Medication Safety

1. Medication Safety The Good Hospital Practice Training Series 2009 The Medical City

2. In this presentation… • The roles of the Medical City staff in ensuring the safe use of medications • Prescription writing • Verbal and phone orders • High risk medication monitoring • Medication reconciliation • Adverse drug event reporting and analysis

3. The problem of medication errors • 44,000 - 98,000 people in the US die annually as the result of medical errors • 19% of all medical errors are medication related. • Only 1-10% of medication errors are voluntarily reported • Medication errors reported do not reflect patient harm

4. The problem of medication safety • Every day more than 4,000 people have ADRs so serious that they need to be admitted to American hospitals • In addition, every day about 2,000 hospitalized patients suffer from ADRs. • About 50% of these ADRs are preventable.

5. Common medication errors 1. Math error when calculating dose. 2. Wrong patient weight. 3. Patient’s armband not checked. 4. Wrong drug amount drawn in syringe. 5. Wrong strength bolus administered. 6. No double check of pump completed. 7. Double checking of dose is only cursory.

6. Root causes of medication errors • Lack of clear and adequate communication among doctors, nurses, pharmacists and patients • Illegible, incomplete prescriptions • Multiple drugs • Look alike sound alike drugs

7. The roles of ALL doctors • Use drugs rationally. More drugs, more errors. Be evidence-based. • Educate patients on rational drug use. • Write all drug orders legibly. Print if in doubt. Don’t use Forbidden Abbreviations. • Stick to medications in the formulary. • Order by generic names, correctly spelled. Allow generic substitution.

8. The roles of ALL doctors • Write the therapeutic indication for every new drug ordered (e.g. losartan for hypertension) • Demand READ-BACK after ordering drugs. Confirm that you are understood. • Practice medication reconciliation. Compare drugs ordered on admission AND on discharge with drugs taken before admission. Be clear with what you want continued or stopped.

9. The role of residents • Write drug orders ON TIME. No phone or verbal orders please. • Write orders LEGIBLY. Print if in doubt. Write the generic names and indications. Avoid abbreviations. • READ BACK written and verbal orders of consultants immediately to confirm if you got it right before executing them

10. The role of nurses • Order drugs in SHAMAN by GENERIC NAMES. • READ BACK the complete drug order to the prescriber and insist on confirmation. • Before administering drugs, confirm the identity of the patient AND the drug. • Administer all medications promptly. • Report any adverse drug event.

11. Writing perfect prescriptions A drug order or prescription must have the ff legibly written parts: • Generic name • Dose, frequency and route • Indication • Signature, printed name • Time and date • No abbreviations please!

12. Avoid these Forbidden Abbreviations

13. Avoid verbal and phone orders A phone order is permitted if an AP can’t write an order promptly AND if a patient urgently needs an order. AP must communicate phone order to the RIC. Nurses are last resort for giving phone orders. MDs and Nurses can help avoid phone orders by going on rounds together and discussing the care plan. This way, the team understands what to do if an urgent need arises.

14. If you REALLY must give a verbal or phone order,… • Ask for a READ BACK from the receiver of the order. • Listen carefully and verbally confirm that your order has been correctly understood. • Do not hang up until you are sure.

15. What is medication reconciliation? Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, MD or level of care.

16. How is medication reconciliation done? • Use the Drug Database Form. • Nurse asks patient to list all meds taken before admission. • AP compares this list with the drugs ordered. • AP decides which medications will be continued and which will be stopped. • AP re-writes orders if needed. • AP communicates the new list to appropriate caregivers and to the patient.

17. When is medication reconciliation done? Some examples • On admission • After a surgical or high risk diagnostic procedure • Transfer to or from the ICU or another unit • Every 7th hospital day • Every 3rd hospital day for patients with more than 3 MDs • After change of AP or RIC • After resuscitation • Before discharge from hospital

18. An example of medication reconciliation AP lists and compares drugs to determine which will be continued, replaced or stopped. Drugs before admission: Metoprolol Glibenclamide Aspirin Calcium Senokot Drugs during confinement: Telmisartan Insulin Aspirin Calcium Drugs on discharge: Telmisartan Glibenclamide Aspirin Calcium Senokot

19. Why do medication reconciliation? More than half of serious medication errors in the JCI database are due to breakdowns in communication that could have been avoided through effective medication reconciliation. Numerous reports of errors due to failure in medication reconciliation have been received by the Institute for Safe Medication Practices (ISMP) since 2005 and by the United States Pharmacopeia (USP) since 2004.

20. High risk medication monitoring High risk drugs are those that have potent cardiovascular, neurologic or metabolic effects. Some of these drugs have narrow margins of safety so that minor medication errors can have catastrophic consequences. The JCI database maintains a list of high risk drugs.

21. The Medical City Drugwatch List All staff must be careful in using these drugs and report any ADVERSE EVENTS involving them. • Insulin • KCl • MgSO4 • Ca gluconate • NaHCO3 • Lidocaine • Dopamine • Dobutamine • Heparin • Coumadin

22. How to prescribe and administer high risk drugs safely • Write complete orders legibly. • Limit the number of doses to a minimum. • Reconcile with other drugs. • Have the head nurse check the drug to be administered. • Have the clinical pharmacist review the drug order. • Monitor patient status after every administration.

23. What are adverse drug events (ADEs)? Any unexpected, unintended, undesired, or excessive response following drug administration that results in 1 of the following: A.    Stopping or changing drug B.    Changing drug dose C.    Admission (for ambulatory patients) or prolonged length of stay (for inpatients) D.    Starting supportive treatment E.    Complicated diagnosis or bad prognosis F.    Temporary or permanent harm, disability, or death G. Therapeutic failure.

24. Why ReportAdverse Drug Events (ADEs)? • Because YOUR patients may be the next victim • Over 2 MILLION serious ADEs yearly • 100,000 DEATHS yearly • ADEs 4th leading cause of death ahead of lung disease, diabetes, AIDS, pneumonia, accidents and automobile deaths • Ambulatory patients ADE rate — unknown • Nursing home patients ADE rate —350,000 yearly Institute of Medicine, National Academy Press, 2000 Lazarou J et al. JAMA 1998;279(15):1200–1205 Gurwitz JH et al. Am J Med 2000;109(2):87–94

25. Costs Associated with ADEs • $136 BILLION yearly • Greater than total costs of cardiovascular or diabetic care • ADEs cause 1 out of 5 injuries or deaths per year to hospitalized patients • Mean length of stay, cost and mortality for ADE patients are DOUBLE that for control patients Johnson JA et al. Arch Intern Med 1995;155(18):1949–1956 Leape LL et al. N Engl J Med 1991;324(6):377–384 Classen DC et al. JAMA 1997;277(4):301–306

26. Why Are There So Many ADEs? • Two-thirds of patient visits result ina prescription • 2.8 BILLION outpatient prescriptions(10 per person in the United States) filled in 2000 • ADEs increase exponentially with4 or more medications Schappert SM. Nat. Center Health Statistics. 1999, Series 13 No. 143 National Association of Chain Drug Stores. 2001 Jacubeit T et al. Agents Actions Suppl 1990;29:117–125

27. New drugs approved by FDA / BFAD are safe, right? Wrong! • Most drugs approved by FDA with average of 1500 patient exposures • Some drugs have rare toxicity profiles (bromfenac hepatotoxicity 1 in 20,000 patients) • For drugs with rare toxicity, more than 100,000 patients must be exposed to generate a signal i.e. after drug is marketed Friedman MA et al. JAMA 1999; 281(18):1728–1734

28. Myths about ADE Reporting • All serious ADEs are documented by the time a drug is marketed, right? • It is difficult to determine if a drug is responsible, right? • ADEs should only be reported if absolutely certain, right? • One reported case can’t make a difference, right? Wrong! Wrong! Wrong! Wrong! Figueiras A et al. Med Care 1999;37(8):809–814 Eland I A et al. Br J Clin Pharmacol 1999;48(4):623–627 Chyka PA et al. Drug Saf 2000;23(1):87–93

29. Drug-Disease Interactions • Liver disease • Renal disease • Cardiac disease ( hepatic blood flow) • Acute myocardial infarction? • Acute viral infection? • Hypothyroidism or hyperthyroidism?

30. Drug-Food Interactions • Tetracycline and milk products • Warfarin and vitamin K-containing foods • Grapefruit juice

31. Interactions Before Administration • Phenytoin precipitates in dextrose solutions (e.g. D5W) • Amphotericin precipitates in saline • Gentamicin is physically/chemically incompatible with most beta-lactams, resulting in loss of antibiotic effect

32. Interaction with the GI Tract • Block absorptionof quinolones, tetracycline, and azithromycin • Reduce absorptionof ketoconazole, delavirdine • Reduces ketoconazole absorption • Binds raloxifene,thyroid hormone, and digoxin • Sucralfate, some milk products, antacids, and oral iron preparations • Omeprazole, lansoprazole,H2-antagonists • Didanosine (givenas a buffered tablet) • Cholestyramine

33. Spectrum of Consequences of Drug Metabolism • Inactive products • Active metabolites • Similar to parent drug • More active than parent • New action • Toxic metabolites

34. You must report suspected ADEs • ADEs may or may not be related or caused by drug intake and this may be difficult to determine. • The important thing is to alert The Medical City that a patient on a particular set of drugs has experienced an adverse event so that appropriate preventive actions can be carried out.

35. What should you do if you suspect an ADE? • Stop the medication immediately. • Fill out the ADE Reporting Form and hand it over to the Clinical Pharmacist. Reporting may be done anonymously. • Coordinate with the Clinical Pharmacist in managing the patient’s ADE.

36. How will your report be handled? • ADE reports are monitored and analyzed by the Therapeutics Committee. • ADE reports provide the basis for drug alerts to the hospital staff. • ADE reports are also sent to the manufacturer and/or BFAD.

37. Are you a safe medication practitioner? • Which of the following are in the Medical City Drugwatch list? • Potassium chloride • Insulin • Magnesium sulfate • All of the above Answer: ? D • Which of the following practice/s promote/s medication safety? a. Writing orders and prescriptions legibly b. Insisting that the pharmacy stock up your brand of antibiotic c. Arranging drugs alphabetically by brand names d. All of the above Answer: ? A. Choices b and c lead to mixing up sound-alike drugs.

38. Are you a safe medication practitioner? 3. Which of the following will lead you to report a possible ADR? a. The drug needed to be stopped or changed. b. A significant dose modification is required. c. The patient suffered temporary or permanent harm. d. All of the above Answer: ? D 4. When reporting a possible ADR a. You must be absolutely sure that it was caused by a drug. b. You must always sign the report with your name. c. You must immediately file the report while patient is confined. d. all of the above Answer:? C. You don’t have to be sure of drug causation and you can file the report anonymously.

39. Are you a safe medication practitioner? 5. Which of the following is an inexpensive but effective intervention to help the pharmacist screen for medication errors? a. Write the side effects on the prescription b. Write the drug indication on the prescription c. Avoid the forbidden abbreviations. d. all of the above Answer: ? B 6. Which among the following is a/are good way/s to prevent ADRs? a. Have nurses read back orders to MDs b. Reprimand nurses who make erroneous computations. c. Suspend residents who write illegibly. d. all of the above Answer: ? A

40. Are you a safe medication practitioner? 7. Which strategy is the LEAST effective way for preventing ADEs? a. Physical (Forcing Functions) b. Natural (Distance, Time) c. Information (Labels, Signs) d. Administrative (Checklists, Policies) Answer: ? D. Forcing functions are the most effective. Policies can be broken. 8. The following is/are reason/s why elderly are more prone to ADEs: a. Old people have trouble remembering their drugs. b. Old people have poor liver and kidney drug handling capacities. c. Old people have lower fat deposits in which drugs are stored. d. All of the above Answer: ? D

41. Are you a safe medication practitioner? 8 out of 8 – your patients are safe from medication errors! 6 or 7 out of 8 – your patients safety level is above average 4 or 5 out of 8 – your patients safety level is just about barely adequate 2 or 3 out of 8 – you can improve the safety of your medication practice!* 0 or 1 out of 8 – let us try again; meanwhile try to keep your medication use on patients to the bare minimum!* * Please go over the slides again.

42. Summary of this presentation • Our ability to ensure the safe use of medications can spell the difference between health and illness, even life and death, for many patients. • Our staff have critical roles to play in promoting medication safety • We must report, monitor and prevent adverse drug reactions to spare our patients from further harm.

43. This SIM Card certifies that______(please overwrite with your name, thank you)__,MDhas successfully completed the Self Instructional Module on Medication Management and Use(Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose AcuinPresident and CEO Director, Medical Quality Improvement