1. N101Y Health Information Technology Module
Medication Safety
Patient Safety
Error Prevention

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

3. 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.

4. Types and when they occur
Medication Errors
Types and when they occur

5. 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.

6. 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.

7. 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 for statistics.
Discuss and refer back to previous slides:
what type was it and when did it occur and?
From
From

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

9. 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

10. 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)

11. 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.

12. 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?

13. 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
Discuss-what phase in med admin do these happen?
Ordering, transcribing, dispensing, administering, or monitoring?
What about computer/software/hardware malfunctions?
Discuss

14. Emerging Patient Safety Technologies
The present and the future

15. 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, , 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 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

16. Smart Rooms
Tiger Institute Smart room

17. 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?

18. 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!
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