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Medication errors NB 12-2011

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Medication errors NB 12-2011 Powered By Docstoc
					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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