Most of you flew to this meeting

Transcription

1 Most of you flew to this meeting on an airplane and, like me, ignored the flight attendant asking you to pay attention and listen to a few safety warnings that were being offered. In spite of having listened, I had to be reminded to turn off my cell phone before departure and I had to be reminded to put my seat back in its upright position when we were landing. The point of this is that there are places with a culture of safety where people are held accountable for assuming personal responsibilities for what they do in high-risk situations like flying. Does that exist within healthcare? When patients are admitted in your hospital, do they receive the same kind of advice about the potential hazards that could happen to them that they might when they board an aircraft? The Institute of Medicine s (IOM s) report suggests that the answer to this question is no. 1 Patient education One of the surprising aspects of the IOM report is its focus on patient involvement, particularly in the inpatient setting. What are the implications of recommendations about the role that hospitalized patients can and should play? How can a patient who is admitted into an acute care hospital sick, maybe even Opportunities for pharmacy PHILIP J. SCHNEIDER unconscious be expected to be more involved in his or her care? The IOM encourages consumers to ask what drugs they are being given. 1 Patients often view themselves as passive witnesses to the care that they receive in the hospital, rather than being involved with their care. Some of the recommendations made in Preventing Medication Errors encourage consumers to be involved more in their care. 1 These recommendations include asking what drugs you are Purpose. To summarize key points from the most recent Institute of Medicine (IOM) report, Preventing Medication Errors, and their relevance to health-system pharmacists. Summary. Creating a culture of safety is an important antecedent to making changes needed to reduce medication errors. The patient can play an important, but often unrealized, role in preventing medication errors. There are considerable opportunities to improve the application of technology to prevent medication errors. The National Hospital Pharmacy surveys conducted ty the American Society of Health- System Pharmacists have demonstrated the slow rate of adoption of technologies. Pharmacists can play a leadership role in improving both the patients role and the use of technology to improve medicationuse safety. Conclusion. There are major opportunities for pharmacists to re-think how involved patients are in their care in the institutional setting, by seeing patients as building another check into the medication-use system and by recommitting ourselves to getting patients involved. There are also opportunities to help with patient-safety technology decisions. These extremely expensive technologies almost always involve people changing what they do and their implementation and use often involve other people besides pharmacists, yet the potential is great for new technologies to reduce medication errors. Index terms: Errors, medication; Hospitals; Institute of Medicine; Patient information; Pharmacists, hospital; Pharmacy, institutional, hospital; Quality assurance; Risk management; Technology; Toxicity Am J Health-Syst Pharm. 2007; 64(Suppl 9):S10-6 being given, not taking a drug without being told to, having a surrogate monitor if you cannot ask, asking about post-surgery consequences prior to surgery, and getting a complete medication list prior to discharge. If we think about the medicationuse system in the hospital and intercepting adverse drug events (ADEs), the nurse is often viewed as the last step. But the patient is really the last step in the process. So, it makes sense to have patients more involved in PHILIP J. SCHNEIDER, M.S., FASHP, is Clinical Professor and Director, Latiolais Leadership Program, College of Pharmacy, The Ohio State University, 500 W. 12th Avenue, Columbus, OH (schneider.5@osu.edu). Based on the proceedings of a symposium held December 3, 2006, during the ASHP Midyear Clinical Meeting in Anaheim, CA, and supported by an educational grant from Cardinal Health. Mr. Schneider received an honorarium for participating in the symposium and writing this article. Mr. Schneider has no financial relationships to report. Copyright 2007, American Society of Health-System Pharmacists, Inc. All rights reserved /07/0702-0S10$ DOI /ajhp S10 Am J Health-Syst Pharm Vol 64 Jul 15, 2007 Suppl 9

2 the medications they receive. It adds an additional double-check to the medication-use system and is an important strategic opportunity for us to improve patient safety. Patient involvement in the hospital consists of medication histories, self-medication programs, medication administration records, and education programs. There is literature showing that pharmacists can take medication histories better than physicians and nurses, yet because of workforce issues pharmacists rarely perform medication histories anymore. 2 In fact, we no longer ask this question in the ASHP National Hospital Pharmacy surveys. Instead, we ask about medication reconciliation, because that has been identified as a practice that is important to identify changes in drug therapy when patients are transferred from one point of care to the next. Medication histories are coming back, probably because of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. Self-medication programs were developed to teach patients how to take their medications before they were discharged. 2 These types of programs have a history in healthcare, but the number of institutions that have them is now relatively small. 2 There is an opportunity to get patients more involved in their care once again. One way is to provide medication administration records to patients so that they can follow along to be sure that the medicine that they are receiving is correct. Some clinicians are afraid to do this, because they are afraid that patients might catch them making a mistake. A better way to look at this is as building another double-check into the medication-use system. In many hospitals, entire departments have been devoted to patient education activities. 2 Based on data from the ASHP National Hospital Pharmacy surveys, pharmacy often is not involved in these programs. 2 Pharmacists may be members of a patient education committee or serve in an advisory capacity, but in the overwhelming majority of hospitals nurses are responsible for patient education programs. 2 When pharmacy directors are asked what determines whether a patient gets counseled about medications, the most frequent reason is a physician order followed by a patient request. 2 Some less frequent ways that patients are selected for patient education programs are focusing on specific targeted medicines, patients with a history of noncompliance, patients on newly prescribed medicines that they have not taken before, patients with certain diseases or taking medications with drug interactions, and patients who are taking a large number of medicines that might cause confusion. A very small number of institutions have a policy to counsel all patients about their medications. Most, however, use ways to select patients who might be most likely to benefit from patient education programs and perhaps target those medicines or those patients. One of the things to consider after reading this report is the extent to which pharmacists should be involved with patient education programs. Even for institutions that have such programs, patient education is not being provided for all patients. Technology The second major recommendation in the IOM report is to increase the use of technology to reduce medication errors. 1 The ASHP National Hospital Pharmacy surveys have tracked the adoption of technologies such as computerized prescriber order entry (CPOE), bar-code medication administration (BCMA), and smart pumps and demonstrated the slowness of change. 3 One of the important recommendations for healthcare providers is that a plan be in place to implement CPOE by 2008 and that this system be in place by 2010, with a caveat that it be well-designed. 1 Decision support that has information about patients and their medicines is what makes electronic transfer of information safer. Monitoring for errors, finding out where errors are common, and trying to learn from those mistakes are important. It is not possible to improve safety simply by purchasing a technology without having a culture of safety. Many of the bad experiences with technology have been the result of not having a culture of safety, not addressing the technology/human interface well, or attempting to implement a system in too short of a time period. 4 Failures happen at all steps in the medication-use system, such as prescribing (39%), transcription/ verification (12%), dispensing (11%), and nurse administration (38%). 5 One of the ways to focus attention on reducing medication errors might be to think about where the mistakes are most common. Interceptability or the discoverability of an error might be another way to establish priorities. Failure mode effects analysis is based on three principles: how often does an event happen, how likely is it to go undiscovered, and how likely is it to cause serious injury if it happens? The closer we get to the patient, the less likely an error is to be discovered. 6 Potential ADEs were intercepted upon physician ordering (48%), transcription/verification (33%), pharmacy dispensing (34%), and nurse administration (2%). 6 One of the ways to increase discoverability at the point of care is to get the patients more involved. The other is to apply technology, such as bar-code medication administration (BCMA), as an additional check before a medication is administered to a patient. Technology adoption How quickly are these technologies being adopted? The adoption of CPOE systems has been a challenge fewer than of hospi- Am J Health-Syst Pharm Vol 64 Jul 15, 2007 Suppl 9 S11

3 tals have implemented this technology (Figure 1). 3 What about safe drug distribution systems? Virtually all hospitals have adopted unit dose and i.v. admixture systems. 7 But now the emphasis has changed to improving the efficiency and even further adding to the accuracy of these systems, through either robotic centralized systems or automated dispensing cabinets that store medications closer to patients. Automated devices more accurately and efficiently compound sterile preparations in the pharmacy. 8 For drug administration programs, the lowest error rates that have ever been recorded was with a pharmacy-coordinated unit dose and drug administration system. 9 Error rates of less than 1% were documented, but this innovation was not widely adopted. 9 More recently, BCMA systems have been recommended, and the FDA has mandated bar codes be printed on all unit dose packages. 10 With i.v. medications, the current technology being recommended is the infusion pump with decision support (smart pump) that alerts or prevents nurses from administering doses that have the potential to harm patients. 1 Errors can be minimized at the bedside. Safe practices at the bedside include: 1) verifying patient's name by verbal questioning; 2) checking pre-medication orders; 3) checking the dose against the order itself; 4) Figure 1. Adoption of CPOE in U.S. hospitals. 4 % of Hospitals 8% 6% 4% 2% % 4.2% removing medications from their packaging right before they are administered to the patient; and 5) witnessing the dose being administered (Figure 2). This does not happen all the time because nurses take shortcuts while administering medications. 11 One of the ways to keep these double-checks in the system is a BCMA system. The adoption of this technology has been a little bit faster than CPOE systems and is now more than (Figure 3). 3 Smart pumps came along much more recently than CPOE and BCMA systems. 3 When implemented in a hospital, they are used throughout the hospital, rather than just in areas or for certain high-risk patients (Figure 4). 3 About one third of hospitals have adopted the use of smart pumps as a patient safety technology (Figure 5). 3 The uptake of smart pump technology appears to be happening at a little bit quicker rate than CPOE or BCMA systems. 3 With all of these technologies, the challenge for hospitals is deciding which one to implement first. There are two ways to think about this. First, where in the medication-use system are mistakes most common? The answer is in the drug ordering and drug administration steps. Second, where is an event least likely to be intercepted? The answer is during the drug administration step. Directors of pharmacy can play a role in helping to decide what to do 6.8% 8.9% first. Rogers found that the diffusion of innovation is a slow process. 12 It takes years before an innovation is widely adopted, and different innovations are adopted at different rates. The information from the ASHP National Hospital Pharmacy surveys shows that some patient safety innovations are being adopted at a faster rate than others. 3 Smart pumps are being adopted at the fastest rate, followed by BCMA systems. CPOE systems are being adopted at the slowest rate. 3 None of these technologies is a bad idea they are all recommended for improving patient safety. Reengineering the medicationuse system Another aspect of the diffusion of innovations is how the speed of adoption of a single innovation can be increased. One of the ways to increase the rate of change is to have either a published recommendation that becomes a standard of practice or an enforceable regulation. For example, medication reconciliation has been rapidly adopted, because JCAHO requires it. 13 It remains to be seen to what extent the new IOM report will increase the speed of adoption of patient safety technologies. Not every innovation is sustainable. An example of an innovation that was not sustainable was the pharmacy-coordinated unit dose and drug administration program, despite the evidence that it was a safer system. 13 Thus, there is a need to be discriminating in considering innovations and determining whether or not they will ever be widely adopted. Are CPOE systems an example of this? Is CPOE simply too hard to do? The recommendation from the IOM report acknowledges the difficulty, but it may be an innovation that does take years to achieve widespread adoption Trend toward decentralization One of the trends in pharmacy is S12 Am J Health-Syst Pharm Vol 64 Jul 15, 2007 Suppl 9

4 Figure 2. Increases in Safe Medication Administration Practices. 4 Patient name verified by verbal questioning or patient s arm band Pre-medication administration order checks (i.e., medication order and item checked before administration) Medications removed from unit dose packaging immediately before administration to patient Witness the patient take dose before documenting administration Not Surveyed in Hospitals with Safe Medication Administration Practice (%) Figure 3. Rapid Adoption of Bar-Code Medication Administration. 4 % of Hospitals 16% 14% 12% 8% 6% 4% 2% 1.5% 3.2% the recognition that unit dose and i.v. admixture programs, which are centrally based and labor intensive, create waiting times and delays that sometimes compromise patient care and nurse satisfaction. There is a trend to make use of technologies to decentralize drug dispensing systems so that medications are closer to patients. 14 There are still strong advocates for a centralized program, because there are fewer work-arounds and medications can be provided in ready-to-use form 4.4% 9.4% 13.2% more often. Despite this view, decentralized automated dispensing technologies are being adopted more quickly than centralized technology. 14 When directors of pharmacy are asked, What do you have now, and where would you like to be in your envisioned future?, there is an interest in moving toward a more decentralized drug distribution system (Figure 6). 14 There appears to be a fundamental shift in drug distribution in healthcare today, from centralized systems to decentralized systems. 14 This has implications for nursing and pharmacy workload and time management. Directors of pharmacy were also asked for their opinions about plans to adopt new technologies in patient safety. They were asked if the technology was already in place, or whether there was a plan to implement it within a year, one to three years, or more than three years, or if there were no plans to implement it at all. It will be interesting to see whether those numbers change after this new IOM report has been published. At least half of the hospitals will not meet the guideline of having a plan to implement CPOE by 2008, unless priorities are changed as a result of the recommendation (Figure 7). 15 Speeding the diffusion of innovations It is important to understand the diffusion of innovation, particularly the length of time that is required to adopt innovation. The IOM and JCAHO make good recommendations that are well thought out and important. The hard part is making the change. One role for leaders in pharmacy is to accept this, realize everything cannot be done at once, and Am J Health-Syst Pharm Vol 64 Jul 15, 2007 Suppl 9 S13

5 Figure 4. Smart Pump Implementation Throughout Hospital. 4 % of Hospitals with Smart Pumps Throughout the Institution < >=400 No. of Staffed Beds Figure 5. Smart Pump are Similarly Diffused in all but the Smallest Hospitals % of Hospitals with Smart Pumps < >=400 No. of Staffed Beds help make the tough choices about what to do first. It is important to realize two things: not every change is the same relative to its uptake and its feasibility, and it takes more time than people might think to make a change. These are very important principles to keep in mind. Even though many of these technologies affect activities that are primarily the responsibility of other people, namely, physicians who prescribe and nurses who administer medications, pharmacists have the expertise and ability not only to help evaluate which of these technologies should be adopted first and in what order, but also to help design the decision support that is necessary for these to work. Rogers noted some of the ways to speed the diffusion of innovations. 12 First, find sound innovations. Some institutions have had bad experiences, because they have purchased off-the-shelf technologies that might not have been configured in a way that really met the needs of the institution, or were not usable by the people that they were trying to help. Role modeling is one of the important strategies that can be used by thought leaders within an institution to drive behavior. Second, find the innovators, support them, and give them time to be trainers. This second step can be very important S14 Am J Health-Syst Pharm Vol 64 Jul 15, 2007 Suppl 9

6 Figure 6. Trend Toward Decentralization of Medications. 7 % of Hospitals Current State Envisioned Future Decentralized Centralized Figure 7. Medication-Use Safety Technology Plans Smart Pumps BCMA Inpatient CPOE No plans More than 3 years Between 1-3 years Within 12 months Have technology for the successful implementation of a technology that has the potential to improve patient safety but may not, if not introduced properly. Third, invest in early adopter activity and make success stories visible to the rest of the staff. For example, it might be useful to regularly tell the staff, Look at the number of errors that we ve prevented or Look at how many preventable events would have been prevented, if you would have used the decision support. This is a very powerful tool for making the benefits of using a technology observable. Fourth, trust and enable reinvention. One example is refining decision support information. If nine out of ten alerts do not really help the staff, they will not pay much attention to them. This will slow or even stop the adoption of an innovation, unless the decision support information is continually refined based on the experience of the staff and the information provided to them focuses on things that really add benefit. Thus, fifth, create slack for change. There needs to be time, not only for reviewing experience and making improvement, but for learning how to use these systems, rather than a big bang theory of expecting a system to be used right off the shelf. Finally, lead by example. Conclusion There are major opportunities for pharmacists to rethink how involved patients are in their care in the institutional setting, by seeing patients as another check in the medication-use system, and by recommitting ourselves to getting patients involved. There are also opportunities to help with patient-safety technology decisions. These extremely expensive technologies almost always involve Am J Health-Syst Pharm Vol 64 Jul 15, 2007 Suppl 9 S15

7 people changing what they do, and their implementation and use often involve other people besides pharmacists, yet the potential is great for new technologies to reduce medication errors. References 1. Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press Covington TR and Pfeiffer FG. The pharmacist-acquired medication history. Am J Hosp Pharm. 1972; 29: Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and Patient Education Am J Health-Syst Pharm. 2007; 64: Bates DW. Computerized physician order entry and medication errors: finding a balance. J Biomed Inform. 2005; 38: Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events implications for prevention. JAMA. 1995; 274: Leape LL, Bates DW, Cullen KJ et al. Systems analysis of adverse drug events. JAMA. 1995; 274: Crawford SY and Myers CE. ASHP national survey of hospital-based pharmaceuticals. Am J Hosp Pharm. 1993; 50: Johnson R, Coles BJ, Tribble DA. Accuracy of three automated compounding systems determined by end-product laboratory testing and comparison with manual preparation. Am J Health-Syst Pharm. 1998; 55: Shultz S, White SJ, Latiolais CJ. Medication errors reduced by unit dose. Hospitals - JAHA. 1973; 47(6): Traynor K. FDA to require bar coding of most pharmaceuticals by mid Am J Health-Syst Pharm. 2004; 61: Schneider PJ, Pedersen CA, Montanya KR et al. Improving the safety of medication administration using an interactive CD- ROM program. Am J Health-Syst Pharm. 2006; 63: Rogers EM. Diffusion of Innovations. New York; 1995: The Free Press. 13. Thompson CA. JCAHO views medication reconciliation as adverse-event prevention. Am J Health-Syst Pharm. 2005; 62:1528,1530, Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration Am J Health- Syst Pharm. 2006; 63: Bussard B, McAlearney AS, Pedersen CA et al. Adoption of technology to improve medication safety: Perspectives of Pharmacy Directors. J Pt Safety. 2006; 2:2(4): S16 Am J Health-Syst Pharm Vol 64 Jul 15, 2007 Suppl 9