Meaningful Use of Medication Event Reporting Data

1. Meaningful Use of Medication Event Reporting Data The significance of Medication Event Reporting Denise Fields, PharmD Decatur County Memorial Hospital

3. 2010 Pharmacy One Source Pharmacist Intervention Challenge Winner Decatur County Memorial Hospital Pharmacy

4. Objectives • Identify Key Elements to be included in medication incident reports. • Learn methods for identifying patients at increased risk for medication events. • Identify measures to monitor the success of safety initiatives.

5. Question #1 On average, how many medication error reports does your organization receive in one month? • Less than 10 reports • 10 – 50 reports • 51-100 reports • More than 100 reports

6. Purpose of Reporting System • Support a culture of open communication • Promote the concept that each employee is an important contributor to improvements • Identify system failures • Provide a record of the event

7. Why Are We Not Getting Many Medication Reports?

8. What is your system for reporting? • Methods of reporting • Paper/Written • Voicemail • Verbal • Electronic • Voluntary Reporting • Active Surveillance

9. Obstacles to Reporting “I don’t think that was a medication event… ...the error didn’t reach the patient” • Lack of a clear definition of a medication event • Good Catches • Potential for Error or Harm • Need to examine potential errors as well as actual errors in a formal process • Internal potential errors • External potential errors (ISMP Quarterly Action Agendas)

10. Sentinel Events (Category G, H, I) 0.05% Harmful Errors Category E, F 1.3% Non-Harmful Errors (Category B, C, D) 88% Potential Errors Category A 10.7%

13. Definition of a Medication Event • Any preventable event that may cause or lead to inappropriate medication use or patient harm. Such events may be related to professional practice, health care products, procedures, and systems, including • Prescribing • Order communication (transcribing) • Product labeling, packaging, and nomenclature • Compounding • Dispensing • Distribution • Administration • Education • Monitoring • Use

14. Other Definitions • Event Type or Category • Event Severity • Node • Event Location • Staff Level Involved

15. Obstacles to Reporting “I don’t have time…..I have to take care of my patients” • Complex reporting process • Need for immediate reporting • Lack of time • Inappropriately designed forms • Too much emphasis put on front line staff to fill out the entire form

16. Information Front-Line Staff Should/Could be Expected to Document: Location where error was discovered Initial level of harm to patient Medication(s) involved Event Type Description of what happened Information Front-Line Staff Should NOT be Expected to Document: Location where the error originated Final level of harm to patient Root Cause(s) Contributing Factors At-Risk Behaviors What Should be on your Form?

17. Obstacles to Reporting “I don’t want to get anyone in trouble” • Reluctance to report incidents involving other staff members • Concern for personal liability • Over concern about medication error rates

18. Half Empty or Half Full? • Consider the unintentional message you may be sending with the terminology you are using….perhaps a simple terminology change could lead to an increase in reporting: • What if you called it a medication EVENT rather than an ERROR? • What if you called it a GOOD CATCH rather than a NEAR MISS? • What if your goal was to increase the number of events caught before harm was incurred rather than just to reduce the number of events reported?

19. What if you assured your staff… • The documentation will be kept confidential • That your main objective for requesting this information be documented is NOT to discipline the person who made the mistake. • That you are trying to prevent someone else from making the same mistake in the future – if one person made the error, then it is very likely that many of us could repeat the same error. • Example: How many hospitals have had similar Heparin Errors? If we all would realize that an error that someone else made could just as easily happen to us, would we be more interested in reading or hearing about the errors made by others in order to create safer systems?

20. I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid. Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the first and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can still raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.. Amzanig huh?

21. Obstacles to Reporting “Why should I take the time...no one ever looks at the information” • Perception that reporting has a low priority • Lack of knowledge about the advantages of an effective reporting system • Need for managers to look within when assessing errors

22. Communication and Education are Key Components • Explain to your staff the process for event review • Tell them who is responsible for this • Explain the process for review and action • Our electronic documentation system emails notifications of medication event reports to multiple managers • Communicate significant changes made in your medication system from reported events to staff • ParX Scanning by technicians • Shrink Wrapping Skeletal Muscle Relaxants • High Alert warnings and flags • Vit K in prefilled syringe (1mg/mL) vs ampule (10mg/mL) • Consider a Medication Safety Newsletter • Align your medication safety goals with your message

23. System vs Human Failures • It is important to critically review medication events to determine if the system failed us, so that we may correct the system. • The system may fail us by not adequately educating/training staff or not identifying in a policy or procedure what action to take. • Human failure would be deliberately bypassing the established policy or procedure without good reason.

24. MeaningLESS Event Reporting? • Ineffective trending of data • Lack of standardization • Using < 6 months data for trending • Total reliance on voluntary reporting • Analysis of data performed, but root causes and contributing factors not identified • Review of internal aggregate data only

25. Voluntary Reporting • Studies of medical services suggest that only 1.5% of all adverse events result in an incident report. O’Neil A., Ann Intern Med 1993; 119: 370-376 • “We found that less than 4% of all adverse drug events involving the use of rescue drugs were reported” Schade, Am J Med Qual. 2006 Sep-Oct; 21(5):335-41

26. Methods of Data Collection • Proactive Risk Assessment • Self Assessments • Failure Mode and Effects Analysis (FMEA) • External sources of Data • Concurrent Risk Assessment • Pharmacy Interventions • Trigger and Markers • Retrospective Risk Assessment • Observational methodology • Data from technology • Chart reviews • Internal, voluntary reporting

27. Aggregate Data Analysis • Examples of Aggregate Data Reports Number of errors by • Outcome category (A-I), or by harm/no harm • Process Node (prescribing, dispensing, administration, monitoring, documentation, storage) • Error Type (wrong dose, wrong patient, wrong route, etc) • Medication or Medication Category

28. Top Five Medications Involved in Error Insulin Heparin Morphine Warfarin Fentanyl Top Five Event Types Wrong Dosage/overdosage Wrong Dosage/underdosage Wrong Route Wrong Frequency Wrong Patient Aggregate Data Example

29. Cross Tabulation Reporting • Rather than just looking at the error wrong dose, you could look at a cross-tabulation of wrong dose attributed to wrong weight being entered:

30. Cross Tabulation Reporting • Or you could look the most common medications involved in wrong dose errors attributed to wrong weight being entered:

31. More Meaningful Trending of Aggregate Data: Examples • Specific breakdown(s) of what happened • Drugs/Drug Classes (High Alert Medications) • Points in transition to different level of care • Locations of medications • Problems with patient information • Look-alike names or confusing labels • Poor design of devices

32. Question #2 You are being admitted to a hospital today and have the choice of two hospitals. You want to be cared for in the “safest” hospital. Which hospital would you choose? a) The hospital with a 5% medication error “rate” b) The hospital with a 10% medication error “rate” c) Neither A or B. I want a hospital with a 0% medication error “rate”!

33. Benchmarking • A myth that one can gauge quality and safety by simply comparing error rates • Differences in • Culture • Definition of an error (harm, close calls) • Patient Populations (tertiary vs rehab) • Types of reporting (passive vs active) • A reporting program alone does not improve patient safety

34. Tips to Remember • Reporting has to be quick and easy for front line staff • Use multiple sources of data to identify risk • Take small bites – keep it simple • Think “Something can go wrong and let’s fix it” • Any modification to the system creates new risk points (example: CPOE)

35. Resources • Institute for Safe Medical Practices (ISMP) • www.ismp.org • www.ismp.org/Newsletters/default.asp • www.ismp.org/selfassessments/default.asp • www.ismp.org/Newsletters/acutecare/actionagendas.asp • Rural Hospital Medication Safety Resource Kit • National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) • www.nccmerp.org • Agency for Healthcare Research and Quality (ARHQ) • http://psnet.ahrq.gov • Institute for Health Improvement • www.ihi.org • United States Pharmacopeia (USP) • www.usp.org • Professional Organizations • www.ashp.org • Accreditation Organizations • Group Purchasing Organizations • Software Vendors/Wholesale Vendors