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									 Fundamentals of Risk Management &
  Patient Safety for Community Health
                 Centers
         On-site RM Training Seminar – November 2008



        Petra S. Berger PhD RN, CPHRM
Healthcare Risk, Quality, and Patient Safety Consultant
     pberger@rmpsi.com       -   Phone: 517–281-7816
                                                          1
             Learning Objectives
   Demonstrate understanding of risk issues inherent
    in providing community health center services
   Explain leadership tools & methods related to:
       Proactively identifying risk concerns, and
       Responding from the risk control, quality, and
        patient safety perspective
   Recognize the critical role played by patients and
    families regarding high risk aspects of patient care


                             2
Definitions
Risk Management & Liability Coverage
   What is “Risk management” @ CHCs
       Dir. & Officers: Financial, Contracting
         Employment Practice, Workers‟ Comp
       General Liability: Property etc.

    Concepts in Professional Liability
       Risk identification & reporting
       Clinical Liability review
       Risk intervention: immediate & QI referral


                           3
VITAL BRIDGE OVER TROUBLED WATERS

             QUALITY MANAGEMENT




Patient Safety = Q. I.    Risk Management
                         = identify risk – respond – prevent

                            4
    CORE PURPOSE of RISK MANAGEMENT

         S T O P ADVERSE OUTCOMES
   Preventing Patient harm
   Protecting Healthcare facility from
        litigation and financial loss
        patient and community distrust
    Protecting involved Providers



                         5
QUALITY OUTCOMES & RISK ASPECTS
on O N E Quality Management Platform

   Patient Satisfaction
     complaint management

   Clinical Effectiveness
     missed diagnosis
   Policies & Protocols
     after hours coverage

   Regulatory compliance
     informed consent

   Efficiency, UR, Cost control

                        6
Risk & Quality Leadership Roles
   A culture of safety in which individuals can
    draw attention to potential or real hazards,
    barriers, gaps, or failures without fear
   Non – punitive reporting
   Strategic Risk & Quality planning based on
    Prioritization
   Implementation of practice guidelines and
    procedures through Monitoring and Q. I.
   “Knowledge transfer” of patient safety practices


                            7
Health Center Trends and Issues
                  FTCA CLAIMS DATA

              Claims Occurrence
   Error in Diagnosis   30%
   Treatment related    21%
   Medication related   10%
   OB Related           22%
   Surgical Procedures 6%

                       Claims Location
                       Health Center 65%
                       Hospital 35%


                            8
Liability Question: Allegation of NEGLIGENCE
Duty – based on existing provider-patient relationship
   To exercise degree of care that a reasonable
   & competent provider would exercise under
   same or similar circumstances
Breach of Duty
   Plaintiff must show that defendants failed to
   exercise ‘reasonable’ care, and adherence to
   established clinical standard (expert testimony)
Injury proximately CAUSED by breach (foreseeable)


                            9
Case: Incomplete Medication History
   58-year-old male patient was scheduled for a
    major diagnostic procedure at the hospital
    where a certified registered nurse anesthetist
    (CRNA) provided conscious sedation.

   A required copy of the clinic medical record
    was sent preoperatively.
   No mention was made of the patient‟s seizure
    medication.


                          10
Case: Seizure & Respiratory arrest
   No recent blood level had been obtained related
    to the patient‟s seizure medication.
   Patient compliance with the medication was
    unknown.
   The patient underwent scheduled procedure
   Patient experienced a grand mal seizure during
    the procedure and had a respiratory arrest.
    Intubation was delayed and the patient suffered
    permanent brain damage.

                           11
Immediate RISK INTERVENTION

   PATIENT STATUS?
   Medical Record As Core Evidence
       Privileged & protected information
   Fact-based investigation
           No premature conclusions
           Timelines and event analysis (RCA)
           Sequestering evidence


                           12
Alleged Negligence: Duty? Breach?
A. Clinical standards of care = „duty‟
      Monitoring, patient medication & document
      Test result reported & signed off by provider
      Treatment plan updated, w/ or w/out change
      Reliable medical record system @ hand off
       with external medical providers and hospital

   B. [CRNA & hospital standards of care]



                           13
    P o l i c y & P r o c e d u r e s:
       Standards by which Care is judged
   Difficult to defend policy & procedure:
       If not based on evidence-based guidelines

       If no allowance is made for clinical
        judgment to vary from protocol

       If local practice not the same as policies

       If not monitored for adherence




                           14
          RISK IDENTIFICATION
   Generic screens: waiting times, no show rate
   Incident (or occurrence) reporting (1 - 30%)
      Omitted or delayed diagnostic reporting
      Adverse medication event –outcome /process
      Patient or family complaint; Feedback

       Staff feedback & surveys
       Risk reporting marathons
   Electronic information system

                           15
                  Procedures of
         Incident reporting
   H o w to complete incident report
       Fact based, objective, w/ timeline
          No speculation, opinion, blaming

       not: “gave wrong med”
       Persons notified: RM, provider, family
   No copy – no staples – no mention, MR placement
   Medical record documentation
       Date & time, provider actions
       Patient’s clinical status; quotes not adjectives
       NO PERSONAL NOTE KEEPING


                              16
    Risk vs. Quality measures: need both
             Sample RISK MEASURES
   Patient complaints
   Misfiled and non initialed test results
   Missed diagnosis: Cancer
   Insulin medication error and patient harm
   Adherence to Anticoagulation guidelines
           Sample QUALITY MEASURES
   Medical record documentation audits /criteria
   Diabetic HgbA1C baseline & improvement
   Pediatric Immunization rates

                           17
TJC: National Pt Safety Goals
   Patient identification
   Verbal orders
   Hand off @ transition
   Medication reconciliation
   Critical lab value reporting
   Patient involvement in care
   Suicide assessment


                      18
Risk aspect #1:   Patient communication
Risk aspect #2:   Provider Team Communication
   PATIENT COMMUNICATION
   Patient interview & Treatment planning
   Health instruction – literacy – interpreters
   Patient feedback & complaints

   PROVIDER TEAM COMMUNICATION
      Hand off @ transition points

      Inter-provider relations & teamwork



                            19
Risk aspects #3: The Medical Record
Risk aspects #4:   Clinic Operation &       Flow
The Medical Record
   Chart content & What To Document
   Legal aspects: alterations, legibility, etc.
   Confidentiality & Release of information
Clinic Operation & Flow
   Continuum of care (62% claims) vs. fragmentation
   Diagnostic test tracking
   After hours coverage; telephone triage


                           20
Risk aspects #5:         Clinical Practice
Risk aspects # 6:   Medical Mis-Diagnosis
   Patient assessment & monitoring
   Treatment & Use of Practice Guidelines
   Medication prescription practice
   Complications, preventable
       OB, Surgical procedures, Emergency visit
    Most frequent Mis-Diagnosis
   Inadequate medical history & physical exam
   Insufficient diagnostic work-up
   Incorrect interpretation of diagnostic tests
   Incomplete follow-up

                           21
Risk aspect # 7:        Medication Safety
Risk aspect # 8: EQUIPMENT – EOC – EMERGENCY

    Adverse Medication events related to phases:
   Product labeling, packaging, nomenclature
   Prescribing: Indications, interaction, off label
   Dispensing: compounding, distribution error
   Administration: wrong drug/ dose/ route
   Emergency Preparedness
   Crash cart (incl. pediatrics) & checks
   Behavioral
   Building /weather

                           22
Risk aspect #9:       Clinic Staff performance
Risk aspect #10:   Medical Provider Quality
   Staff qualification & orientation
     Clear directives & protocols
     Orientation and Training
     Staffing levels
     Material resources

   Medical Provider Quality & Peer review
   Review mechanism – why, who and how
   Data sources and Measures
       Quality indicators
       Risk indicators and events

                             23
Risk Aspects of Clinic Services I




                                    24
High Risk Clinic Service Aspects – I
   Diagnostic ordering and test tracking
   Patient & Family Communication
   Informed consent and refusal
   Telephone triage, After hours, No shows
   Patient satisfaction & complaints
   Health Literacy
   Non compliance
   Termination of Care


                        25
Risk aspect #4:
Diagnostic test tracking & QC audits

       Test ordered by med. provider & log
       Request form created - copy retained
       Test completed - patient compliance?
       Results received & logged in / ck log
       Results reported to provider (same
        day for abnormal /critical results)
       Patient notification documented

                        26
Risk aspect #1: Patient communication

   Patient assessment & interview
   Treatment planning & consent
       Conflict resolution; Non compliance
       Termination of care
   Health instruction – literacy – interpreters
       Explain back / read back
   Patient feedback & satisfaction
       Complaint management



                            27
            Medication compliance
        PATIENT COMMUNICATION

   Medical literacy & English proficiency
       Lay language
       Validated understanding
   Hearing, vision limitations ?
   50% non-adherence to prescribed meds
   8.4 mio not taking hypertension meds



                        28
Why Do People Sue?
   Study of law suits against a large medical
    center indicated Problematic Relationships:
       Perceived desertion of the patient
       Devaluing patient and/or family views
       Poorly delivering health information
       Failing to understand the perspective of
        patient and/or family



                           29
Informed Consent
   Used whenever an invasive procedure is
    proposed that carries a material risk of harm
   Need to have a discussion of the
       Procedure and benefits (P)
       Risks of the procedure ( R)
       Alternatives to the procedure (A)
       Questions asked (Q)
   What should be documented?
       Consent process, any questions answered

                           30
Informed Refusal - signed
   Should be obtained whenever refusal to
    have a test or procedure done may have
    adverse results – related to index of suspicion
   Examples
       Mammograms
       Chest or other x-rays
       Cardiac work-ups
       Lumbar punctures




                                31
Telephone triage & Legible Documentation
    Using protocols adopted by medical staff,
    or direct consultation w/ med. provider
   Name of Caller & purpose of call
   Advice & orders given (prescription refills)
   Follow-up instructions
   Date, time, AND initial of provider
   Review through Q.I. process
       Based on criteria of clinical protocols



                            32
Telephone communication
   Document phone calls incl. AFTER HOURS
    calls, in the medical record if the following
    was discussed:
      medical symptoms, new or continued

      abnormal test results reported

      medical advice offered

      questions about medical treatment

      prescriptions provided




                          33
Missed appointments – No Shows
   Tracking high-risk patients who miss
    scheduled appointment
      Pending diagnostic results?

   Documenting all notification attempts
   Include medical implication of missing
    appointments
   If worsened outcome possible, a certified
    letter is sent, with copy & receipt in medical
    record

                           34
Risk ID through Patient Complaint

   Categorize types of complaints
   Prioritize by severity & risk level
   Establish who is responsible for
    responding to the complaints
   Log and trend complaints & resolution
   Address systems issues through P.I.



                          35
              Risk-related Inventory
          Reasons for Care Termination
   Group A
   1. Repeatedly missing appointments w/out prior notification
   2. Disagreement over treatment recommendations
   3. Non-adherence /non-cooperation w/ treatment plan
   Group B
   1. Verbally disruptive and hostile behavior toward medical
    provider and/or staff [by patient or family /caregiver]
   2. Threatening behavior toward medical provider / staff
   Group C
   1. Noncompliance with office policy re: prescriptions
   Group D
   1. Delinquency on bill payments

                                 36
                Termination of Care
                Solution of ‘last resort’

   Patient given notice of termination
       Evidence of certified letter in chart
   Patient given reasonable amount of time in
    which to obtain alternative care
       Usually thirty days
   Patient given assistance in obtaining
    alternative care
       e.g., a list of appropriate potential providers


                                  37
Perhaps not now -- Termination of Care
   During treatment for an imminent or unstable
    medical condition
       Mental health disability if yet untreated
       in process of medical workup for diagnosis
   Pregnant patient, approx. last trimester
       Pregnant patient approx. last 2 trimesters if high risk
   Patient in immediate postoperative stage
   Precaution w/discrimination issues, e.g. HIV
   Remote area and lack of alternate providers

                                   38
Risk Aspects of Clinic Services II




                                     39
High Risk Clinic Service Aspects – II
   Staff communication & Human Factors
   Credentialing, Privileging, Peer review
   Clinical risk factors in Perinatal, Surgical,
    Behavioral Health, and Dental Services
   Emergency Response


                            40
     Provider Team Communication

   Half of communication breakdowns
    occurred as patients were HANDED OFF
    @ TRANSITION POINTS between
    providers (verbal & written)
   2/3 of serious medical errors occur @
    transition points (TJC reports)

   Inter-provider relations & teamwork


                         41
Risk aspect #9: STAFF PERFORMANCE
   Staff qualification & orientation
       Clear directives/protocols & Training
       Staffing levels & Material resources
       Human factor remedies:
        distraction, memory overload, fatigue,
        confirmation bias
       Provide Performance feedback


                         42
Human Factor:
Patient safety Ownership & Just Culture

   Imperfect behaviors, lapses, oversight
       Inadequate realization of risk, poor risk awareness,
        inadequate diligence – systems barriers & gaps?
   At-risk behaviors -- e.g. shortcuts
       Intentional conduct that unintentionally increases
        risk of harm: policy non compliance re: double checks
   Reckless behavior /questionable moral judgment
       Recognition of high risk, BUT risk is disregarded;
        commission of intentionally hazardous acts -- cause
        violation of trust; e.g. alteration of medical records


                                43
           Quality & Peer review:
          Clinical Practice Pattern
   Medical evaluation & Treatment
       Complex medical condition: Cancer, Co-morbidities
       Medication therapy
       Pre-natal risk factors
       Pre-, intra- & post-surgical Tx & evaluation
   Use of Practice Guidelines: decrease variability
       Asthma, Anticoagulants, Stroke, Pediatric Fever
   Complications, preventable
       OB, Surgical procedures, Emergency
Sample protocols can be accessed at http://www.guideline.gov/



                                   44
Clinical Protocols w/ Risk Focus
   Pre natal risk assessment & OB practice
   Fever in Children (ACEP)
   Stroke
   Chest pain
   Abdominal pain
   Anticoagulant Management

   Sample protocols can be accessed at
    http://www.guideline.gov/



                               45
Pain assessment: a diagnostic Key
   Assessment (Pain & Headache) & DOCUMENT
     Location and Radiation (All locations)
     Onset – Duration - Frequency
     Severity (per scale 1 – 10)
     Pain Quality or Type (pressure, cramps etc.)
     Last dose of Pain medication / frequency
     Recent Health history, events, procedures
     Other S & S: weakness, numbness, neck pain,
       stiffness, photophobia, diaphoresis, N-V, SOB
       (LMP)


                           46
Confirmation Bias

         Paris in the
         the Spring
 Once we decide that we “know” what
 something is, we tend to exclude or neglect
 information that may be contrary to our
 original perceptions

                      47
Pre-natal risk assessment
   PRE NATAL ASSESSMENT per protocol (standardized)
        Consistent documentation, prenatal visits
        Prompt high risk referral
   PRE NATAL MED. RECORD TO HOSPITAL @ 36 wks
   Maternal conditions: hypertension – prior
    PE – diabetes – drug & alcohol – antepartum
    hemorrhage – cardiac risk factors
http://www.rmf.harvard.edu/; AAFP standards / ACOG standards



                                       48
           SURGICAL PROCEDURES

   Scope of Privileges
   Patient assessment, pre procedure
       History & Physical
       Prev. complications related to procedures
   Informed Consent and Refusal
       Patient education / Health literacy
   Post procedure follow up:
       Complication? Infection? Pain?


                             49
BEHAVIORAL HEALTHCARE
   Initial Assessment & Treatment Plan
       Suicide assessment and Safety precautions
   Case management
   Medication therapy (?informed consent)
       Monitoring of effects and compliance
       Patient /family education: purpose /side effects
   On-going acuity assessment & referrals
   Documentation standards & confidentiality


                              50
Suicide assessment - Document
   Concurrent Dx: depression \bi-polar \psychosis
   Family history
        Previous patient attempts
   Lack of social support
        Recent significant loss
   Alcohol /drug intoxication
   Terminal or chronic debilitating disease
   Abrupt withdrawal from normal routine
   John Hopkins Health Information, 1998. Spotting the Warning Signs of Suicide



                                          51
              Incidental Assessment
               of Abuse or Neglect

   Domestic violence: child – dep. adult – partner
   Mandatory reporting laws: suspect, not prove
   How to assess:
       Ask about abuse in private w/ respect, non blame
       Feel safe? What stress? Should I be concerned?
       Emergency plans? Resources: friends, family?
       Contusions, abrasions (head, chest, abd); fractures
       Abuse during pregnancy
   DOCUMENT in detail a n d objectively


                               52
        Human Performance Factor
          for Medical Providers
   Clinical /technical judgment & knowledge
   Diagnostic practice pattern & experience
   Medication knowledge – indications,
    interaction, off label use, etc.
   Understanding Patient needs: dialogue,
    health education & clinical monitoring
   Communication skills: providers, patients
   Documentation skills

                        53
        Credentialing Focus
Initial credentialing varies from re- credentialing

   INITIAL:
    Licensure verification, References re: privileges
    Qualifying education & experience, NPDB
   RE-CREDENTIALING:
    Quality & Risk data required
       Which value-added measures to select
       How to obtain the data efficiently
       What to do with quality information

                           54
            Credentialing process:
                     Initial

   Responsibility of medical staff and board
   Include all mid level providers & residents
   Documented process to grant privileges
       Reference letters address privileges sought
       Qualifying education & experience - criteria
   NPDB query, all states w/ previous practice
       Initial criminal background check
       Check all staff & volunteers, pertinent states

                            55
Re-credentialing & Quality indicators
   Patient assessment & monitoring (MR)
       Diagnostic services and follow up
       Unclear /inconsistent documentation
   Medication prescription pattern
   Guideline adherence: e.g. Anticoagulant Tx
   Communication – team & patient relations


                         56
California Dept. Managed Health Care (DMHC) Fines
Kaiser Health Plan for Lack of Quality Oversight (7/07)

DMHC observed that of 228 peer-review files, one-
  third were deficient, such as
 Not handling quality concerns promptly

 Not fully considering a physician‟s
  complaint history in evaluating peer-
  review matters.
 Not carrying out corrective actions

HRC Alerts at http://www.ecri.org



                                    57
Credentialing Files: Risk & Quality section
   Credentialing files organized into 2 sections
   Separate Quality file per practitioner
       Sect. A:
        Guideline adherence; Documentation
       Sect. B:
        P.C.E. = Potentially compensable event
        Adverse event review
        Peer review result
   Top Confidential, keep secured


                           58
Risk aspect #8:
EQUIPMENT – EOC – EMERGENCY RESPONSE

Emergency protocols implemented and monitored
   Medical emergency
   1 BLS trained staff on-site at all times
   Crash cart (incl. pediatrics) & checks
   Behavioral
   Building /weather (power outage; fire)



                          59
Pediatric office emergencies
   “…occur more commonly than perceived by
    family physicians; most offices not well
    prepared
   Obtaining training in pediatric emergencies,
    performing mock „codes‟ to assure office
    readiness can improve actual handling of
    pediatric emergencies
   Common airway emergencies include foreign-
    body aspiration and croup.”
Source: Wheeler, Kiefer and Poss. American Family Physician, Pediatric Emergency
    Preparedness in the Office, June 1, 2000.



                                            60
            EQUIPMENT LIABILITY
           How to protect against risk

   THE EQUIPMENT WAS:
   used in reasonable manner (vs. „user error‟)
   inspected for obvious defects prior to use
   on regular preventative maintenance schedule
All staff using the equipment were trained
Procedures developed & staff trained on
   how to respond in case of equipment failure




                         61
             Environment of Care
    Infection control & Hazardous Material

   Develop, implement and monitor an Infection
    control (I.C.) plan pertinent to the facility
   Involve I.C. professional
   Trend I.C. issues & take corrective action

   Protect staff, providers, patients, and
    visitors from hazardous material


                           62
                 Behavioral Emergencies
    OSHA cites healthcare facilities under general
     duty clause for failure to prevent patient violence
     against healthcare workers
    Medical providers & staff exposed to potentially
     dangerous confrontations incl. ill-intended
     trespassers
    Security audits needed to reveal problems
    Address aspects of potential risk of violence
Source: ECRI, HRC Risk Analysis – Overview: Managing Risks in Physician Practices, July
     2003.



                                              63
Risk Aspects, Clinic Services III




                                    64
High Risk Clinic Service Aspects – III

   Medical Record Documentation

   Medication Management




                    65
Risk aspects #3:
The Medical Record - Content
   Medical history, comprehensive & in ink
       Diagnosis & Current medical problem list
       Double check @ each visit before chart returned
   Lab work, other diagnostic results
       All results initialed by medical provider: QC
       Patient notification documented: QC
   Current medication log in ink (herbals, OTC)
       Double check @ each visit before chart returned
       Cross off old info w/single line, explain i. e. D/C


                              66
Personal Health Record (PHR)
   Manual or electronic version
       Portable / Paper / web based / CD ROM
   Content
       Updated medication list incl. OTC
       Allergies & immunizations w/ dates
       Significant recent diagnostic test results
       Medical history incl. procedures
       Special diet and other health measures
       Health insurance information
       Living will

                           67
What To Document – Concurrent
   Referrals & consultations
   Patient notification
   Instruction to patient /family, in writing
      Questions addressed
   Patient's failure to keep appointments
   Informed consent / refusal DISCUSSION
   All entries timed, dated & signed /initialed



                           68
Guess that Prescription
 Handwritten prescriptions are often misread

 In the prescription above, the drug name
    “Avandia”
   was incorrectly interpreted as Coumadin.

   http://www.medscape.com/viewarticle/557740?src=mp
   From American Journal of Health-System Pharmacy




                                 69
Risk & litigation aspects
MEDICAL RECORD DOCUMENTATION
   ?Treatment rationale; ?Diagnostic Follow Up
   Omissions \ delays
   Contradictions; confusion between provider
   Finger pointing, subjective statements
   Corrections: Write overs & White out
   Illegibility & error prone abbreviations
   Altered Medical Records; “Late entries”
   Do not: mention „incident report completed‟

                            70
    Alteration of Medical Records
   A recent case in Ohio involved a physician who
    “whited out” the following phrase:
     “I do not feel that a biopsy is necessary
        at this time”
   And replaced it with:
     “The patient does not want a biopsy at
        this time”
   Jury returned a verdict for $3 Million in an
    otherwise defensible case !
   Destruction of records is equally detrimental

                           71
Policy development
Confidentiality & Release of information
Release of information
   verify request authenticity
   Incapacitated adults; Minors
   Families of deceased patients
   Law enforcement officials /agencies
   Employers and other third parties
Protecting Confidentiality
   Leaving message on answering machine /at work
   Sign in sheet at front desk & privacy
   Privacy re: staff conversation /phone calls, reception area
   Faxing protocols

                                72
Faxing documents & Confidentiality
   What not to fax: HIV results, mental health records
   Avoid sending to general locations, e.g. mailrooms
   Request that the recipient acknowledge receipt
   Include confidentiality statement on fax cover sheet
   If intended recipient does not receive fax because
    of incorrect dialing, fax request using incorrect fax
    number & request return or destruction of material

                              73
                Medication Safety
     Adverse Medication events related to phases:
   Product labeling, packaging, nomenclature
   Prescribing: Indications, interaction, off label
         Antibiotics, anticoagulants, narcotics,
          cardiovascular, steroids; serum levels
   Dispensing: compounding, distribution error
   Administration: wrong drug/ dose/ route
Source: National Coordinating Council on Medication Error Reporting and
Prevention –www.nccmerp.org



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PROVIDER COMMUNICATION             & MEDS
                     PHARMACIST function

   Legible prescriptions for Pharmacist
   Including indications / purpose and/or
    diagnosis
   Include all of the following components in order:
    dose – strength – units/metric – route – frequency
   Guarding against LASA drugs:
     Restoril ordered, Remoran dispensed
      (Antidepressant)
     Patient also taking another anti-depressant



                            75
PROVIDER COMMUNICATION & MEDS
           NURSES and Verbal Orders
   Restricting Verbal Orders – Limit to Emergencies
   Speaking slowly & deliberately
   Specific indications /purpose provided for all
    medication, including for “as needed” P.R.N.
   “Read back” verification, with spelling of drug
    name as necessary
       Caution w/ sound alike and high alert drugs
   Nurses to ask for clarification of illegible or
    unclear orders; eliminating second guessing

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Clinical Protocols
Documenting MEDICATION MONITORING

   Cholesterol – liver panel, lipids
   Anticonvulsants – drug levels, liver, CBC
   Chronic anti-inflammatory /arthritis meds
       kidney function, esp. geriatric patients
   Anticoagulant
       Warfarin / Coumadin – INR, PT, PTT


                            77
Anti Coagulant Monitoring
heparin – warfarin – other anticoagulants
   Warfarin dispensed by pharmacy per Patient
       Clinical pharmacist resource support
   Education about anticoagulants for
    prescribers, nurses and pharmacists

   Patient /caregiver education includes
       reasons and benefits of therapy
       follow-up monitoring /compliance
       dietary restriction; potential drug interaction


                             78
ABBREVIATIONS “Do Not Use” list
   - NOT: U (unit) or IU (international unit)
   - NOT: Q.D., Q.O.D.
   - NOT: MS, MSO4, MgSO4
   - NOT: Trailing zero (X.0 mg)- write X mg

   - DO use leading zero (NOT .X mg) instead
       Do write 0.X mg




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Sample drugs & Medication security
   Manage controlled substances
   Manage sample drugs
       Storing & securing (authorized access;
        log in & out)
       No prescription pads in exam rooms
       Monitoring expiration dates
       Dispensing function
           log in & out; lot #
       Recall function


                              80
Protocol: Prescription refills
   Medical records reviewed prior to renewals for
       Needed labs,
       Most recent & next appointment (missed appt?)
   Medication renewals limited to patients
    previously seen by medical provider in clinic

   Pain med renewal ONLY by Medical provider
   Document:
     Medication name, dose, amount, date of last
       appointment, completed labs as applicable


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            Medication Reconciliation

   RN/ MA intake interview: takes time
     Interview skills
     Medication knowledge
     Pt. brings in all current medications & OTC
     Establish / update Medication Inventory
            Keep in visible location on pt. chart
       Patient keeps copy and updates
       Patient uses Medication inventory daily
       Update medication supply @ each visit to
        reduce refill requests between visits


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• Make change             • Select problem
  permanent                 process
  (standardize) or        • Understand
• Continue the              the process
  PDCA cycle              • Decide on
                            process steps
                            to improve




• Collect data
                          • Data collection
• Analyze data
                          • Data analysis
• Determine the
  effectiveness           • Implement the
  of the change             change /pilot




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