preventing medical errors: jcaho update- medication use policies

1. PREVENTING MEDICAL ERRORS:JCAHO UPDATE-Medication Use Policies Shands Jacksonville Medical Center

2. Accreditation and Credit Accreditation: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit: The University of Florida College of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

3. Disclosure Author: Pamela Schauben, MS, RPh Department of Pharmacy Shands Jacksonville Pamela Schauben has indicated that she has no financial relationships to disclose.

4. General Information Requirements for Successful Completion: In order to receive credit, UF physicians at Shands Jacksonville must view all PowerPoint slides and complete a separate online post-test. One CME credit will be awarded upon successful completion of the post-test. Media: Internet Release Date:  March 1, 2006 Expiration Date:       March 1, 2007 Estimated time to complete: 60 minutes Sponsorship:  This activity is sponsored by the University of Florida College of Medicine

5. Intended Audience University of Florida Physicians practicing at Shands Jacksonville Medical Center

6. Learning Objectives Upon completion of this activity, participants should be able to Identify specific Shands Jacksonville Patient Safety Goals and JCAHO medication-related standards, which include

7. Learning Objectives (con’t.) Maintaining awareness of look-alike and sound-alike drug names Clearly specifying dosage form, drug strength, and complete directions on prescriptions Learning the list of prohibited abbreviations Obtaining and documenting a complete list of patients’ medications Reviewing certain policies and procedures for high risk meds and emergency access to meds Communicating patients’ medications to next provider of care

8. What is the new survey process? UNANNOUNCED! (1 hr notice) Patient selected randomly Patient followed to each area (e.g., ED, OR, Cath Lab, etc.) Physicians, nurses, etc. who interacted with the patient are interviewed Current charts scrutinized

9. What is our role? Be prepared Be able to explain our policies! Make sure charts are compliant Show that we are providing safe, quality care to our patients

10. Recent Survey Questions….

11. Question 1: Does an indication for each medication need to be specified?

12. Indication for Use of Drugs? YES! Each drug ordered must have an indication written SOMEWHERE in the medical record. Example: “Bisacodyl 5 mg 1 tablet po BID PRN” Chart must list “constipation” or “prevention of constipation” Can be in the order, the progress notes, the H&P, OR the nurses note (preferably the order for prns) Medication Orders SH core # CP2.49p Example: pt admitted for leg fx, on eye drops @ home – chart must indicate “glaucoma” in H&PExample: pt admitted for leg fx, on eye drops @ home – chart must indicate “glaucoma” in H&P

13. Question 2: Can two “prn” medications with similar indications be prescribed?

14. Issue is consistency, such that each nurse interprets exactly the same way Issue is consistency, such that each nurse interprets exactly the same way

15. Question 3: What do you do if you need medication information?

16. Medication Information:

17. Question 4: Tell me what you have done about high risk medications?

18. High-Alert Med Policy High Alert Medications SJ # Rx-11-057 Gives recommendations for safe use of the most dangerous medications Example: Amiodarone Assure correct dose and rate for indication Use filter Extravasation precautions Must be in glass bottle for maintenance

19. Question 5: What have you done about SALAD* drugs?

20. Look-alike, Sound-alike Drugs We read back and spell out any sound-alike medications on verbal/telephone orders Medication Orders SH core # CP2.49p Pharmacy has added “Tallman” lettering to the Pyxis Helps to distinguish meds that look alike Ex.:chlorPROPamide vs. chlorproMAZine High Alert Medications SJ # Rx-11-057

21. Question 6: How do you handle medication orders with ranges? Example: 1 to 2 tablets Q 3-4 hours prn pain?

22. Range Order Policy: Begin with the smallest dose If no relief within Thirty minutes (for IV administration) One hour (for oral or IM medication) Use the remainder of the dose (up to the next prescribed amount) For subsequent doses, the total amount administered to obtain relief may be given Medications Prescribed With a Dose Range SJ # Rx-11-043 Issue of consistent interpretation again; nurses use standard approach, so that dose pt receives same each time.Issue of consistent interpretation again; nurses use standard approach, so that dose pt receives same each time.

23. Example (dosage): “Morphine 2-4mg IV Q 3 hrs prn pain” Give 2 mg Reassess pain in 30 minutes (IV med) If pain is not relieved, an additional 2 mg may be given. For subsequent doses, 4 mg may be given at the appropriate time interval

24. Example (frequency): Orders indicating a frequency range The shortest frequency is allowable for “as needed” orders. Example: “Percocet 1 tablet every 4-6 hours prn pain” Doses can be given as frequently as every four hours, upon request by the patient.

25. Titrating orders Orders for medications that require titration must contain parameters. Example: Dopamine 400mg/250ml, start at 5 mcg/kg/min, titrate to systolic of 90mmHg.

26. Question 7: Under what circumstances can medications be obtained prior to a pharmacist review?

27. Medications can be removed without pharmacist review: In an emergency that is documented in the medical record Example: patient needs naloxone STAT Only 1 episode may be treated before pharmacist review In specialized areas where a licensed independent practitioner (LIP) is overseeing medication use (must be physically present) Examples: OR, Radiology Emergency Access to Medication SJ # Rx-11-042

28. Question 8: How long do you keep multi-dose vials?

29. Multi-dose Vials Multidose Vials SJ # Rx-01-011 Maximum 28 days if contaminated, must discard earlier Vial must be dated when opened Lidocaine exception- Only a single use then discard!!! Lidocaine is very inexpensive, especially relative to treatment of hospital-acquired infections Lidocaine is very inexpensive, especially relative to treatment of hospital-acquired infections

30. Question 9: What are the requirements to take telephone or verbal orders?

31. Telephone/verbal orders Physician Orders SJ # MS-01-002 TO – for emergency only if the prescriber is in the hospital VO - for emergency only or if prescriber is gloved Must write down order and read it back, then document (Ex: T.O./RB Dr. Jekyll/Ms.Hyde, RN) Goal: demonstrate that we keep TO’s and VO’s to a minimum to avoid errors Goal: demonstrate that we keep TO’s and VO’s to a minimum to avoid errors

32. Question 10: Is it acceptable to write “resume preop meds” or “resume meds” for transfer orders?

33. “Resume meds?” No, it is not acceptable to write “blanket” orders such as “resume meds.” Each order must be re-written if a patient is post-op or has been transferred between levels of care. Other “blanket” orders to avoid: “Rx to dose” “if test is negative/positive, give…” “give 1mg/kg” (must specify dose) Medical Staff Rules and Regulation Orders for Care and Treatment of Patients SH core #CP2.48p Again, consistent interpretation of orders; only prescriber determines dosage or whether to administer Again, consistent interpretation of orders; only prescriber determines dosage or whether to administer

34. OTHER REQUIREMENTS All orders must be signed to be implemented (including pre-printed) Do not cross out previously written orders. A new order must be written (e.g., “discontinue ….” Medical Staff Rules and Regulations

35. Question 11 Are the following orders written correctly? Levothyroxine 75 µ daily 2 gms MgSO4 IV x 1 dose Xanax .5 mg 1 tablet PO prior to MRI Heparin 5000u SQ Q12H Nexium 40 mg po QD D/C all abx Vancomycin 1 gram IV QOD Start SSI protocol #2

36. All contain inappropriate abbreviations Levothyroxine 75 µ daily Write mcg or microgram instead of µ 2 gms MgSO4 IV x 1 dose Write out magnesium sulfate – can be mistaken for morphine sulfate Xanax .5 mg 1 tablet PO prior to MRI Use leading zero before a decimal point (0.5) and do not use a leading zero after (5)

37. All contain inappropriate abbreviations Heparin 5000 u SQ Q12H Write out units Nexium 40 mg po QD Write out daily or QDay D/C all abx Write out antibiotics Vancomycin 1 gram IV QOD Write out every other day Start SSI protocol #2 Write out sliding scale insulin

38. Prohibited abbreviations Enough said!Enough said!

39. Medication Reconciliation Specific process under development Nursing to document medication history on Home Med form Pharmacy to reconcile @ admission, treatment, and postoperatively At discharge, prescriber must document the plan for each medication on Home Med list (circle continue, discontinue or revised)

40. POST TESTFor UF Faculty at Shands Jacksonville: Complete and submit the online posttest (see next slide) and you will receive a confirmation email indicating the number of questions you answered correctly. If you answered at least 7 questions correctly, one CME credit for “Preventing Medical Errors” will be added into the College of Medicine CME transcript system. The test may be retaken only once. You may request a copy of your CME transcript from the UF Jacksonville CME Office by calling 244-3158 or emailing bobbi.cox@jax.ufl.edu

41. CME for Florida License It is important to note that this one-hour CME activity was designed to partially meet the TWO-hour course requirement for Preventing Medical Errors required for medical licenses in Florida.

42. POST TESTTo complete 10-question posttest, click on url below:http://www.hscj.ufl.edu/cme/pme.aspNote: If above hyperlink is not active, please copy the url and paste into your browser