1. Presented by:Kenny-Joe Wallen Independent Double Checks for High Alert Medications in the Perioperative period

2. Introduction Medication errors are all too common in the United States and are extremely costly to all parties involved. Certain medications are known to carry a higher risk of harm than other medications, these are known as High Alert Medications (HAM) Implement a manual Independent Double Check (IDC) in the perioperative period when administering all HAM will help ensure that patients receive medications in the safest manner possible.

3. Key points Definition. Medication Errors Effects of Medication Errors Why Medication Errors Happen Conformational Bias in the perioperative period High Alert Medications (HAM) Ways to Minimize Medication Errors Putting it all Together

4. I. Definition Medication Errors 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” (U.S. Food and Drug Administration, 2013). High Alert Medications : Drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients (The Institute for Safe Medication Practices, 2009).

5. Remain one of the leading threats to patient safety. On average, a U.S. hospital patient is subjected to at least one medication error per day; making them the most common cause of preventable adverse patient events Medication error are more likely to occur in intensive care units, operating rooms, and emergency departments Occur at any step in the medication process but most frequently in the perioperative period during the administration phase. The Institute of Medicine (IOM) states that not only are patients effected, but also their families, their employers, and the hospitals, health-care providers, and insurance companies. Are most likely to occur in intensive care units, operating rooms, and emergency departments Medication Errors

6. Physical Harm –1.5 million preventable adverse drug events (ADE) occur each year in the United States with roughly 100,000 of those resulting in death due to medical mistakes Financial Cost –Medication errors adds roughly $8,750 per patient to the cost of the hospital stay, with an annual cost of drug related morbidity and mortality between 1.56 billion and 5.6 billion –Patients injured by ADEs have their hospital stays extended by an average of two days, at an additional cost of $2,000 to $2,500 per patient. –Medication errors are said to cost between $17 billion and $29 billion per year in hospitals nationwide, including the expense of additional care necessitated by the errors, lost income and household productivity, and disability. Effects of Medication Errors

7. Lost Trust –Medication Errors diminish satisfaction by both patients and healthcare professionals. Patients –experience longer hospital stays and experiences additional physical and psychological discomfort. –They lose trust in the provider and the healthcare system. The Healthcare System –Lose morale and frustration not being able to provide the best care possible. Society –Bears the cost of errors in terms of lost worker productivity, reduced school attendance by children, and lower levels of population health status Effects of Medication Errors

8. Humans are fallible and errors inevitable. They are a part of Human Nature Providers are overworked, minimal resources, staffing shortages, poor communication However, the majority of medication errors do not occur due to individual recklessness or the actions of a particular group yet they are due to faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent those. Why Medication Errors Happen

9. Conformational Bias Conformational Bias is one condition that causes people to make mistakes Grissinger defines it by saying that, “Most mental processing occurs outside of conscious awareness. The amount of information that can be taken in by our senses is limitless, but the brain has limited resources when it comes to attentiveness. Our senses receive much more information than what can possibly be processed at one time. To combat information overload, the brain allows large amounts of information to enter, almost entirely unassimilated, and peels off just a few pieces of selected information for a closer look” ( 2012).

10. Conformational Bias in the perioperative period When anesthesia providers prepare drugs in the operating room (OR), they retrieve the needed medication from a cart, read the vial or ampule label, draw up the medication, and apply a color-coded adhesive label to the syringe Often times though there are multiple drugs within a class. Most of the time they are in the same size vial or container and have the same color sticker, but have very different properties.

11. Conformational Bias in the perioperative period Providers become so amerced in providing care for their patient that people do not always read labels as carefully as they should. Instead they depend on a single variable, such as the color, shape, or size of the container, when selecting a drug. The problem is the more colors that are used, the greater the risk of confusing a color and its meaning. In fact, many errors in fact are made by intelligent, vigilant, and attentive people; and that the cause is usually rooted in “inattentional blindness,” a condition all people exhibit periodically

12. Classes/Categories of Medications Adrenergic agonists I.V (e.g, epinephrine, phenylephrine, norepinephrine ). Adrenergic antagonists I.V ( e.g, propranolol, metoprolol, labetalol ) Anasthetic agents: inhaled and IV ( e.g, propofol, ketamine ) Antiarrhythmics, I.V ( e.g, lidocaine, amiodarone ). Anticoagulant : (e.g, heparin, warfarin ). Chemotherapeutic agents : parentral and oral. Oral hypogylcemics. Inotropic medications I.V ( e.g, digoxin, milrinone ). Moderate sedation agents I.V (e.g, midazolam ), Oral (e.g, chloral hydrate ) Narcotics/Opiates I.V, transdermal and oral. Neuromuscular blocking agents ( e.g, succinylcholine ). High Alert Medications (HAM)

13. Specific medications Colchicine injection. Insulin : S.C and I.V. Magnesium sulfate injection. Methotrexate : oral ( non – oncologic use ). Oxyticin I.V. Nitroprusside sodium for injection. Potassium chloride for injection. Promethazine I.V. Sodium chloride for injection. High Alert Medications (HAM)

14. Insulin Opiate and Narcotics Injectable Potassium chloride or phosphate Injectable Anticoagulant Sodium chloride solution above 0.9% –Errors in the administration of these medications can have catastrophic clinical outcomes. Top five High Alert Medications (HAM)

15. Ways to Minimize Medication Errors 1.Perform Independent Double Check (IDC) 2.“5-Rights” of Medication Administration 3.Listen for bells and whistles

16. 1.Perform Independent Double Check (IDC) –Used to detect potentially harmful errors before they reach patients. –Is a primary way to identify all high-alert drugs –Reduces medication administration errors by up to 95%. –Requires two people to separately and independently check each component of the work. –This is done to reduce the risk of bias when a person is preparing and checking medications –Is an all-around effective approach to prevent errors and make errors visible, thus reducing unnecessary harmful situations for patients and hospitals alike.

17. 1.Perform Independent Double Check (IDC) –The first healthcare provider who will be administering the medication will prepare the medication as per hospital policy. –The first provider will then communicate to the second provider the rationale for use of the medication and any pertinent clinical findings or lab values. –The second healthcare provider will then conduct an IDC of the medication. Once the second provider performs the double check and both providers are satisfied that the medication is accurate, the double check will be documented. –The second provider should write “checked by” or similar wording next to his/her initials to indicate that she/he performed this check. The double check will be conducted prior to the medication being administered. Additional checks may be conducted at the discretion of the healthcare provider

18. 2.“5-Rights” of Medication Administration

19. The primary reason for implementing IDC for HAM in the perioperative period is improving efficiency with regards to medication administration and patient outcomes. They are not perfect and will sometimes fail They should be bundled with other risk-reduction strategies, and system changes must also be made to reduce the frequency of errors Even though they are not foolproof; when performed judiciously and properly, they will reduce the risk of an error reaching the patient. Putting it all Together

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