Medication Error Prevention

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Medication Error Prevention


M. Lisa
Pagnucco
, BS
Pharm
,
PharmD
, BCACP

Assistant Professor, Pharmacy Practice

University of New England, College of Pharmacy

mpagnucco@une.edu

September 8
th
, 2013

Disclosure

I have no conflicts of interest to disclose.

Objectives

1)
Discuss why a culture of safety is an important
element to improve the medication use process in
any practice setting.

3)
Explain one or more strategies

used to reduce or
eliminate errors identified at each stage in the
medication use process
.

2)
Describe one example of an error occurring at
each

stage in the medication use process.

Patient Safety


Adverse Events

42%

36%

18%

4%

Medication Errors
Patient Care
Surgery or other
procedures
Infection
DHHS. Office of Inspector General. (2010) Adverse Events in Hospitals: National Incidence Among Medicare
Beneficiaries. Retrieved from
http://oig.hhs.gov/oei/reports/oei
-
06
-
09
-
00090.pdf
. Last accessed July 2012.

The Problem: Scope and Cost

Preventable Medication Errors:



Occur in
3.8 million
(inpatient admissions)


Occur in
3.3 million
(outpatient visits)



NEHI. (2011) Preventing Medication Errors: A $21 Billion Opportunity. Retrieved from
http://www.nehi.net/bendthecurve/sup/documents/Medication_Errors_#20Brief.pdf
. Last accessed July 2012.



$21 billion ($21,000,000,000)


$16.4 billion (inpatient)


$4.2 billion (outpatient)

Estimates that

30
-

50% of

$2.7 trillion annual

US healthcare spending
is……


wasteful.


http://
thinkprogress.org
/health/2013/01/11/1432291/surprising
-
root
-
wasteful
-
spending
-
health
-
care/?mobile=
nc

What 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.



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, 2004







Error of Omission


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 surgery


Error of Commission


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.

AHRQ, Patient Safety Network (
PSNet
), Glossary

Where Do Medication Errors Occur (%)


39%

12%

11%

38%

Prescribing
Transcription
Dispensing
Administration
Leape

LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events.
JAMA
. 1995;274:35
-
43.

Where are errors caught?

Stage

of

Medication Use

Errors (%)

Interception (%)

Prescribing

39%

48%

Transcription

12%

33%

Dispensing

11%

34%

Administration

38%

2%

Leape

LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events.
JAMA
. 1995;274:35
-
43.


Established by National Academy of Sciences in 1970 to
examine policy issues related to the health of the public




The
Quality of Health Care in America
project (1998)


T
o develop a strategy for quality improvement in next ten years



The first report from the project was released in 1999:


“To Err is Human: Building a Safer Health System”


“To Err is Human:

Building a Safer Health System”

Landmark report,
1999


Examined impact of medical errors


Identified errors are caused by faulty system


Processes and conditions that lead people to
make mistakes or fail to prevent them


Suggested national strategy for improvement



Estimated
annually

in US:


44,000 to 98,000 patient deaths from

patient care errors


7,000 deaths from medication errors


Institute of Medicine.
To err is human:
building a safer health system
.
Washington, DC: National Academy
Press, 2000.


“To Err is Human: …1999”

Strategies for Improvement



1)
Establish a national focus

to create leadership, research,

tools and protocols to enhance the knowledge base about safety.


2)
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.


3)
Raise performance standards and expectations for improvements
in safety through the actions of oversight organizations, professional
groups, and group purchasers of health care.


4)
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.


“Crossing the Quality Chasm:

A New Health System for the 21
st

Century”


R
eport released in 2001



H
ealth care harms patients frequently



C
hasm:


T
he divide between the current health
care and what health care could be like




S
tudy how the health system can be

reinvented to foster innovation and

improve the delivery of care

Institute of Medicine.
Crossing the
quality chasm: a new health system
for the 21
st

century
. Washington,
DC: National Academy Press, 2001.

“Crossing the Quality Chasm:…2001”

Strategies for Improvement

1)
Safe

2)
Effective

3)
Patient
-
centered


4)
Timely

5)
Efficient

6)
Equitable


Six Aims for Improvement:

Institute of Medicine.
Crossing the quality chasm: a new health system for the 21
st

century
.
Washington, DC: National Academy Press, 2001.

“Preventing Medication Errors”


R
eport released in 2006



A
dverse drug event (ADE):


P
atient harm due to administration of a drug;
may be preventable (related to any error in the
medication use process) or non
-
preventable.



Hospitalized patients:


O
ne medication error
per patient per day


Estimated
annually

in US:


At least 1.5 million preventable ADEs


At a cost of $3.5 billion

Institute of Medicine.
Preventing
medication
errors
: quality chasm
series. Washington, DC: National
Academy Press,
2006.

“Preventing Medication Errors” 2006

Strategies for Improvement

1)
Improving the Patient
-
Provider Partnership


A
llow and encourage patients to take a more active role in their care


Better communication with patients at all steps by all providers

2)
New and Improved Drug Information Resources


Improve consumer access to information about medications

3)
Electronic Prescribing and other IT Solutions


POC references, e
-
prescribing, EHR, HRO focus on medication safety

4)
Drug Naming, Labeling and Packaging


Industry and agency collaboration to improve drug nomenclature, labeling
and information sheets


Institute of Medicine
. Preventing
medication
errors:

quality chasm series. Washington, DC: National Academy Press,
2006.

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.

Preventing Medication Errors

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.

Institute of Medicine
. Preventing
medication
errors
: quality chasm series. Washington, DC: National Academy Press,
2006.

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.

Box S
-
5

Issues 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.


Recommendation
2:


Government agencies (AHRQ, CMS, FDA, NLM)
should enhance the resource base for consumer
-
oriented drug information and medication self
-
management support.


Preventing Medication Errors

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.

Recommendation
3:


All health care organizations should make available
to providers patient information and decision

support tools.

Preventing Medication Errors

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.

Recommendation
4:


Better labeling is needed, as are better methods

for communicating medication information to
consumers.


Preventing Medication Errors

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.

Institute of Medicine.
Preventing
medication
errors
: quality chasm series. Washington, DC: National Academy Press,
2006.

Box S
-
6

Drug Naming, Labeling, and Packaging Problems



Brand names and generic names that look or sound alike


Different formulations of the same brand and generic drug


Multiple abbreviations to represent the same concept


Confusing word derivatives, abbreviations, and symbols


Unclear dose concentration/strength designations


Cluttered labeling


small fonts, poor typefaces, no background
contrast, overemphasis on company logos


Inadequate prominence of warnings and reminders


Lack of standardized terminology



Recommendation
5:


Industry and government should collaborate to
establish standards affecting drug
-
related healthcare
information technology (HIT).

Preventing Medication Errors

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.

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.


Preventing Medication Errors

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*.

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.


Preventing Medication Errors


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.

“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;320:768
-
770.


The Swiss

Cheese
model of how defences, barriers, and safeguards
may be penetrated by an accident trajectory.

©2000 by British Medical Journal Publishing Group

Reason J. Human Error: models and management.

BMJ

2000;320:768
-
770.


Swiss Cheese Model

Active failures


Latent failures


Unsafe acts by persons in
direct contact with patient or
system



Slips, lapses, fumbles,
mistakes, procedural
violations



‘Sharp end’
of process



RN,
PharmD
, MD, DO, RT



Administrative level decisions



Error provoking conditions



Long lasting weaknesses



‘Accidents waiting to happen’



Should review proactively





B
lunt end’

of process

Traditional Approach to Errors


Person approach



Fault of the individual


P
hysician, nurse, pharmacist


T
rained for error
-
free practice


R
einforced by “blame game”



Trained to work
without

thinking


A
utomatic

The Person Approach to Errors



Focuses on unsafe acts by an individual



Unsafe acts are result of aberrant mental processes



Correction by reducing unwanted variability in
human behavior



‘Bad things happen to bad people’


The Systems Approach


Organizations operating in hazardous
conditions that have fewer than their
fair share of adverse events



Preoccupied with possibility of
failure



Study
Safety

rather than just
Failures



Rehearse scenarios of failure



Workforce trained to expect errors,
recognize and recover from them



High Reliability Organizations (
HROs
)

US Air Flight 1549

Hudson River January 2009

The Systems Approach
-

HROs

Design a system for safety:



Assume things will fail


Anticipate what should be done


Non
-
punitive reporting system


Encouraged to report

HROs:

Aviation, Nuclear Power, Space Travel



Equally hazardous


As complex as healthcare



Organizational Safety Cultures


F
ear of legal or criminal actions after an error


Associated with hiding or not reporting errors


R
educed likelihood of sharing ‘close calls’; missed opportunities
to learn and prepare


‘Just culture’
:


Address system issues that lead individuals to engage in


unsafe behaviors


M
aintains individual accountability by establishing zero
tolerance for reckless behavior


Based on type of behavior associated with error,
not

the

severity of error

Safety Culture Project


A safety culture enables trust and quality improvement.


A safety
c
ulture empowers staff to speak up about:


Risks to patients


Report errors and near misses


Summary of knowledge, attitudes, behaviors and beliefs that
staff share about the importance of patient safety


AHRQ survey 2010:


1,032 hospitals, 472,397 hospital staff


56% felt mistakes would be held against them


54% had not reported any events in the previous 12 months


Errors are……..Opportunities


Root Cause Analysis (RCA)


AFTER

an error has occurred


‘Reactive’


What
DID

happen, why, why, why?


Use results for system/process improvements


Failure Mode and Effects Analysis (FMEA)


BEFORE

errors occur; anticipation


‘Proactive’


What
COULD

happen, how and why?


Build safeguards into process before change


Patient Safety Organizations


Patient Safety and Quality Improvement Act of 2005


Authorized 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
.

Institute for Safe

Medication Practices (ISMP)


Non
-
profit, 501c (3) organization


D
evoted to medication error prevention

and safe medication use


ISMP is a certified PSO


Expert analysis of errors


Dissemination of medication error and
safe medication use information for over
35 years; column in Hospital Pharmacy


Newsletters, seminars, consultant services

Michael Cohen,
President, ISMP
founder,
Medication
Safety Expert,
Pharmacist


Index of suspicion:


A
wareness or concern for potentially serious underlying and unseen injuries

or illness

Suspicion:


“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
.

Where Do Medication Errors Occur (%)


39%

12%

11%

38%

Prescribing
Transcription
Dispensing
Administration
Leape

LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events.
JAMA
. 1995;274:35
-
43.

Prescribing

Challenges


Missing information


R
eferences, patient, history,
labs, home meds


M
edications unfamiliar


Distractions


Patient cases, missing charts


O
ffice hours and on
-

call


Pagers


Ordering process


NCR, verbal orders,
telephone, hand written

Improvements


Improved information access


Remote computer system access


C
linical decision support systems
(CDSS)


E
lectronic drug, disease information


Electronic Health Record (EHR)


Use of checklists, care plans


Improved communication


R
educed phone time; less pager use,
increased messaging and in person


Legibility, abbreviations
strategies


Computerized Provider Order Entry
(CPOE), E
-
prescribing

Transcription

Challenges


Order appearance


L
egibility, abbreviations, decimals,
spaces


Order clarifications


V
erification of calculations


I
ncomplete orders, paging


P
ertinent labs, allergies, patient
history


Wrong patient


Order transmission


Verbal, facsimile, NCR

Improvements


Safety


written and printed


“Do Not Use Abbreviations”


P
re
-
printed order forms/sets


QI/credentialing for legibility


Improved information access


C
omputer system interfaces


CDSS and informatics


Improved patient demographics


Scanning or CPOE


Minimize use of verbal orders


E
-
prescribing


ISMP Error Prone Abbreviations

http://
ismp.org
/Tools/
errorproneabbreviations.pdf

ISMP Error Prone Dose Designations

Error Prone

Intended

Consequences

‘Naked’ decimal

.5 mg


0.5 mg

Missed

decimal as 5 mg leading
to 10
-
fold too high dose

Trailing zero

1.0 mcg


1 mcg

Missed decimal as 10 mcg
leading to 10
-
fold too high dose

Missing space

Tegretol300

mg


Tegretol

300 mg

Mistaken

‘l’ as ‘1’ when
medication name ends with ‘l’

Missing

space

100mg


100

mg

‘m’ mistaken for zero(s), leading
to ㄰
-
㄰1⁦o汤⁥牲or

Adapted from http
://
ismp.org
/Tools/
errorproneabbreviations.pdf

Dispensing

Challenges



Environment


D
istractions, workload, stress,
workflow, storage, poor lighting


Drug labels, drug names


L
ook
-
alike, sound
-
alike


P
oor labels from Rx computer


H
igh
-
risk medications


Rx system issues


P
roblematic drug database


U
pdates not timely


Medication shortages




Improvements


Process/system evaluations


E
rgonomics, lighting, reduce
distractions, redesign storage, work
flow


Identify LASA, high
-
risk, use of tall
-
man lettering


Computer label format guidance


R
esources
-

system maintenance


Staffing improvements


S
cheduling based on workload


T
echnician support duties


Technology


R
obotics, carousel, compounder, bar
-
code verification, biometrics



Administration

Challenges


Information: patient, drug


Missing age,
ht
/
wt
, allergies,
diagnoses, home medications


Reference books outdated


Dose admixtures and rates


IV admixture, calculate IV rate


D
ose preparation from bulk


Order verification


R
ight order, med, patient


M
aintain manual MAR


Distractions


P
hones, pagers, call buttons


Missing or misplaced doses




Improvements


Better Information Access


C
omputer system interfaces


Point
-
of
-
Care current drug info.


CDSS pertinent lab verification


Patient identification verification


USP 797, unit dose
and
TJC


SMART pumps


Electronic MAR


Bar Code Medication Administration


Automated Dispensing Cabinets


Reduced interruptions/distractions


Patient engagement

Partnering with the Patient

to Prevent Medication Errors


Invite information sharing


Use clear communication


Assess and assist with
medication adherence


Identify financial barriers


Health literacy awareness


Culturally competent care


Identify interpreter needs,
hearing,
or visual
aids


Engage care managers


Support
health/wellness


Facilitate
safe transition

IOM Report

2006



Preventing

Medication

Errors

Patient

Education

to Avoid

Medication Errors



National Patient


Safety Foundation

Key Elements to

Prevent Medication Errors

1)
Create a culture of safety:


Empower staff, patients, caregivers to speak up


Report errors, near misses for process improvement


Share information about problems and solutions


Raise awareness of errors




3)
Incorporate technology:


Consider highest risk error stages early


Engage expertise of end users before implementation


Revisit process change often for continual quality improvement





2)
Improve communication:


Between all providers, providers and patients/caregivers


Consider all communication forms for clarity and safety