Independent Double Check (IDC) Medication Management Safety Team (MMST) May 10 th, 2017

Transcription

1 Independent Double Check (IDC) Medication Management Safety Team (MMST) May 10 th, 2017

2 Learning Objectives Understand why an Independent Double Check (IDC) is necessary Understand what can go wrong with the process of IDC Know the components of an IDC Understand the risks and errors associated with IDCs. Promote learning and help prevent medication errors from occurring within Covenant Health.

3 Independent Double Check (IDC): Definition An IDC is a verification process whereby a second health care provider conducts a verification of another health care provider s completed task. The most critical aspect is to maximize the independence of the double-check by ensuring that the first health care provider does not communicate what he or she expects the second health care provider to see, which would create bias and reduce the visibility of an error. - Institute for Safe Medication Practices [ISMP], 2005

4 Could what I am about to do cause harm? There is no human that does not make mistakes regardless of how experienced they are. If we consider that every medication process has the potential to harm the patient, then our perception changes.

5 Patient Safety-Modern Studies MEDICATION ERRORS- 24% ARE PREVENTABLE Adverse Events: 37% are highly preventable Canadian Adverse Events Study 2004 Adverse Events: in 7.5 % acute care hospitals admissions Adverse Events: 9,000 24,000 die/year 1:9 adults - potentially given wrong medication

6 Why is an IDC necessary? Medication use is complex!!! Best practice literature suggests that medication errors are reduced by about 30% when a CORRECTLY PERFORMED IDC is used. Accreditation Canada states service providers shall seek an IDC before administering high risk medications. ISMP indicates the risk would be reduced significantly from 5:100 to 0.25:100 patients affected if correctly performed IDC was consistently practiced. Why Hospitals Should Fly, by John Nance, states that [nurses] are the patient s last chance and the best chance to prevent errors.

7 Canadian Adverse Events 7.5% of all hospitalizations had adverse events that harmed the patient 37% of these were preventable 9,250-23,750 people die each year from preventable adverse events 24% of these were related to medications or fluids 1 in 9 adults will potentially be given the wrong medication Healthcare expenses due to preventable medical errors cost Canadians 750 million dollars each year. A hospital patient can expect to be subjected to more than one medication error every day Canadian Adverse Events 2004 confirmed again 2015 (Baker, Norton studies) Statistics from the Canadian Adverse Events study (MAY 2004), the Canadian Institute of Health Information & the Institute of Medicine 2006.

8 Our goal is zero medication errors!! 95% of potential medication errors are detected on the first medication check 95% of remaining 5% on the second check and With an IDC leaving 0.1% 0.1% equates to; a major plane crash every 3 days(250 average ) 16,000 lost items in the mail every hour 37,000 errors by ATM machines every hour

9 What can go wrong? Deference to Authority: the second person who is going to do the IDC feels that they are lower in the hierarchy than the first person (first nurse is senior the second is a new nurse) Reduction of Responsibility: when one of the two responsible for the IDC feels that they need not engage fully in the process because the other one will pick up the error. Complacency Distraction: when a process is interrupted by social/unrelated conversations. This has been confirmed by the aviation industry. No talking below 10,000 feet. The No DISTRACTION rule should always be exercised when preparing medications.

10 What can go wrong with the process of IDC? Auto-processing: One person is NOT engaged and actively listening and uses non committing language such as a nod or verbal yes. Perceived or actual lack of time : Process is not followed correctly, or omitted because of a perceived lack of time ( I have no time) Key message: IDC procedure needs to be followed explicitly to be an effective error reduction strategy

11 Cognitive Thinking Saves Patients Ask yourselves Do I have the full clinical picture? Was Medication Reconciliation completed? Did I have a shift review of all medications? Did the clinical interdisciplinary team review all medications?

12 Who Can Perform an IDC? Any health care professional, working within their scope and role, and in alignment with Covenant Health policy, can perform an IDC. Unregulated health care providers are NOT able to participate in the IDC process This includes but is not limited to healthcare aides, patients and family members Undergraduate Nurse Employees (UNE) and students may not sign for an IDC, but may work with the nurses/pharmacists to learn about the process.

13 When does an IDC need to be performed? The Covenant Health IDC Policy requires an IDC prior to the administration of the following medications: Continuous narcotic (opioid) infusions; Heparin infusions; Insulin infusions; Antineoplastic medications infusions Parenteral nutrition

14 An IDC also needs to be performed when 1. Complex medication processes or calculations are required 2. Caring for high-risk patient populations 3. Patient-specific High Alert Medications (HAM) are unusual for that area 4. Dose Error Reduction pumps are not available 5. Administering medication in non-standardized concentrations

15 An IDC also needs to be performed when 1. Best practice dictates 2. A medication has consistently been associated with medication errors in a specific program and this is an appropriate safety strategy 3. Requested by another health care professional 4. At the health care professional s discretion

16 HOW: 2 Health Care Professionals Two health care professionals shall independently verify the: most current order; patient s relevant laboratory values and/or diagnostic results medication dosage calculations (if required) line and tubing verification as per Covenant corporate policy There is NO communication of findings Results are shared only when both health care professionals (HCP) have completed their verification independently of each other.

17 IDC Policy Rights Medication Administration Medication Rights Right patient Right medication and formulation Right reason Right dose Right time Right route Right documentation Right to refuse a medication Pump Programming Rights Right infusion pump type/tubing Right software (use dose error reduction software if available) Right version and right profile using the most up-to-date version/correct profile Right infusion pump program settings (values entered into pump) Right solution/medication Right concentration /volume/rate

18 In the event of a discrepancy: The IDC is repeated by both Health Care Professionals If a discrepancy still remains a third Health Care Professional is consulted If the discrepancy is unresolved then the first Health Care Professional is required to consult the prescriber to clarify

19 HOW: 1 Health Care Professional working alone Medication checked by Pharmacy Preferred if working alone Health Care Professional performs role of second professional Medication NOT checked by Pharmacy Performs both roles independently Performs another task for 5 minutes Return and repeat the required steps Remote access may be used to verify medication orders and infusion pump settings

20 HOW : The final steps Infusion Pump no dose error reduction software available Documentation clinical documentation of IDC is required may include: HCP signatures, initials, names date and times of IDC Reporting use the Reporting and Learning System (RLS) to report adverse events or close calls

21 Tips for Success Minimize distractions and interruptions while preparing medication Prepare medications for one patient at a time Consult the prescriber if you have any doubts about a medication order Please ensure that the Infusion Line and Tubing Verification Policy is followed for all infusions which includes all the mandatory classifications of the Independent Double Check Policy

22 CH Algorithm one professional and two professionals

23 Learning Resources for Staff: Independent Double Check policy & procedure **new** Medication Safety An Overview PowerPoint at: 8/pages/pagelistview/pgcnt High Alert Medications (HAM) education module should be reviewed at: 8/pages/pagelistview/pgcnt

24 References / Resources Duke University: types of errors: Duke University Systems to Reduce Errors: Medication Errors: Definition and Classifications: Vincent, C.(2010). Human error and systems thinking: In C.Vincent, Patient Safety.(pp ) London,UK. Wiley- Blackwell Vincent, C.(2010). Human Error and Systems Thinking. In Patient Safety, Churchill Livingstone; 2010 Canadian Patient Safety Officer Online Program. ( 2014).Unit 3 Human Factors Designed For Patient Safety. Ontario : Author Canadian Patient Safety Institute

25 Resource Videos for Medication A medication error AHS educational slide share re=youtu.be

26 Picture by Danielfoster Hakui Deck 437