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Creating a Culture of Safety to Reduce Medication Harm

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					Creating a Culture of Safety to
  Reduce Medication Harm
           International Safety Symposium
                November 10th, 2011


        Megan Winegardner, Pharm.D.
        Medication Safety Coordinator
        Henry Ford Hospital, Detroit MI
                     Objectives
n   Describe the incidence and severity of adverse drug
    events in the United States
n   Explain the differences between a Punitive Culture, a
    Blame-Free Culture, and a Just Culture
n   List steps that can be taken to establish a culture of
    safety to reduce medication harm
Causes of Death in the US




    Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.
               Adverse Events in
              Hospitalized Patients
n   13.5% of Medicare patients experience a serious
    adverse event during hospitalization
    (134,000 pts/month)
n   Most common causes:                • Bleeding
    n   Medications (31%)                            • Delirium

    n   Ongoing patient care (28%)                   • Hypoglycemia
                                                     • Acute renal failure
    n   Surgery (26%)
                                                     • Hypotension
    n   Infection (15%)                              • Respiratory complications
                                                     • Allergic reaction



                                    Office of Inspector General. Adverse events in hospitals:
                        National incidence among Medicare beneficiaries. November 2010.
               Adverse Events in
              Hospitalized Patients
n   An additional 13.5% of Medicare patients experience
    temporary harm during hospitalization
n   Most common causes:              • Delirium
    n   Medications (42%)                            • Hypoglycemia
    n   Ongoing patient care (36%)                   • Opportunistic infection

    n   Surgery (18%)                                • Allergic reaction
                                                     • Others
    n   Infection (4%)
n   50% of medication-related events considered
    preventable

                                    Office of Inspector General. Adverse events in hospitals:
                        National incidence among Medicare beneficiaries. November 2010.
              Recommendations
n   Enhance patient safety leadership and knowledge
n   Use error reporting systems to learn from errors
n   Set performance standards
n   Create safety systems




              Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.
        Culture of Safety Timeline

  Before 1990s               Mid 1990s                       2000s


 Punitive Culture       Blame-Free Culture                Just Culture




• Fear of retribution   • Lack of accountability
• Decreased reporting
  • Work-arounds

                                                   Institute for Safe Medication Practices.
                                                    Medication Safety Alert. Sept 7, 2006.
                   Just Culture
Type of Behavior       Description                 Suggested
                                                   Response
  Human Error       Unintentional acts               Console

    At-Risk            Short-cuts                      Coach

    Reckless           Intentional                  Discipline
                     Substantial risk
                    Outside the norm


                                          Institute for Safe Medication Practices.
                                    Medication Safety Alert. September 21, 2006.
            Just Culture
During a busy shift, a pharmacist fails to check
 a patient’s renal function when entering an
            order for an antibiotic.
          The patient is not harmed.


Type of Behavior                  Response
  Human error                      Console
     At-risk                        Coach
    Reckless                      Discipline
                 Just Culture
A pharmacist inadvertently hits the zero key an
  extra time and enters an order for 100 mg
   instead of 10 mg. The patient receives an
 overdose and must be transferred to the ICU.


Type of Behavior                            Response
  Human error                                Console
     At-risk                                  Coach
    Reckless                                Discipline

Response is dictated by type of behavior, not outcome of patient.
       Creating a Culture of Safety
1.   Critically evaluate your reporting system
2.   Increase medication safety incident reporting
3.   Develop a system for follow-up of reports
4.   Analyze incident report data
5.   Provide feedback to staff members
    1. Evaluating a Reporting System
n   Standard fields:
    n   Patient
    n   Date/time/location
    n   Description of event
    n   Outcome
n   Additional fields to consider for medication-related
    events
    n   See NCC MERP Taxonomy of Medication Errors
    n   Provides standard language and structure
      NCC MERP Taxonomy for
         Medication Errors
 Product Information                              Type of Error
    Dosage form                                    Wrong drug
     Packaging                                    Wrong patient
         Drug Class                               Dose omission


         Causes                                Contributing Factors
     Communication                                   Lighting
     Name confusion                               Interruptions
        Labeling                                     Staffing

* Not an all-inclusive list   National Coordinating Council for Medication Error Reporting
                              and Prevention, 1998.
                Maximizing Output
n   Minimize free-text fields
    n   Lose ability to “pull” data
    n   May be necessary for description of event
n   Sortable/retrievable lists:
    n   Drug name (generic or brand)
    n   Drug class
    n   Type of error
    n   Process node (prescribing, dispensing, administration)
    n   Causes / contributing factors
2. Increasing Incident Reporting




                 Classen DC et al. Health Affairs 2011;30:581-589.
       Ideas to Increase Reporting
n   Provide education
n   Set targets
n   Provide incentives
           Pharmacy Department Incident Reporting
        3. Incident Report Follow-up
n   Required follow-up
    n   Does a pharmacist review ALL medication incidents?
n   Division of responsibility
    n   Large group: smaller workload, hard to spot trends
    n   Small group: larger workload, easier to spot trends
n   Ensuring accuracy of information in report
    n   Example: severity level often too “high”
    n   Garbage in = garbage out
              4. Analyzing Your Data
n   Create a medication safety dashboard
                                            January   February   March
     Total # of reports
     # of reports submitted by your dept.
     # of high severity reports
     Types of errors
     Medication class involved
     Process node
     Patient location
     Causes
     Contributing factors
     Type of response (system-based?)
                  Analyzing Your Data
n   Create dashboard cross-tabs to answer questions
    n   Medication class most commonly reported to cause
        patient harm?
         n   Medication class x “High severity” incidents
    n   Wrong patient errors occurring during medication
        prescribing?
         n   “Wrong patient” error type x “Prescribing” process node
n   Compare yourself to national data
    n   USP MEDMARX database
    n   IHI 5 million lives campaign
    n   Others
     5. Providing Feedback to Staff
n   Share examples of system-based changes
    n   New manufacturer for look-alike vials
    n   Change to instruction field of MAR
n   Create a medication safety annual report
    n   Summarize dashboard data
    n   Point out high risk medications, processes
    n   Identify areas for future quality improvement activities
n   Establishes a non-punitive culture of openness,
    transparency
       Creating a Culture of Safety
1.   Critically evaluate your reporting system
2.   Increase medication safety incident reporting
3.   Develop a system for follow-up of reports
4.   Analyze incident report data
5.   Provide feedback to staff members
                            Challenges
n   Criminal penalties for medication errors
    n   2006:
         n   Wisconsin nurse charged with criminal neglect for an epidural
             error that resulted in the death of a pregnant patient
    n   2009:
         n   Ohio pharmacist sentenced to prison for a chemotherapy error
             that resulted in the death of a child




                                                                      www.ismp.org
Creating a Culture of Safety to
  Reduce Medication Harm
           International Safety Symposium
                November 10th, 2011


        Megan Winegardner, Pharm.D.
        Medication Safety Coordinator
        Henry Ford Hospital, Detroit MI

				
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