Medication Error Prevention in 2014

1. Medication Error Prevention in 2014 Wendy Perry, Pharm.D. September 28, 2013

2. Objectives Describe a Medication Safety Officer’s responsibilities. List new safety challenges that are a result of technological advances. Discuss the mechanisms for obtaining medication error data. Describe a data analysis process and appropriate follow up. Define “Just Culture.” Discuss methods to reduce medication errors.

3. Why Medication Error Prevention in 2014?

7. Medication Safety Officer Job Description • Guide and coordinate the organization’s medication safety activities • Analyze data to identify trends and recommend priorities • Examine entire medication use system • Engage key stakeholders • Knowledge expert on committees • Present educational sessions Larson CM, Saine D. Medication Safety Officer’s Handbook. ASHP;2013

9. Computerized Provider Order Entry (CPOE) and Clinical Decision Support (CDS) • Pros • Decreased number of steps in the medication process, pre-populated fields, etc. improves safety • Provision of clinical info related to allergy, dose, duplicate therapy, etc. improves safety • Cons • Complicated screens • Easier to make incorrect choice in patient, drug sentence • Alert fatigue

10. Post – CPOE1 st PSE received: Wrong Patient Order for insulin received by pharmacist who was familiar with patient and recognized not appropriate Wrong patient was selected by MD Prevention methods: Only one patient MR open at once Create patient list

11. Bar Code Medication Administration (BCMA) • Background • 34% of all med errors occur in administration • 50% of hospitals in 2011 • 25% of nursing time spent on med-related activities • Prospective before and after observational study • 386 bed academic teaching hospital • 2 medical-surgical units, 2 ICUs • Med admin errors assessed by comparing observed med administered to med intended for that patient Helmons PJ. Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. Am J Health-Syst Pharm. 2009;66:1202-10.

12. Results • Error rate = # of errors total opportunities for error • Separated wrong time errors from other errors • Med-surg: overall 8% to 3.5% (p<0.0001) omissions 4% to 1% (p<0.0001) ICUs: NS, charting compliance improved

15. BCMA Safety Opportunities • Scanning omissions • Bypass alert • Work-arounds • Barcode copies • Wrong time • Front or back scanning for convenience, patient availability • To complete documentation • Wrong reason chosen

16. Automated Dispensing Cabinets (ADC) • Non-profile units • Override medications • Incorrect medication fill – decreased with bar codes • Spill over • LASA medications • Replacement by nurses • Quantity to be scanned • Alert fatigue

17. Smart IV Pumps • Override functionality – drug libraries are the core safety feature • Alert fatigue • Lack of interface

18. Tools to Identify Safety Needs • Voluntary reporting data • Trigger tools • Culture surveys • Published literature and reporting sources • Walk around • Pharmacist clinical interventions • Med administration BCMA scan failures • Bypassed alerts and overrides • Failure mode and effects analysis (FMEA)

20. Voluntary Reporting • Reported medication error rates are simply a measure of the ability of the organization to recognize and report medication-related problems. • Therefore, an organization with a large number of error reports may actually (and in many cases is likely to) have a lower true underlying medication error rate than an organization where few reports are received, analyzed, and acted on. Larson CM, Saine D. Medication Safety Officer’s Handbook. ASHP;2013

22. Specific Event TypeMandatory: YesPick List Values (Single-pick) • Adverse Drug Reaction • Administration Technique Incorrect • Dose Incorrect • Drug With Known Allergy • Medication Administered Not Ordered • Narcotic Count Incorrect • Illegible Order • Time Incorrect/Delayed • Outdated/Unusable Medication • Drug Incorrect • Monitoring Issue • Patient Incorrect • Omission • Route Incorrect • Storage Incorrect • Drug Preparation Issue • Pump Programming Issue • Documentation Error • Other (please specify)

23. Contributing FactorsMandatory: No Pick List Values (Multi-pick): • Communication/Handoff Failure • Competency of Staff • Lack of Training/Education • Insufficient Staff • Action by Family Member/Caregiver • Action by Patient • Policy/Procedure Issue • Physical Environment Condition/Design • Insufficient Monitoring/Supervision • Work Environment-Fatigue • Language Barrier • Administration Issue/Calculation Error • Drug Name Confusion(e.g. Look Alike & Sound Alike) • Medication Not Available • Distractions/Interruptions Monitoring – Vital Signs Not Checked • Patient Unavailable • Incomplete/Ambiguous Order • Preparation – Delayed Delivery • Preparation – Wrong Drug/Dose/Strength • Transcription Issue – Incorrect Computer Order Entry • Transcription – Order Not Entered In Computer System • Drug Info Missing – Inadequate Medication Reconciliation Process • Patient Info Missing – Allergies • Patient Info Missing – Lab Values • Patient Info Missing – Weight • Other (please specify)

24. ADR vs ADE • Medication Error A preventable error occurring in any step of the medication process • Adverse Drug Event An undesirable occurrence associated with a medication • Adverse Drug Reaction An idiosyncratic reaction or other adverse effect of a medication that is not preventable

26. Interpretation • Near Misses are Med Errors • Caught by chance • Caught by following a safety process • ADRs are not Med Errors • All ADRs are ADEs • Not all ADEs are ADRs • Focus and follow up is different • Involves patient management • Future prevention and education • Reporting if necessary

28. E - I

29. Purpose of Nomenclature and Definitions • Communication within institutions and corporations • Regulatory self-assessment • Trending and consolidation • Monitoring performance • Benchmarking

30. Don’t get overwhelmed with data collection and/or analysis The most important aspect of medication safety is to apply what has been learned to implement changes in the organization to decrease the potential for harm to patients.

31. How to Set Priorities • National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP) – Categories A – I • Causes of a level where harm occurred often also seen in near misses

32. Data Analysis • Departmental Event Type: Pump Programming Contributing Factor: Hand-off Failure Severity: E-I Medication: Insulin Location: 5NE • Interdisciplinary Committee Medication Management: Nursing and Pharmacy, monthly • Hospital Committee E-I Patient Safety Event Review: Multidisciplinary, biweekly • Quality Department Root Cause Analysis (RCA)

33. Tools from Highly Reliable Industries • Failure Mode and Effects Analysis (FMEA) FMEA is an ongoing quality improvement process that is carried out in healthcare organizations by a multidisciplinary team. It can be employed to examine the use of new products and the design of new services and processes to determine points of potential failure and what their effect would be – before any error actually happens. FMEA is a proactive process used to look more carefully and systematically at vulnerable areas or processes. In this regard, FMEA differs from Root Cause Analysis (RCA).

34. 2. Root Cause Analysis (RCA) Usually RCA is a reactive process, employed after an error occurs, to identify its underlying causes. Required by The Joint Commission for sentinel events, defined as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” Includes an action plan, and monitoring the effectiveness of the plan.

35. Just Culture Whack-a-Moleby David Marx, J.D. 2009 This book argues that our Whack-a-Mole approach to inevitable and often predictable human error is ineffective, inefficient, and unjust; it does nothing to enable us to learn what we might do differently next time, or what systems we might put in place to minimize the chances of causing the same adverse outcome again.

36. Just Culture We spend far too much time looking at the severity of the adverse outcome (how bad was it?) and who was the unfortunate soul to be closest to the harm. In turn, we spend far too little time addressing the system design that got us there and the behavioral choices of the humans in those systems that might have ultimately contributed to the adverse outcome.

37. Just Culture The Behaviors We Can Expect: • Human error -inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. • At-risk behavior –behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. • Reckless behavior -behavioral choice to consciously disregard a substantial and unjustifiable risk.

38. Just Culture • Console the human error. • Coach the at-risk behavior. • Punish the reckless behavior. • Independent of the outcome.

39. It’s About Changing Staff Expectations(from Just Culture literature) • Looking for the risks around me • • Reporting errors and hazards • • Helping to design safe systems • • Making safe choices • –Following procedure • –Making choices that align with organizational values • –Never signing for something that was not done

40. Error Prevention Strategies • Improve communication and handoff • Situation, Background, Assessment, Recommendation (SBAR) • Handoff Checklist • Catch phrases • Multidisciplinary or team safety meetings • Technology • Catch of the Month • Double Checks

41. Double Check The virtues of independent double checks – they really are worth your time! ISMP December 17, 2009 The average “checking error rate” (errors missed during a double-check) is about 5%. In studies where “artificial errors” were introduced into medication carts and sample pharmacy orders, 93% to 97% of such mistakes were identified during an independent double-check.

42. Double-checks work best when they are conducted independently. • The person checking has to form an independent judgment without cues from the person doing the initial work (why ISMP encourages “independent double-checks”). • It would be more effective, for example, to have two people calculate a dose separately and then compare their answers, than to have them perform the calculation together or to have one share his answer with the other before the double-check occurs. • People may be swayed by the opinions of others, even more so if the other person holds a position of authority or has more experience.

43. Heparin 25,000 units/500 ml standard solution • Store in high risk section; boxes placed below • Tech places HEPARIN sticker on bag; pharmacist initials when checks • Tech ran out of bags, placed HEPARIN sticker on additional bags that were not checked by pharmacist • Additional bags were actually Lidocaine

44. Limit checks to high-risk situations • While it’s true that independent double-checks are not as effective as system changes that make it hard for people to make mistakes, if performed properly, they can reduce the risk of an error reaching the patient • Challenge: when does technology suffice

45. Learn from captured errors. • Document mistakes discovered during double checks • Analyze to understand the reasons behind them • Identify precautions that need to be taken • Not doing so has resulted in fatal errors

46. What is your action plan?