumer access to information about medicationsElectronic Prescribing and other IT SolutionsPOC references, e-prescribing, EHR, HRO focus on medication safetyDrug Naming, Labeling and PackagingIndustry and agency collaboration to improve drug nomenclature, labeling and information sheetsInstitute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
18 Preventing Medication Errors Recommendation 1:To improve the quality and safety of the medication- use process, specific measures should be instituted to strengthen patients’ capacities for sound medication self-management.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.
19 Box S-3 Patient Rights Patients have the right to: Be the source of control for all medication management decision that affect them (that is, the right to self-determination).Accept or reject medication therapy on the basis of their personal values.Be adequately informed about their medication therapy and alternative treatments.Ask questions to better understand their medication regimen.Receive consultation about their medication regimen in all health settings and at all points along the medication-use process.Designate a surrogate to assist them with all aspects of their medication management.Expect providers to tell them when a clinical significant error has occurred, what the effects of the event on their health (short- and long-term) will be, and what care they will receive to restore their health.Ask their provider to report an adverse event and give them information about how they can report the event themselves.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
20 Issues for Discussion with Patients by Providers Box S-5Issues for Discussion with Patients by Providers(Physicians, Nurses, and Pharmacists)Review the patient’s medication list routinely and during care transitions.Review different treatment options.Review the name and purpose of the selected medication.Discuss when and how to take the medication.Discuss important and likely side effects and what to do about them.Discuss drug-drug, drug-food, and drug-disease interactions.Review the patient’s or surrogate’s role in achieving appropriate medication use.Review the role of medications in the overall context of the patient’s health.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
21 Preventing Medication Errors Recommendation 2:Government agencies (AHRQ, CMS, FDA, NLM) should enhance the resource base for consumer-oriented drug information and medication self-management support.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.
22 Preventing Medication Errors Recommendation 3:All health care organizations should make available to providers patient information and decision support tools.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.
23 Preventing Medication Errors Recommendation 4:Better labeling is needed, as are better methods for communicating medication information to consumers.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.
24 Drug Naming, Labeling, and Packaging Problems Box S-6Drug Naming, Labeling, and Packaging ProblemsBrand names and generic names that look or sound alikeDifferent formulations of the same brand and generic drugMultiple abbreviations to represent the same conceptConfusing word derivatives, abbreviations, and symbolsUnclear dose concentration/strength designationsCluttered labeling – small fonts, poor typefaces, no background contrast, overemphasis on company logosInadequate prominence of warnings and remindersLack of standardized terminologyInstitute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
25 Preventing Medication Errors Recommendation 5:Industry and government should collaborate to establish standards affecting drug-related healthcare information technology (HIT).Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.
26 Preventing Medication Errors Recommendation 6:Congress should fund AHRQ to work with other agencies to develop a broad research agenda on safe and appropriate medication use, especially testing of error prevention strategies.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9*.
27 Preventing Medication Errors Recommendation 7:Oversight and regulatory organizations and payers should use (tactics) to motivate the adoption of practices that can reduce medication errors and ensure that providers have needed competencies.Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.
28 “We cannot change the human condition, but we can change the conditions under which humans work.” Reason J. Human Error: models and management.BMJ 2000;320:
30 Swiss Cheese Model Active failures Latent failures Unsafe acts by persons in direct contact with patient or systemSlips, lapses, fumbles, mistakes, procedural violations‘Sharp end’ of processRN, PharmD, MD, DO, RTAdministrative level decisionsError provoking conditionsLong lasting weaknesses‘Accidents waiting to happen’Should review proactively‘Blunt end’ of process
31 Traditional Approach to Errors Person approachFault of the individualPhysician, nurse, pharmacistTrained for error-free practiceReinforced by “blame game”Trained to work without thinkingAutomatic
32 The Person Approach to Errors Focuses on unsafe acts by an individualUnsafe acts are result of aberrant mental processesCorrection by reducing unwanted variability in human behavior‘Bad things happen to bad people’
33 High Reliability Organizations (HROs) The Systems ApproachHigh Reliability Organizations (HROs)Organizations operating in hazardous conditions that have fewer than their fair share of adverse eventsPreoccupied with possibility of failureStudy Safety rather than just FailuresRehearse scenarios of failureWorkforce trained to expect errors, recognize and recover from themUS Air Flight 1549 Hudson River January 2009
34 The Systems Approach - HROs HROs: Aviation, Nuclear Power, Space TravelEqually hazardousAs complex as healthcareDesign a system for safety:Assume things will failAnticipate what should be doneNon-punitive reporting systemEncouraged to report
35 Organizational Safety Cultures Fear of legal or criminal actions after an errorAssociated with hiding or not reporting errorsReduced likelihood of sharing ‘close calls’; missed opportunities to learn and prepare‘Just culture’:Address system issues that lead individuals to engage in unsafe behaviorsMaintains individual accountability by establishing zero tolerance for reckless behaviorBased on type of behavior associated with error, not the severity of error
36 Safety Culture Project A safety culture enables trust and quality improvement.A safety culture empowers staff to speak up about:Risks to patientsReport errors and near missesSummary of knowledge, attitudes, behaviors and beliefs that staff share about the importance of patient safetyAHRQ survey 2010:1,032 hospitals, 472,397 hospital staff56% felt mistakes would be held against them54% had not reported any events in the previous 12 months
37 Errors are……..Opportunities Root Cause Analysis (RCA)AFTER an error has occurred – ‘Reactive’What DID happen, why, why, why?Use results for system/process improvementsFailure Mode and Effects Analysis (FMEA)BEFORE errors occur; anticipation – ‘Proactive’What COULD happen, how and why?Build safeguards into process before change
38 Patient Safety Organizations Patient Safety and Quality Improvement Act of 2005Authorized creation of Patient Safety Organizations (PSOs) to improve the quality and safety of U.S. health care delivery.Encourages clinicians and health care organizations to voluntarily report and share quality and patient safety information without fear of legal discovery.The Agency for Healthcare Research and Quality (AHRQ) administers the Patient Safety Act and Rule for PSO operations.
39 Institute for Safe Medication Practices (ISMP) Non-profit, 501c (3) organizationDevoted to medication error prevention and safe medication useISMP is a certified PSOExpert analysis of errorsDissemination of medication error and safe medication use information for over 35 years; column in Hospital PharmacyNewsletters, seminars, consultant servicesMichael Cohen, President, ISMP founder, Medication Safety Expert, Pharmacist
40 Suspicion: Mindfulness: Index of suspicion: Awareness or concern for potentially serious underlying and unseen injuries or illnessSuspicion:“the act or an instance of suspecting something wrong without proof or on very slight evidence, or a state of mental uneasiness and uncertainty.”Mindfulness:Defining characteristic of High Reliability Organizations (HROs)Sense of unease and preoccupation with failure that arises from admitting the possibility of error, even with well-designed stable processes.
41 Where Do Medication Errors Occur (%) Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
42 Prescribing Challenges Improvements Missing information References, patient, history, labs, home medsMedications unfamiliarDistractionsPatient cases, missing chartsOffice hours and on- callPagersOrdering processNCR, verbal orders, telephone, hand writtenImproved information accessRemote computer system accessClinical decision support systems (CDSS)Electronic drug, disease informationElectronic Health Record (EHR)Use of checklists, care plansImproved communicationReduced phone time; less pager use, increased messaging and in personLegibility, abbreviations strategiesComputerized Provider Order Entry (CPOE), E-prescribing
43 Transcription Improvements Challenges Order appearance Legibility, abbreviations, decimals, spacesOrder clarificationsVerification of calculationsIncomplete orders, pagingPertinent labs, allergies, patient historyWrong patientOrder transmissionVerbal, facsimile, NCRSafety – written and printed“Do Not Use Abbreviations”Pre-printed order forms/setsQI/credentialing for legibilityImproved information accessComputer system interfacesCDSS and informaticsImproved patient demographicsScanning or CPOEMinimize use of verbal ordersE-prescribing
45 ISMP Error Prone Dose Designations IntendedConsequences‘Naked’ decimal.5 mg0.5 mgMissed decimal as 5 mg leading to 10-fold too high doseTrailing zero1.0 mcg1 mcgMissed decimal as 10 mcg leading to 10-fold too high doseMissing spaceTegretol300 mgTegretol 300 mgMistaken ‘l’ as ‘1’ when medication name ends with ‘l’100mg100 mg‘m’ mistaken for zero(s), leading to fold errorAdapted from
46 Dispensing Improvements Challenges Environment Drug labels, drug names Distractions, workload, stress, workflow, storage, poor lightingDrug labels, drug namesLook-alike, sound-alikePoor labels from Rx computerHigh-risk medicationsRx system issuesProblematic drug databaseUpdates not timelyMedication shortagesProcess/system evaluationsErgonomics, lighting, reduce distractions, redesign storage, work flowIdentify LASA, high-risk, use of tall-man letteringComputer label format guidanceResources - system maintenanceStaffing improvementsScheduling based on workloadTechnician support dutiesTechnologyRobotics, carousel, compounder, bar-code verification, biometrics
47 Administration Challenges Improvements Information: patient, drug Missing age, ht/wt, allergies, diagnoses, home medicationsReference books outdatedDose admixtures and ratesIV admixture, calculate IV rateDose preparation from bulkOrder verificationRight order, med, patientMaintain manual MARDistractionsPhones, pagers, call buttonsMissing or misplaced dosesBetter Information AccessComputer system interfacesPoint-of-Care current drug info.CDSS pertinent lab verificationPatient identification verificationUSP 797, unit dose and TJCSMART pumpsElectronic MARBar Code Medication AdministrationAutomated Dispensing CabinetsReduced interruptions/distractionsPatient engagement
48 Partnering with the Patient to Prevent Medication Errors Invite information sharingUse clear communicationAssess and assist with medication adherenceIdentify financial barriersHealth literacy awarenessCulturally competent careIdentify interpreter needs, hearing, or visual aidsEngage care managersSupport health/wellnessFacilitate safe transition
49 IOM Report 2006 Preventing Medication Errors Patient Education to Avoid Medication Errors
53 Key Elements to Prevent Medication Errors Create a culture of safety:Empower staff, patients, caregivers to speak upReport errors, near misses for process improvementShare information about problems and solutionsRaise awareness of errorsImprove communication:Between all providers, providers and patients/caregiversConsider all communication forms for clarity and safetyIncorporate technology:Consider highest risk error stages earlyEngage expertise of end users before implementationRevisit process change often for continual quality improvement