N101Y Health Information Technology Module Medication Safety Patient Safety Error Prevention

What is a culture of safety? Patient Safety What is a culture of safety?

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 Errors Adverse Drug Events Adverse Drug Reactions Assessing the Culture Teamwork Patient Involvement Systems Openness/Transparency Accountability Six elements: Assessing the Culture Teamwork Patient Involvement Systems Openness/Transparency Accountability IOM 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 packaging Medications that are not commonly used or prescribed Commonly 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 error If 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.

Types and when they occur Medication Errors Types and when they occur

Types of Med Errors Prescribing error Omission error Wrong time error Unauthorized drug error Improper dose error Wrong dosage-form error Wrong drug-preparation error Wrong administration-technique error Deteriorated drug error Monitoring error Compliance error Other medication error Prescribing error Incorrect drug selection (based on indications, contraindications, known allergies, existing drug therapy, and other factors), dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician (or other legitimate prescriber); illegible prescriptions or medication orders that lead to errors that reach the patient Omission error The failure to administer an ordered dose to a patient before the next scheduled dose, if any Wrong time error Administration of medication outside a predefined time interval from its scheduled administration time (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 patient Improper dose error Administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient, i.e., one or more dosage units in addition to those that were ordered Wrong dosage-form error Administration to the patient of a drug product in a different dosage form than ordered by the prescriber Wrong drug-preparation error Drug product incorrectly formulated or manipulated before administration Wrong administration-technique error Inappropriate procedure or improper technique in the administration of a drug Deteriorated drug error Administration of a drug that has expired or for which the physical or chemical dosage-form integrity has been compromised Monitoring error Failure to review a prescribed regimen for appropriateness and detection of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy Compliance error Inappropriate patient behavior regarding adherence to a prescribed medication regimen Other medication error Any medication error that does not fall into one of above predefined categories 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 From IOM 1 also.

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 See table at http://www.psqh.com/sepoct05/barcodingrfid1.html for statistics. Discuss and refer back to previous slides: what type was it and when did it occur and? From http://www.psqh.com/sepoct05/barcodingrfid1.html From http://www.psqh.com/sepoct05/barcodingrfid1.html

Preventing Medication Errors: Technology and Equipment Beyond the 5 Rights.

Medication Administration Technology ORDERING/TRANSCRIBING: eMARs ePrescriptions CPOE (Computerized Provider Order Entry) CDSS (Clinical Decision Support Systems) When the technology is used and how it prevents errors Emars- fields, tracking, links with BCMA Cpoe- 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

Medication Administration Technology DISPENSING: Automated medication dispensing devices (“Pyxis®”) ADMINISTERING: BCMA (Bar Code Medication Administration) RFID Smart Pumps MONITORING: Smart Rooms EMR How it is used and how it prevents errors AMDD- inventories, controls, tracks users/meds, BCMA RFID- confirms ID Smart Pumps- identifies 5 rights of med admin, safety “guard rails” Smart Rooms EMR (see next slide)

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. 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 labs High Risk med- forced to document that another nurse has double checked high risk med admin POC documentation- accurate time, able to record results IE- vital signs , lab results (fingersticks) etc Mandatory fields- prevent errors of omission, required data is recorded so others can make decisions about pt care Smart 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.

Potential for errors with technology Errors with BMCA: Medication does not come packaged as bar-coded unit-dose product Nurse fails to scan medication Bar code on patient and/or medication is unreadable Pharmacy does not scan products arriving in pharmacy for readability Patient wristbands are not on patients but other locations (e.g., clipboards, med rooms) 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 overlooks alert displayed on computer screen Nurse overrides alert without investigating its cause Nurse fails to scan patient Discuss-what phase in med admin do these happen? Ordering, transcribing, dispensing, administering, or monitoring?

Potential for errors with technology ERRORS WITH CPOE/EMR/eMAR/ePrescribing: Mostly user interface issues: Wrong patient chosen Drop down menu issues (too many choices!) Software issues In 2010 computers at a major Midwest hospital chain : EMR would switch to another patient record without the user directing it to do so 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 Discuss-what phase in med admin do these happen? Ordering, transcribing, dispensing, administering, or monitoring? What about computer/software/hardware malfunctions? Discuss

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: Bedside monitoring CDSS Communication Tools Educational Smart rooms Often technology that helps in one area may conflict in another. Especially # Monitoring- +integrated into EMR, interprets, - false alarms, alarm fatigue, still require nursing judgement CDSS +educational, falls scales, Braden or CIWA scales, prompts and alerts, - prompts and alerts Communication tools (Vocera, email, 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 email 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 staff Smart rooms- integration of technologies, increase real time delivery of care, information, etc

Smart Rooms http://youtu.be/09PSFU7loV0 Tiger Institute Smart room

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? CDSS- delays in care, incorrect info, interface issues AMDD- improperly stocked, delays in care if not stocked or inventoried correctly Smart Pumps work arounds, improper soft stops programmed Smart Rooms Others?

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 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 facility’s 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 ECRI’s 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/

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