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Medication Error Reporting: Transformation to safety Nora Al-Banyan, R.Ph., SSC, PhP Clinical Pharmacist Medication Safety Officer King Fahad Medical City (KFMC), 1100 beds, Riyadh, SA Outline Medication Medication use Errors process Classification Types of of Introduction Definition medication medication Prescribing Dispensing Administration Monitoring error error Transformation to safety Case Scenario Medication Error Developing Root Reporting cause analysis Action plan DID YOU KNOW Medication Errors: USA versus SA 1.5 million are injured yearly in USA 150 000 are injured yearly in Saudi Arabia Institute of Medicine, July 2009 Committee on Identifying and Preventing Medication Errors WHAT What is a medication error? Any preventable error in the medication use process, whether there are adverse consequences or not Medication use process Medication Error 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. The Institute of Medicine; To Err is Human; National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), 1999 Terminology Commission Omission: Near-miss event: A mistake in prescribing, dispensing or Not administering or ordering Commission: planned medication administration that is detected and giving the wrong Which is a required medication. corrected through intervention ( by another health caremedication. provider or patient), before actual medication administration. Definitions of safety Patient safety Patient safety is the freedom from accidental injury in healthcare. Patient safety incident A patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving healthcare. The definition of an error is that it is unintended Your role in medication safety Physicians and Pharmacists play a strong role in reducing medication errors and making the healthcare system safer. Increased medication error reporting will help identify areas for patient safety improvement. However, to maintain an effective medication error reporting system we need to develop and encourage a culture of patient safety through administrative support. Types medical of errors Diagnostic Use of outmoded therapy Failure to act on results of monitoring or testing Treatment Error in the performance of an operation, procedure, or test Error in administering the treatment Error in the dose or method of using a drug Avoidable delay in treatment Inappropriate (not indicated) care Preventive Failure to provide prophylactic treatment Inadequate monitoring or follow-up of treatment Other Failure of communication Equipment failure Types of medication error •Incorrect drug product selection Prescribing •dose, dosage form, quantity, route of administration, concentration, rate of administration, Omission •The failure to administer an ordered dose •Administration of medication outside a predefined time interval from its Wrong time scheduled administration time •Dispensing or administration to the patient of medication not authorised Unauthorized drug by a legitimate prescriber. •Dispensing or administration to the patient of a dose that is greater than Dose or less than the amount ordered by the prescriber or administration of multiple doses to the patient •Dispensing or administration to the patient of a drug product in a Dosage form different dosage form than that ordered by the prescriber Types of medication error •Drug product incorrectly formulated or manipulated before dispensing or Drug preparation administration. Route of •Wrong route of administration of the correct drug. administration Administration •Inappropriate procedure or improper technique in the administration of a drug other than wrong route. technique •Dispensing or administration of a drug that has expired or for which the Deteriorated drug physical or chemical dosage-form integrity has been compromised. •Failure to review a prescribed regimen for appropriateness and detection Monitoring of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy •Inappropriate patient behavior regarding adherence to a prescribed Compliance medication regimen. Classification of medication error Category/ NCC-MERP Error Outcome Category Index Description Error Near Miss NO HARM A Circumstances or events that have the capacity to cause error. Error NO HARM B An error occurred but the error did not reach the patient (An "error of omission" does reach the patient) C An error occurred that reached the patient but did not cause patient harm D An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm Error HARM E An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention F An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization G An error occurred that may have contributed to or resulted in permanent patient harm H An error occurred that required intervention necessary to sustain life Error DEATH I An error occurred that may have contributed to or resulted in the patient’s death The Safety Iceberg Above the waterline and visible. Claims Adverse Events Near Misses Dangerous Below the water line and often not situations visible. Deviations, variances Outline Medication Medication use Errors process Classification Types of of Introduction Definition medication medication Prescribing Dispensing Administration Monitoring error error Medication use processes Medication error prevention strategies can be built around phases with high problem rates. Four phases: Phase 1- Ordering/ Prescribing Phase 2- Preparation/Dispensing Phase 3- Administration Phase 4- Monitoring Where Do Medication Errors Occur? Transcribing Preparing Ordering 12% Administering 39% 11% 38% Leape, et al ,Breland BD Strategies for the Prevention of Medication Errors. Hospital Pharmacy Report 2000; Vol. 14 No 8; pp 56-65. Medication use processes Phase 1- Ordering/Prescribing Essential patient information readily available. Patient identification, Allergies, Height, Weight, Diagnoses, Co-morbid Conditions, Laboratory Values, current medication regimens and any other key information. Medication use processes Phase 1- Ordering/Prescribing Have essential medication references (such as PDR, Nurses Drug Handbook, MicroMedex, etc.) readily available on the units where medications are ordered/prescribed. Avoid abbreviations. Order medication by total dose required and not by volume, number of ampules or number of tablets. Standardize times of administration of medications where possible. Medication use processes Phase 1- Ordering/Prescribing Develop policies that prohibit the use of potentially confusing orders such as “resume same medications” or “resume pre-op medications”. Develop policies/procedures that address order legibility and clarification. Medication use processes Phase 1- Ordering/Prescribing Develop protocols for verbal orders to assure that: Ordering/prescribing practitioners must be identified Patients must be clearly identified Verbal orders must be clear and concise Verbal orders are taken only in emergencies No verbal orders are taken for chemotherapy All verbal orders are repeated for verification Medication use processes Phase 1- Ordering/Prescribing Dangerous Abbreviations: Drug names [MgSO4, MSO4, HCTZ, AZT] Any abbreviation for the word daily [QD, q.d.] “U” for the word unit “ug” for microgram “QOD” for every other day “SC,” “SQ,” or “sub q” for subcutaneous “CC” for cubic centimeter “D/C” for discharge and/or discontinue Why use “mL” (milliliter) versus “cc” ? Don’t Use “Tablets”, “Ampoules”, “Vials” or “Volume” Order for “Tylenol 2 tabs Q 4 HRS” Which strength should be administered? 80 mg, 160 mg, 325 mg, 500 mg or 650 mg strength Medication use processes Phase 2- Dispensing Ensure that essential patient information is available Any order that is incomplete, illegible, or otherwise questionable to be clarified. Create an environment for the dispensing area that minimizes distractions and interruptions Medication use processes Phase 2- Dispensing Require that a second pharmacist double-check the accuracy of order entry and dose calculations for all orders involving high risk drugs. Publicize and enhance the awareness of look-alike and sound-alike medications. Medication use processes Phase 2- Dispensing Communicate drug information. Barriers to clear order communication Illegible handwriting Dangerous abbreviations and dose designations Verbal orders Ambiguous orders Fax-related problems Medication use processes Phase 3- Administration Ensure that essential patient information, is available. Create an environment for administration that minimizes distractions and interruptions, provides appropriate lighting, safe noise levels. Ensure that nursing staff receives adequate education on the operation and use of devices and equipment used for medication administration (e.g. infusion pumps, PCA pumps, syringe pumps, etc.) Medication use processes Phase 3- Administration Administer only medications that have been fully labeled with medication name, dose .. etc Confirm all of the “Seven Rights” Right patient Right drug Right dose Right route Right time Right documentation Right education Medication use processes Phase 3- Administration Have another nurse double-check infusion pump settings when critical, high-risk drugs are infused. Maintain medication in its unit-dose package until the point of actual administration. Establish policies/procedures for double-checking that includes verification of the original order, calculation, appropriateness, patient information and actual prepared medication. Medication use processes Phase 3- Administration Environmental Factors: Inadequate (cluttered) and unsafe physical environment Inefficient workflow and workload distribution High patient acuity – stress Weak staffing patterns - fatigue Medication use processes Phase 4- Monitoring Monitor patients receiving medications with a narrow therapeutic index/critical dose, e.g. digoxin, theophylline, heparin, warfarin, phenytoin, lithium, etc. If automated systems are not available, develop systems and processes to address such drugs. Review all out-of-therapeutic-range serum drug levels reported by the laboratory for patients throughout the hospital and intervene as appropriate. Medication use processes Phase 4- Monitoring Establish protocols and guidelines for use with critical and/or problem-prone medications to help optimize therapies and minimize the possibility of adverse events. Outline Medication Medication use Errors process Classification Types of of Introduction Definition medication medication Prescribing Dispensing Administration Monitoring error error Transformation to safety Medication Error Developing Root Reporting cause analysis Action plan Medication Error Reporting Medication Error Reporting Medication Safety Medication Error Reporting Process Step 2 Fill up the form Step 3 Save and close Step 1 Intranet KFMC home page (Click Medication Error Reporting Form) Barriers to effective error reporting Culture of blame Barriers to effective error reporting Lack of statutory protection Barriers to effective error reporting Lack of leadership Barriers to effective error reporting Benchmarking errors Factors That Promote Error Reporting Clear definition of a medication error Information will be used to improve the medication system or address reported issues Easy and efficient reporting; forms not complex No fear for legal issues Thank you for reporting Feedback to staff about actions taken Outline Medication Medication use Errors process Classification Types of of Introduction Definition medication medication Prescribing Dispensing Administration Monitoring error error Transformation to safety Medication Error Developing Root Reporting cause analysis Action plan What is Root Cause Analysis? Technique most commonly used after an incident has occurred in order to identify underlying causes Root Cause Analysis in Healthcare: Tools and Techniques, Joint Commission Resources Need to Answer the Question: What should we do to prevent this in the future? What should we have done to prevent this from having occurred? Root Cause Analysis Effective a root cause analysis must : Be aimed at improving processes and systems Improvements will be monitored and evaluated Be well documented Involve the people who participated in the original incident Gain the support of those who can make the changes “Swiss Cheese” Model of System Error: Example Electronic med ordering Pharmacy reviews med Unit dosing Patient Appropriate staffing needs a medication Patient Slices represent barriers that prevent errors Loyola University Health System Presentation Safety Science: Human Error, Quality and Patient Safety Committee, 2007 “Swiss Cheese” Model of System Error: Example Distracted pharmacist misses error Patient Hurried RN doesn’t needs a recognize error medication End Result: Tired Resident When holes in selects wrong dose barriers align, patient Medication not supplied receives wrong in unit dose medication Adapted from Loyola University Health System Presentation Safety Science: Human Error, Quality and Patient Safety Committee, 2007 A Root Cause Analysis needs: • To involve the “right people” – Leadership representatives, and Individuals closely involved in process and system – Consultants/experts (e.g. purchasing) – Interdisciplinary • To continually dig deeper – ask “why” at each level of cause and effect • To include consideration of relevant literature • To be thorough • Time A Thorough and Credible RCA Should Be: Possess Clear Relevant depth Possess Accurate Complete breadth of scope Precise Systematic Conducting a RCA and Developing an Action Plan • Define the team (small groups and individuals for consultation) • Define the problem exactly • Study the problem • Determine what exactly happened • Identify proximate and underlying causes • Confirm the causes through consultation • Explore and identify risk reduction strategies • Formulate recommendations/actions • Consider Human Factors and FMEA before changes A product of a RCA is an A product ‘Action Plan’ Responsibility for implementation Pilot testing if Effectiveness needed measurement Time lines Outline Medication Medication use Errors process Classification Types of of Introduction Definition medication medication Prescribing Dispensing Administration Monitoring error error Transformation to safety Case Scenario Medication Error Developing Root Reporting cause analysis Action plan 32 المائدة If any one saved a life, it would be as if he saved the life of the whole people. Whole people Reporting Preventing Saving life lives Thank You How can we improve our reputation ??!!
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