Medication Error Report FY 19 Q1 – Q3 July 2, 2019

1. Quality Improvement Committee (QIC) Medication Error Report FY 19 Q1 – Q3 July 2, 2019

2. Agenda • Medication Errors by Month • Medication Errors by Facility Type • Reasons for Serious Medication Errors • Violation as a Result • Reasons by Violation • Violations by Investigation Outcomes

3. Medication Errors by Month Medication Errors (Serious Medication Errors and Medication Errors Reportable Incidents made up 3% of all accepted incidents ( for the period from October 1, 2019 through June 26, 2019 (FY 19 Q1 – Q3).

4. Medication Errors by Facility Type Supported Living sites had many of the Medication Error incidents (64.5%) with only one incident being reported from a Natural Home setting (>1%). Intermediate Care Facilities made up 13.6%, which represents the second highest setting of Medication Error incidents over the period.

5. Reasons for Serious Medication Errors Many of the incidents are attributed to the medication not being available at the time of administration. The second most frequent reason for serious medication errors the period was due to pre-pouring of medication. These errors for this period specifically are attributed to one event which resulted in three incident reports.

6. Violation as a Result Violations were developed to clarify the result of the reason and are used only to classify the incident specific to medication administration. As seen, most incidents (64.2%) resulted in Missed Dose/Application/Measure.

7. Reasons by Violation The medication not being available was the main cause for Missed Dose/Application/Measure Errors.

8. Violations by Investigation Outcome This graph shows how violations were attributed to investigation outcomes. As noted, most investigations received an outcome of Resolved – No Abuse or Neglect Found.

9. Based on this review • Reporting of all medication errors regardless of classification (SRI/RI) should require the exact time of the error to assist in identifying problem timeframes (change of shift, mornings, etc.) • Documentation Errors appear to stem from a lack of oversight (failing to change or update orders timely, failing to follow Doctor’s orders, etc.). Providers might consider shift by shift review of the MAR to ensure that all proper documentation has been completed (Incoming TME signs off on outgoing TME’s administrations, etc.) • Providers might consider that people assessed to self-medicate may continue to require supports to ensure appropriate and consistent administration of medication. • Counseling or scheduling strategies might be considered for people to remember to be available at designated medication times. • Medication stocks should be reviewed on a schedule to ensure that all medications are available as necessary. • Providers might consider regularly scheduled refresher training of TME guidelines to ensure that staff are compliant with TME guidelines and certifications. • When looking at reasons for specific violations, clarification is needed in the severity of Missed Dose/Application/Measure due to it appearing in both Serious Medication Errors and Medication Errors reportable.

10. Contact us with any concerns Immediate Response Committee (IRC) Supervisor Dianne Jackson, Supervisor, Quality Resource Unit dianne.jackson3@dc.gov 202-664-7471 Serious Reportable Incident (SRI) Investigator Supervisor Greg Coffman, Supervisor Investigator Greg.coffman@dc.gov 202-615-9420 SRI Recommendations Supervisor Greg Banks, Supervisor, Quality Resource Unit Gregory.banks@dc.gov 202-870-9778

11. Committee Recommendations?