Medication Error Prevalence

1. Medication Error Prevalence

2. 1999 Healthcare is not as safe as it can be and should be. Strategies for improvement 2001 Reinventing the delivery of healthcare IOM Reports

3. Consequences • Costly to hospitals – $17- $29 billion per year • Patients loose trust in the healthcare system • Patients pay in psychological and physical discomfort and healthcare professionals pay in frustration for the inability to deliver the best care.

4. The Findings • Errors are not the result of one person’s reckless actions but of system failures. • Systems analysis is essential to discover the failures. • Front line staff’s participation in the analysis is necessary to understand what is truly happening. • Healthcare has become increasingly complex. • Rapid changes in practice and technology has left healthcare unable to transfer the knowledge into practice. • To align knowledge with practice, all stakeholders must work together to identify a limited number of priority conditions and develop strategies to improve the delivery of care for these conditions.

6. Recommendations • Establish a national focus • Identify and learn from errors through mandatory and voluntary reporting systems • Raise performance standards and expectations • Establish a culture of safety • Goal to reduce preventable errors by 50% over 5 years

7. Aims Care must be Safe Patient Centered Effective Equitable Timely Efficient Aims must be emphasized and imbedded in all health delivery systems Rules Based on continuous healing Organized based on patient needs and values Controlled by patient Knowledge is shared Decision making is evidence based Safety is a system property Transparency is necessary Needs are anticipated Waste is continuously ↓ Cooperation among clinicians is a priority The VisionRecommendations include adopting six aims for improvement and ten rules for system design.

8. ADEs and Medication errors • 7000 deaths annually related to prescription error • Drug related morbidity and mortality may cost up to 77 billion annually • Patients who experience an ADE have an average LOS 8-12 longer. • Errors rates involving children are three times that of errors involving adults.

9. Medication Safety Alerts • 11/00: • an infant dies after receiving 5mg of morphine instead of the ordered .5mg. • 5/01 • A 9-month-old died after receiving 5 mg of morphine instead of the ordered .5 mg of morphine. No leading zero Misread and transcribed as 5 mg

10. A 9 Year Study • 1987-1995 • All medication errors with potential for adverse outcome detected were recorded and analyzed • Errors increased from 522 to 2115 and correlated to admissions. • Most common dosing; errors and inappropriate forms, and prescribing a medication for which the patient was allergic. • Hospitalized patients are at a greater risk for an ADE • Limited changes occurred as similar errors repeated with increasing frequency. • Healthcare organizations and providers must incorporate reduction, prevention and detection mechanisms into daily provision of care. • Arch of Internal Med. 1997 Jul 28;157(14):1569-76

11. Study – Cost of ADEs in Hospitalized Patients • Cohort study including 4108 admissions • 190 ADEs; 60 preventable • Additional LOS 2.2 • Additional LOS for preventable 4.6 • Increased cost of $2595 for all ADES and $4685 for preventable ADEs • Equates to $2.8 million (700 bed hospital) and $5.6 million (bed hospital) • This does not include the cost of patient harm and malpractice payments • JAMA Vol 277 No 4, Jan 1997

12. Malpractice • 1990-2003 • 7,472 medication related malpractice acts or omissions • 26% of malpractice acts or omissions • $920,577,368 in payments • 2003 • 49 reports made against RNs • 61 payments made by RNs • Mean payment $181,162

13. Medication management system. Marketing Ordering/prescribing Transcribing Dispensing Administration Monitoring Interventions to reduce likelihood for ADEs and ADRs AERS CPOE Automated dispensing cabinets Bar coding NPSG Where do errors occur and what is being done to reduce incidence?

14. Common causes • Poor communication • Ambiguities in product names, directions for use and strength designation on labels • Poor procedures or technique “Variation is the enemy of quality.”

16. FDA – Gate keeper for medication safety. Estimated that half of the side effects from pharmaceuticals are avoidable.* Premarket risk assessments and postmarket surveillance Complex system – unclear roles and responsibility postmarket Global market *Bates, D.W., L.L. Leape and S. Petrycki, “Incidence and Preventability of Adverse Drug Events in Hospitalized Adults,” J Gen Intern Med., 8:289-294, 1993. Managing the risks and benefits from medical product use Marketing

17. It is simply not possible to identify all the side effects of drugs before they are marketed.* * Wood, Stein and Woosley, New England journal of Medicine, 339,pp. 1851-1854 (1998)

18. Improvements in Post Market Surveillance • Move from mandatory reporting of all user facilities to annual reports by a representative sample – sentinel sites • Establishment of an office to oversee post-market risk assessments (OPDRA – Office of Post Marketing Risk Assessment) • Expand AERS to integrate reporting of post marketing safety information worldwide

19. Current Model New Model

20. Model for Improvement

21. Illegibility – 6%* Abbreviations Improper Dosing – 7%* Dosing Errors Ordering medications to which patient was allergic Duplicate therapy – 5%* Unclear/incomplete medication history *JAMA 1995;274(1):29-43 Standardized pre-printed orders Standard abbreviations including abb. Not to use. Calculators Pharmacy involvement Read back policies Medication reconciliation Ordering/Prescribing

22. CPOE – computerized physician order entry Although published studies report that CPOE reduces medication errors up to 81%* a recent survey of hospitals responding to the Leap Frog Group’s hospital Quality and Safety survey, only 64 out of 1,143 have CPOE fully implemented. *Koppel, Metlay, Cohen, Abaluck, Localio, Kimmel, Strom, JAMA.2005;293:1197-1203

23. Benefits of CPOE • Decrease LOS • Reduce costs • Decrease medical errors • Improve compliance with guidelines • Decrease overuse, underuse and misuse. • Study: • 2 year implementation; within first 30 days, 4,500 medication orders with 40 drug-drug interactions noted requiring intervention; within first 4 months at approx. 5000 med orders/month, 72 drug-drug interactions.

24. Issues Associated with CPOE • Substantial cost • Technology • Organizational analysis and process design • Redesign • Support • Training • Study: 261 house staff surveyed, five focus groups and 32 1 to 1 intensive interviews with house staff, IT, pharmacy, physician and nurses identified that the CPOE system facilitated 22 types of medication errors including inflexible ordering formats that generated wrong orders and inventory displays mistaken as dosage guidelines. These types of errors were experienced weekly or more often. (Jama, 2005;293:1197-1203)

25. Unexpected increase in mortality • Study included children transferred to tertiary care children’s hospital during an 18 month period • CPOE system was rapidly implemented over 6 days during this period • Retrospective analysis 13 month before and 5 months after implementation • Mortality rate increased from 2.8% (39/1394) prior to implementation to 6.57% after (36/548) Pediatrics. 2005 Jan;117(1):216-7

26. Examples • Lower case l misidentified by the software as I and instead of Lodine, pulled up Iodine • Most commonly misidentified were I/l, O/0 and Z/2 • Many computer systems display drug doses using naked decimal points and unsafe abbreviation (QD and U)

27. ISMP Recommendations • List products by generic name using “tall-man” letters to distinguish look-alike, sound-alike medications. Ex. hydrOXYzine and hydrALAZINE. • Express weights and measures in standard fashion • List brand names in upper case to differentiate from generic; standard in pharmaceutical industry • Provide ways to communicate patient or medication related warnings related to prescribed medication; i.e. colored font, italics • 26 total recommendations as of 2003

28. MOE – One Study • 500 bed hospital • 7.9 one time operating and capital expense with 1.35 annually • Opted for MOE over CPOE • Less costly • Provides decision support • Addresses legibility issues • Cost return in short time

29. Transcription • Intervene to clarify unclear orders. • Contact prescriber to clarify unapproved abbreviations even if they appear clear • Use triggers to prompt. • If two medical professionals can not read the order or to continue to have questions, contact the prescriber.

32. Labeling errors during repackaging Lack of access to the right medication at the right time Less control over inventory Poor/no audit trail Single dose units Mandatory bar coding Automated medication dispensing cabinets. Dispensing

33. Benefits of ADC • Control over inventory • Creates audit trail • Links patient to medication • Provides timely access to a greater number of medication • Improved security for medications

34. Issues with ADC • Not enough cabinets to service the patient care area • Override functions can facilitate orders carried out prior to review by pharmacy • Reminders and alerts may not provide adequate information • No forcing function to control and record narcotic wasting

35. Wrong patient Wrong medication Wrong time Wrong dose Wrong route Bar coded patient identification system Clear policies and procedures for medication administration including patient identification. Red rules to impress importance Administration

36. Red Rule PATIENT SAFETY ALERT ALL CLINICAL STAFF RED LETTER RULE #3 MEDICATIONS When administering medications, the Medication Administration Record (MAR) and the medication in the original packet or unit dose must be brought to the patient’s bedside. The following steps must occur: Verify patient identification using two identifiers (neither to be the patient’s room)– resolve discrepancies before administering medication. Ensure compliance with the 5 Rights of Medication Administration: • Right Patient • Right Drug • Right Dose • Right Route • Right Time Validate with another RN a documented double-check for all insulin, heparin, warfarin and narcotic medications prior to the administration of the medication. THERE ARE NO EXCEPTIONS TO THIS RULE

37. Failure to recognize adverse reactions Failure to report adverse reactions Failure to educate patients about potential side effects. Prompt added to MAR to identify new medication and document patient response. Get patients involved in their healthcare decisions Computerized monitoring utilizing signals. Lab values Rash Fever Diarrhea Monitoring

39. ADEs and ADRs can occur along the entire medication management system. • Approval for public use • Ordering • Transcribing • Administering • Monitoring

40. Good systems – “Each system is designed to get exactly the results it gets.” • Constantly evaluate your systems and find opportunities for improvement. • Quality is not perfection.

41. Computerized Monitoring • Computer assisted antibiotic dosing monitor tracks renal function daily and identifies patients who may receiving excessive doses of antibiotics. • Integrated with lab, pharmacy and other patient specific information identifies allergies, drug-drug and food-drug contraindications • Detects possible ADES through combinations of orders and lab results: an order for a drug along with an abnormal lab value that would indicate a possible ADE

42. Review Study • 617 ADEs were discovered • Chart review – 398 • Computer monitoring – 275 • Voluntary reporting – 23 Although chart review discovered the most, computer monitoring was considered more efficient because it discovered more than voluntary reporting and was less time consuming than chart review. J Am Med Inform Assoc 1998;5(3):305-14

43. Reason’s Model