Constant Pursuit of Medication Safety. Geraldine Koh Chief Pharmacist

Size: px
Start display at page:

Download "Constant Pursuit of Medication Safety. Geraldine Koh Chief Pharmacist"

Transcription

1 Constant Pursuit of Medication Safety Geraldine Koh Chief Pharmacist 1

2 Alexandra Hospital 400 beds Multi discipline except Paeds & ObGyn Restructured in Oct 2000

3

4

5 Transformation

6 Creating A Safety Culture Patients are our primary focus Patients have ready access to quality care Standards of practice are safe, effective and efficient Embrace continuous improvement Prevent adverse outcomes through risk management patient safety measures

7 Swiss Cheese Model Some medication errors: Typing medications wrongly Not familiar with drug names ipharm system down Packing wrong medication Not detected Harm to patient

8 Potential Errors Before Prescription Reaches Pharmacy 1. Two patients with similar names 3. IMR with drug orders left at the nursing station by the doctor ERRORS HARM 2. Patients next to each other in the ward 4. Both patients are discharged and prescription mixed up All these mistakes can occur before the prescription is sent to the pharmacy

9 Safety in Standardization Standard Abbreviations List Reduce / Separate Look Alike and Sound Alike Medication Protocols Insulin, Dilution of GTN, Dopamine, Dobutamine, Heparin IV Administration Dilution and Infusion Charts Use of Programme able Pumps for Infusions

10

11

12 Safety in Proper Labelling TALL man lettering on drug labels Colour coded drug labels Drug Allergy labels Do Not Crush labels Central vs Peripheral TPN

13

14

15

16 Safety in Harnessing IT Encourage use of Electronic Prescriptions Drug Allergy Alerts Drug Interaction Alerts

17 Safety in Continuous Improvement Improvements to Inpatient Medication Record

18

19

20

21

22

23

24

25 Safety in Reporting Medication Error Reporting Near Misses Reporting Monthly Reports to Nursing Admin on various nursing interventions ADR Reporting

26 About 60 Drug Allergy reports monthly linked to National Central Database

27 Safety in Education Active involvement in training course for nurses e.g. orientation, induction, continuing education programmes to improve drug knowledge and reduce medication errors

28 Safety in Pharmacist Review Medication Reconciliation Dedicated ICU Pharmacist Pharmacists Review of Medication Orders Anticoagulation Service Outpatient and Inpatient

29 Safety in Restricting Access Removal of Conc KCl from General Wards Introduced premixed KCl infusion bags Removal of concentrated electrolytes from General Wards Drug Allergy Status

30

31 Dr to TICK if no drug allergies. SN will not serve meds if allergy box NOT indicated

32 Safety in Audits Medication Audits Wards and SOCs Medication Use Evaluations Antithrombotic Workgroup Oversee anticoagulation use in the hospital Peri procedural bridging of anticoagulants

33 Medication Reconciliation Poor communication of medication information at transition points 50% of all medication errors in the hospitals up to 20% of adverse drug events

34 Medication Reconciliation Obtain complete and accurate list of each patient s current home medication Compare doctor s admission, transfer and discharge orders Discrepancies brought to attention of the prescriber Changes made accordingly

35 Before Patients are interviewed for medication history Doctors rely on previous discharge notes or electronic records for reference References may not be updated May not include any medication ordered by other doctors outside the hospital e.g. GPs

36 Pilot Started Jul 2005 Medication reconciliation interviews were conducted Within 24 hours of admission (weekends and PH excluded) At discharge, physical reconciliation of drugs also done

37

38 Results a) Total no. of medication reconciliation done 194 b) Total no. of new admissions in the same period 344 c) Number of drugs/line items missed by Dr 64 d) Number of errors in dosage/dose /frequency 101

39 Impact a) Potential adverse drug events (ADEs) prevented 18 b) Medication errors detected and prevented (165 / 344) 48% c) Potential ADEs detected and prevented (18 / 244) 5.2%

40 Critical Meds Missed Out Insulins* Tolbutamide* Hyzaar Metformin Lovastatin Enalapril Prazosin Combivent MDI* Galantamine Baclofen* Fludrocortisone* Midodrine* Digoxin Simvastatin ISDN Becotide MDI Salbutamol MDI* Prednisolone* Benzhexol* Losartan Amlodipine Glibenclamide* Amitriptylline Fluvoxamine Aspirin

41

42 At Discharge

43 Patient s own meds from home Dr s discharge prescription Staff working out the balance quantity to supply

44

45 BEFORE

46 TODAY Paper, 28 Jun 07

47 Innovations Conducting physical reconciliation upon discharge ensures patients go back with sufficient drugs and updating correct dosing Sorting out old medication and topping up adequate supply till next appointment reduce medication costs due to excess medication

48 Innovations Ziplocking old and new supplies together to reduce confusion Bedside dispensing and advising patients on which medication to continue or discard Developing inclusion criteria for patients with high risks for medication errors

49 Achievements Improve med safety, reduce potential harm Greater accuracy in medication history taking upon admission and discharge Prevented potential medication errors by 48% Prevented potential ADEs by 5.2% Direct savings on medication up to 50% by reducing excess supply Indirect cost savings on potential ADE reduction

50 Achievements Raised awareness of importance of effective communication between HCP Development of med recon model GP liaison ensure safe transfer of patient care Potential problems associated with incorrect med hx Closer collaboration between disciplines

51 Pilot Medication Reconciliation in an Outpatient Setting How to Improve Safety of Medication Administration in the HOME setting Started Aug 2008

52 OMR Workflow How to get patients to bring home meds? How to set up workflow to do physical reconciliation? Sees doctor Outpatient Visit Patient comes to the hospital Patient comes to Pharmacy Patient goes home

53

54

55

56

57 Sort! Re Label! Re labeling of medicines As is To be

58 Communication to Patient Patient Medication List Info carried by patients to other HCP

59 Results Cost Savings Through OMR Total Cost Savings (S$) Average savings: $2, per month Total savings: $13, Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Month

60 Post OMR Survey Patients' Satisfaction on OMR Service (N=51) Percentage Scale Very Useful

61 Post OMR Survey Patients' Willingness to Pay for OMR Service (N=51) Percentage Free <$2 $3-5 >$5 (Any Amount) FREE!! Amount of Fees

62 Moving Forward Medication List Patients to PRE COUNT their balance medication Pictures of medication and dosage instructions Different languages SMS patients to bring their home medication

63

64 Communicate Value of OMR Automatic calculation of cost savings Show patients upon dispensing

65 Individualized Patient Medication List

66 Self Administration of Medication Allows selected patients to administer their medication on their own, under supervision of staff nurses during their stay in the hospital.

67 Targeted Approach Targeting 2 groups of patients Patients who are relatively FIT and on simple medication Patients who are admitted for newly diagnosed conditions which need multiple chronic medication e.g. stroke, TIA AIMS: Patient Education Familiarize with medication regime improve compliance when return home

68 Workflow SN identify the patients and obtain consent Inform Pharmacy by noon Pharmacists involved have designated hour in the afternoon to do beside patient education and counselling

69 Short Term Goal Moving forward, to target Patients who are admitted for newly diagnosed condition who needs multiple chronic medication Benefits this group of patients the most Joint collaboration between Nursing and Pharmacy department

70 Khoo Teck Puat Hospital 550 beds Multi discipline INCLUDING Oncology, Paediatrics & Women s Health Opened 28 Mar 2010

71

72

73 Medication Safety A JOURNEY

74 NURSES CAREGIVERS DOCTORS PHARMACISTS PATIENTS / CUSTOMERS OTHER HCPS

75 Thank you

SPSP Medicines. Prepared by: NHS Ayrshire and Arran

SPSP Medicines. Prepared by: NHS Ayrshire and Arran SPSP Medicines Prepared by: NHS Ayrshire and Arran Medication Reconciliation: Story so far MR happening in primary care, acute adult, paediatrics and mental health Started in acute then mental health,

More information

Pharmaceutical Services Report to Joint Conference Committee September 2010

Pharmaceutical Services Report to Joint Conference Committee September 2010 Pharmaceutical Services Report to Joint Conference Committee September 21 Background: Pharmaceutical Services staffing has increased by 31 FTE from 26 due to program changes and to comply with regulatory

More information

Improving Safety Practices Anticoagulation Therapy

Improving Safety Practices Anticoagulation Therapy Improving Safety Practices Anticoagulation Therapy Katie Cinnamon, PharmD, BCPS Clinical Pharmacist Genesis Medical Center - Davenport Objectives Review background information on medication errors and

More information

Medication Reconciliation

Medication Reconciliation Medication Reconciliation Where are we now? Angie Powell, PharmD Director of Pharmacy Baxter Regional Medical Center Disclosures I, Angie Powell, have no relevant financial relationships to disclose. Learning

More information

APPENDIX 8-2 CHECKLISTS TO ASSIST IN PREVENTING MEDICATION ERRORS

APPENDIX 8-2 CHECKLISTS TO ASSIST IN PREVENTING MEDICATION ERRORS APPENDIX 8-2 CHECKLISTS TO ASSIST IN PREVENTING MEDICATION ERRORS Use the following checklists in the appropriate areas of your office, facility or practice to assist in preventing medications errors:

More information

MEDICINES RECONCILIATION GUIDELINE Document Reference

MEDICINES RECONCILIATION GUIDELINE Document Reference MEDICINES RECONCILIATION GUIDELINE Document Reference G358 Version Number 1.01 Author/Lead Job Title Jackie Stark Principle Pharmacist Clinical Services Date last reviewed, (this version) 29 November 2012

More information

Medication Safety Dashboard

Medication Safety Dashboard How Safe Are Your Patients? Creating a Meaningful & Actionable Medication Safety Dashboard By: Helga Brake, PharmD, CPHQ Patient Safety Leader Northwestern Memorial Hospital No Conflicts of Interest to

More information

Pharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02

Pharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02 Pharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02 V02 issued Issue 1 May 11 Issue 2 Dec 11 Planned review May

More information

Medication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety

Medication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety Medication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety Background The Institute of medicine (IOM) estimates that 1.5 million preventable Adverse Drug Events (ADE) occur

More information

Medicine Reconciliation FREQUENTLY ASKED QUESTIONS NATIONAL MEDICATION SAFETY PROGRAMME

Medicine Reconciliation FREQUENTLY ASKED QUESTIONS NATIONAL MEDICATION SAFETY PROGRAMME Medicine Reconciliation FREQUENTLY ASKED QUESTIONS NATIONAL MEDICATION SAFETY PROGRAMME The Process What is medicine reconciliation? Medicine reconciliation is an evidence-based process, which has been

More information

Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Objectives

Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Objectives Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Morgan Pendleton, PharmD, BCOP Hematology/Oncology Clinical Pharmacist Wake Forest Baptist Health Objectives Evaluate the need

More information

Importance of Clinical Leadership in Pharmacy

Importance of Clinical Leadership in Pharmacy Importance of Clinical Leadership in Pharmacy Rita Shane, Pharm.D., FASHP, FCSHP Chief Pharmacy Officer Cedars-Sinai Medical Center, Los Angeles Assistant Dean, Clinical Pharmacy UCSF School of Pharmacy

More information

Licensed Pharmacy Technicians Scope of Practice

Licensed Pharmacy Technicians Scope of Practice Licensed s Scope of Practice Adapted from: Request for Regulation of s Approved by Council April 24, 2015 DEFINITIONS In this policy: Act means The Pharmacy and Pharmacy Disciplines Act means an unregulated

More information

Medicines Reconciliation: Standard Operating Procedure

Medicines Reconciliation: Standard Operating Procedure Clinical Medicines Reconciliation: Standard Operating Procedure Document Control Summary Status: Version: Author/Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation

More information

South Staffordshire and Shropshire Healthcare NHS Foundation Trust

South Staffordshire and Shropshire Healthcare NHS Foundation Trust South Staffordshire and Shropshire Healthcare NHS Foundation Trust Document Version Control Document Type and Title: Authorised Document Folder: Policy for Medicines Reconciliation on Admission and on

More information

10/2/2017. Bozeman Health Deaconess Hospital Transition of Care Pharmacist Initiative. Problem. Problem

10/2/2017. Bozeman Health Deaconess Hospital Transition of Care Pharmacist Initiative. Problem. Problem Bozeman Health Deaconess Hospital Transition of Care Pharmacist Initiative KRISTAL BARKER, PHARMD EMILY STEED, PHARMD Problem Medical Error is the 3 rd leading cause of death in the United States http://www.bmj.com/content/353/bmj.i2139

More information

Go! Guide: Medication Administration

Go! Guide: Medication Administration Go! Guide: Medication Administration Introduction Medication administration is one of the most important aspects of safe patient care. The EHR assists health care professionals with safety by providing

More information

Consulted With Post/Committee/Group Date Senior Pharmacy Management Team May 2016 Professionally Approved By Jane Giles, Chief Pharmacist June 2016

Consulted With Post/Committee/Group Date Senior Pharmacy Management Team May 2016 Professionally Approved By Jane Giles, Chief Pharmacist June 2016 PMAR (PRESCRIPTION MEDICINE ADMINISTRATION RECORD) ENDORSEMENT BY PHARMACY STAFF CLINICAL GUIDELINE Register no: 10092 Status - Public Developed in response to: Local need Contributes to CQC 12 Consulted

More information

One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration

One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration Presented by: Marla Husch Northwestern Memorial Hospital Northwestern Memorial Hospital Chicago, Illinois

More information

All Wales Multidisciplinary Medicines Reconciliation Policy

All Wales Multidisciplinary Medicines Reconciliation Policy All Wales Multidisciplinary Medicines Reconciliation Policy June 2017 This document has been prepared by the Quality and Patient Safety Delivery Group of the All Wales Chief Pharmacists Group, with support

More information

Running head: MEDICATION ERRORS 1. Medications Errors and Their Impact on Nurses. Kristi R. Rittenhouse. Kent State University College of Nursing

Running head: MEDICATION ERRORS 1. Medications Errors and Their Impact on Nurses. Kristi R. Rittenhouse. Kent State University College of Nursing Running head: MEDICATION ERRORS 1 Medications Errors and Their Impact on Nurses Kristi R. Rittenhouse Kent State University College of Nursing MEDICATION ERRORS 2 Abstract One in five medication dosages

More information

The Joint Commission Medication Management Update for 2010

The Joint Commission Medication Management Update for 2010 Learning Objectives The Joint Commission Medication Management Update for 2010 U.S. Army Medical Command Fort Sam Houston, TX Describe most recent changes in The Joint Commission (TJC) Accreditation Program

More information

Identifying Errors: A Case for Medication Reconciliation Technicians

Identifying Errors: A Case for Medication Reconciliation Technicians Organization: Solution Title: Calvert Memorial Hospital Identifying Errors: A Case for Medication Reconciliation Technicians Program/Project Description and Goals: What was the problem to be solved? To

More information

Hospital & community differences. Goals of hospital pharmacists. Roles of Hospital Pharmacists. Clinical Pharmacy in Hospital Setting

Hospital & community differences. Goals of hospital pharmacists. Roles of Hospital Pharmacists. Clinical Pharmacy in Hospital Setting Hospital & community differences Patients eg critically ill, isolated, surgical Medical conditions eg oncology, transplants, infectious diseases Drugs and therapies eg injectable drugs, chemotherapy, parenteral

More information

Storyboard Submission NHS Wales Awards Title Improving Patient Safety How ABHB Ward Pharmacists Monitor Elevated INRs

Storyboard Submission NHS Wales Awards Title Improving Patient Safety How ABHB Ward Pharmacists Monitor Elevated INRs Storyboard Submission 1. Title Improving Patient Safety How ABHB Ward Pharmacists Monitor Elevated 2. Brief Outline of Context As part of the 1000 Lives Plus initiative, ward pharmacists throughout ABHB

More information

Medicines Reconciliation Policy

Medicines Reconciliation Policy Medicines Reconciliation Policy Lead executive Medical Director Authors details Senior Clinical Pharmacy Technician - 01244 39 7494 Document level: Trustwide (TW) Code: MP19 Issue number: 3 Type of document

More information

Ensuring our safeguarding arrangements act to help and protect adults PRACTICE GUIDANCE FOR REPORTING MEDICATION INCIDENTS INTO SAFEGUARDING

Ensuring our safeguarding arrangements act to help and protect adults PRACTICE GUIDANCE FOR REPORTING MEDICATION INCIDENTS INTO SAFEGUARDING Ensuring our safeguarding arrangements act to help and protect adults PRACTICE GUIDANCE FOR REPORTING MEDICATION INCIDENTS INTO SAFEGUARDING Contents Page 1.0 Purpose 2 2.0 Definition of medication error

More information

Medication Safety & Electrolyte Administration. Objectives. High Alert Medications. *Med Safety Electrolyte Administration

Medication Safety & Electrolyte Administration. Objectives. High Alert Medications. *Med Safety Electrolyte Administration Medication Safety & Electrolyte Administration Jennifer Doughty, PharmD PGY2 Pharmacy Resident Emergency Medicine Stormont Vail Health, Topeka, KS Objectives Define and identify high alert medications

More information

electronic Medication Management (emm) Innovation and Systems Research

electronic Medication Management (emm) Innovation and Systems Research electronic Medication Management (emm) Innovation and Systems Research Presented by Stephen Kalyniuk Senior Project Manager 1 Australian Commission on Safety and Quality in Health Care (ACSQHC) Implementing

More information

Using MEDMARX for Reporting and Benchmarking. Anne Skinner, RHIA Katherine Jones, PhD, PT

Using MEDMARX for Reporting and Benchmarking. Anne Skinner, RHIA Katherine Jones, PhD, PT Using MEDMARX for Reporting and Benchmarking Anne Skinner, RHIA Katherine Jones, PhD, PT Purpose of the Grant: Assist small rural hospitals to Voluntarily report and analyze medication errors Identify

More information

Influence of Patient Flow on Quality Care

Influence of Patient Flow on Quality Care Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District

More information

Pharmacy Medication Reconciliation Workflow Emergency Department

Pharmacy Medication Reconciliation Workflow Emergency Department Objectives of the Pharmacy Forum Page To become familiar with EPIC functionalities used in prior to admission (PTA) medication reconciliation (Section 1) 2 7 To understand the pharmacy technicians role

More information

How can the labelling and the packaging of drugs impact on drug safety? Prof. Pascal BONNABRY. Head of pharmacy. Swissmedic, Bern, June 19, 2007

How can the labelling and the packaging of drugs impact on drug safety? Prof. Pascal BONNABRY. Head of pharmacy. Swissmedic, Bern, June 19, 2007 How can the labelling and the packaging of drugs impact on drug safety? Head of pharmacy Swissmedic, To err is human (USA) Serious adverse events in 3% [2.9-3.7%] of hospitalizations 10% [8.8-13.6%] of

More information

University of Mississippi Medical Center University of Mississippi Health Care. Pharmacy and Therapeutics Committee Medication Use Evaluation

University of Mississippi Medical Center University of Mississippi Health Care. Pharmacy and Therapeutics Committee Medication Use Evaluation University of Mississippi Medical Center University of Mississippi Health Care Pharmacy and Therapeutics Committee Medication Use Evaluation TJC Standards for Medication Management March 2012 Purpose The

More information

Safe Medication Practices

Safe Medication Practices Safe Medication Practices Patient Safety: Preventing Adverse Events OHA Conference Renaissance Toronto Hotel at SkyDome Toronto June 14, 2004 David U President & CEO, ISMP Canada Agenda ISMP Canada Patient

More information

The Power of Quality. Lindsay R. Smith, MSN,RN Quality Manager Vanderbilt Transplant Center

The Power of Quality. Lindsay R. Smith, MSN,RN Quality Manager Vanderbilt Transplant Center The Power of Quality Lindsay R. Smith, MSN,RN Quality Manager Vanderbilt Transplant Center What do you think of when you hear the word quality? LEAN RCA PDSA QAPI SIX SIGMA PIP TQM 5s Objectives Transplant

More information

Medicine Management Policy

Medicine Management Policy INDEX Prescribing Page 2 Dispensing Page 3 Safe Administration Page 4 Problems & Errors Page 5 Self Administration Page 7 Safe Storage Page 8 Controlled Drugs Best Practice Procedure Page 9 Controlled

More information

Accreditation Program: Long Term Care

Accreditation Program: Long Term Care ccreditation Program: Long Term are National Patient Safety Goals indicates scoring category ; indicates scoring category ; indicates situational decision rules apply; indicates 2009 The Joint ommission

More information

Reconciliation of Medicines on Admission to Hospital

Reconciliation of Medicines on Admission to Hospital Reconciliation of Medicines on Admission to Hospital Policy Title State previous title where relevant. State if Policy New or Revised Policy Strand Org, HR, Clinical, H&S, Infection Control, Finance For

More information

SHRI GURU RAM RAI INSTITUTE OF TECHNOLOGY AND SCIENCE MEDICATION ERRORS

SHRI GURU RAM RAI INSTITUTE OF TECHNOLOGY AND SCIENCE MEDICATION ERRORS MEDICATION ERRORS Patients depend on health systems and health professionals to help them stay healthy. As a result, frequently patients receive drug therapy with the belief that these medications will

More information

Medication Administration & Preventing Errors M E A G A N R A Y, R N A M G S P E C I A L T Y H O S P I T A L

Medication Administration & Preventing Errors M E A G A N R A Y, R N A M G S P E C I A L T Y H O S P I T A L Medication Administration & Preventing Errors M E A G A N R A Y, R N A M G S P E C I A L T Y H O S P I T A L Principles of Medication Administration Talk with the patient and explain what you are doing

More information

Introduction of EPMA in paediatric practice in UK:

Introduction of EPMA in paediatric practice in UK: Introduction of EPMA in paediatric practice in UK: REALISING THE CLINICAL BENEFITS AND ENGAGING CLINICAL STAFF Stephen Marks Consultant Paediatric Nephrologist and EPMA lead Great Ormond Street Hospital

More information

MEDICATION USE EFFECTIVE DATE: 06/2003 REVISED: 2/2005, 04/2008, 06/2014

MEDICATION USE EFFECTIVE DATE: 06/2003 REVISED: 2/2005, 04/2008, 06/2014 TITLE / DESCRIPTION: SAFETY PROCEDURES FOR MEDICATION USE DEPARTMENT: Pharmacy PERSONNEL: All Pharmacy Personnel EFFECTIVE DATE: 06/2003 REVISED: 2/2005, 04/2008, 06/2014 Leadership and Culture A culture

More information

Aged residential care (ARC) Medication Chart implementation and training guide (version 1.1)

Aged residential care (ARC) Medication Chart implementation and training guide (version 1.1) Aged residential care (ARC) Medication Chart implementation and training guide (version 1.1) May 2018 Prepared by and the Health Quality & Safety Commission Version 1, March 2018; version 1.1, May 2018

More information

HIQA s Medication Safety Monitoring Programme in Public Acute Hospitals. One Year Later

HIQA s Medication Safety Monitoring Programme in Public Acute Hospitals. One Year Later HIQA s Medication Safety Monitoring Programme in Public Acute Hospitals One Year Later Sean Egan Head of Healthcare Regulation Health Information and Quality Authority Presentation outline Recap on the

More information

Maimonides Medical Center Makes a Quantum Leap with Advanced Computerized Patient Record Technology

Maimonides Medical Center Makes a Quantum Leap with Advanced Computerized Patient Record Technology Maimonides Medical Center Makes a Quantum Leap with Advanced Computerized Patient Record Technology Healthcare Information and Management Systems Society Electronic Poster Session CPR System Planning The

More information

Driving the value of health care through integration. Kaiser Permanente All Rights Reserved.

Driving the value of health care through integration. Kaiser Permanente All Rights Reserved. Driving the value of health care through integration February 13, 2012 Kaiser Permanente 2010-2011. All Rights Reserved. 1 Today s agenda How Kaiser Permanente is transforming care How we re updating our

More information

Preventing Adverse Drug Events and Harm

Preventing Adverse Drug Events and Harm Preventing Adverse Drug Events and Harm Frank Federico, RPh, IHI Executive Director Steve Meisel, PharmD, IHI Faculty March 27th,2012 12:00-1:00pm ET Beth O Donnell, MPH Beth O Donnell, MPH, Institute

More information

COMPASS Phase II Incident Analysis Report Prepared by ISMP CANADA February 2016

COMPASS Phase II Incident Analysis Report Prepared by ISMP CANADA February 2016 COMPASS Phase II Incident Analysis Report Prepared by ISMP CANADA February 2016 INTRODUCTION Incidents as part of COMPASS (Community Pharmacists Advancing Safety in Saskatchewan) Phase II reported by 87

More information

End-to-end infusion safety. Safely manage infusions from order to administration

End-to-end infusion safety. Safely manage infusions from order to administration End-to-end infusion safety Safely manage infusions from order to administration New demands and concerns 56% 7% of medication errors are IV-related. 1 of high-risk IVs are compounded in error. 2 $3.5B

More information

Influence of Patient Flow on Quality Care

Influence of Patient Flow on Quality Care Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District

More information

Medication Reconciliation Review

Medication Reconciliation Review The Medication Reconciliation Review tool provides step-by-step instructions for conducting a review of closed patient records to identify errors related to unreconciled medications. Organizations that

More information

Electronic Prescribing of Chemotherapy-It s Not a Video Game!

Electronic Prescribing of Chemotherapy-It s Not a Video Game! Faculty Disclosures Electronic Prescribing of Chemotherapy-It s Not a Video Game! Mary Mably has no disclosures Mary S. Mably, RPh, BCOP Pharmacy Oncology Coordinator, University of Wisconsin Hospital

More information

In-Patient Medication Order Entry System - contribution of pharmacy informatics

In-Patient Medication Order Entry System - contribution of pharmacy informatics In-Patient Medication Order Entry System - contribution of pharmacy informatics Ms S C Chiang BPharm, MRPS, MHA, FACHSE, FHKCHSE, FCPP Senior Pharmacist Chief Pharmacist s Office In-Patient Medication

More information

Clinical. Prescribing Medicines SOP. Document Control Summary. Contents

Clinical. Prescribing Medicines SOP. Document Control Summary. Contents Clinical Prescribing Medicines SOP Document Control Summary Status: Version: Author/Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key

More information

Safermeds Survey Report

Safermeds Survey Report We will work with patients, healthcare professionals and organisations to reduce patient harm associated with medicines or their omission Safermeds Survey Report National Medication Safety Programme May

More information

PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management

PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management Mission: To improve the health of the people of Connecticut through safe and effective medication

More information

SAFE Standard of Care

SAFE Standard of Care SAFE Standard of Care THE NEW UK STANDARD OF CARE BANISH MEDICATION ERRORS We all know that when medication is prescribed, dispensed and administered correctly it can dramatically improve the quality of

More information

COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE)

COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) Ahmed Albarrak 301 Medical Informatics albarrak@ksu.edu.sa 1 Outline Definition and context Why CPOE? Advantages of CPOE Disadvantages of CPOE Outcome measures

More information

Change Management at Orbost Regional Health

Change Management at Orbost Regional Health Change Management at Orbost Regional Health Our change management journey 1 Medication Change System Meds at Beds 2 The slightly exaggerated before process 3 Project Goals The purpose of the Meds at Beds

More information

Pharmacists in Transitions of Care: We Can All Make a Difference

Pharmacists in Transitions of Care: We Can All Make a Difference Pharmacists in Transitions of Care: We Can All Make a Difference Disclosure The speakers of this panel have no actual or potential conflict of interest in relation to this program to disclose. Kenda Germain,

More information

INQUEST INTO THE DEATH OF: MARIE TANNER

INQUEST INTO THE DEATH OF: MARIE TANNER INQUEST INTO THE DEATH OF: MARIE TANNER Details Name of Deceased: Marie Tanner Date of Death: January 21, 2002 Place of Death: Peterborough Regional Health Centre Cause of Death: Cardiac Arrest Caused

More information

The International Patient Safety Goals

The International Patient Safety Goals The International Patient Safety Goals Updated for 6 th edition Hospital Standards The International Patient Safety Goals What are The International Patient Safety Goals (IPSG)? Required as of 1 st January

More information

UHF Quality Institute. Patient-Reported Outcomes in Primary Care New York PROPC-NY. Module 2 Webinar

UHF Quality Institute. Patient-Reported Outcomes in Primary Care New York PROPC-NY. Module 2 Webinar UHF Quality Institute Patient-Reported Outcomes in Primary Care New York PROPC-NY Module 2 Webinar Lucy Savitz, Assistant Vice President for Delivery System Science, Intermountain Healthcare January 24,

More information

PERFORMANCE MEASURE DATE / RESULTS / ANALYSIS FOLLOW-UP / ACTION PLAN

PERFORMANCE MEASURE DATE / RESULTS / ANALYSIS FOLLOW-UP / ACTION PLAN Resident-to-Resident Assaults AIM: To decrease incidents of Resident to Residents assaults by 5% in the Fiscal Year (FY) 2011-2012. MONITORING: Data is collected from all instances in which State of California

More information

Medication Errors in Chemotherapy PORSCHA L. JOHNSON, PHARM.D. CLINICAL PHARMACIST II MEDSTAR WASHINGTON HOSPITAL CENTER SATURDAY, SEPTEMBER 17, 2016

Medication Errors in Chemotherapy PORSCHA L. JOHNSON, PHARM.D. CLINICAL PHARMACIST II MEDSTAR WASHINGTON HOSPITAL CENTER SATURDAY, SEPTEMBER 17, 2016 Medication Errors in Chemotherapy PORSCHA L. JOHNSON, PHARM.D. CLINICAL PHARMACIST II MEDSTAR WASHINGTON HOSPITAL CENTER SATURDAY, SEPTEMBER 17, 2016 DISCLOSURE STATEMENT I have nothing to disclose regarding

More information

Drug Distribution Services for Long Term Care Facilities. Susan L. Lakey, PharmD 1/11/06

Drug Distribution Services for Long Term Care Facilities. Susan L. Lakey, PharmD 1/11/06 Drug Distribution Services for Long Term Care Facilities Susan L. Lakey, PharmD 1/11/06 Drug distribution The process: Receipt / transcription of order Interpretation / evaluation of order Filling and

More information

3/9/2010. Objectives. Pharmacist Role in Medication Safety and Regulatory Compliance

3/9/2010. Objectives. Pharmacist Role in Medication Safety and Regulatory Compliance Pharmacist Role in Medication Safety and Regulatory Compliance Janet Greiwe Vice President, Systems Management Cleveland County Health System Objectives By the end of this presentation, you should be able

More information

Out of hours supply of medication by nurses on the children s ward.

Out of hours supply of medication by nurses on the children s ward. Out of hours supply of medication by nurses on the children s ward. Next review Page 1 of 5 Protocol: Executive Summary: Out of hours supply of medication by nurses on the children s ward. This protocol

More information

Nursing Home Medication Error Quality Initiative

Nursing Home Medication Error Quality Initiative Nursing Home Medication Error Quality Initiative MEQI Report: Year Five October 1, 2007 to September 30, 2008 MEQI A report on the fifth year of mandatory reporting of medication errors for all state licensed

More information

SELF - ADMINISTRATION OF MEDICINES AND ADMINISTRATION OF MEDICINES SUPPORTED BY FAMILY/INFORMAL CARERS OF PATIENTS IN COMMUNITY NURSING

SELF - ADMINISTRATION OF MEDICINES AND ADMINISTRATION OF MEDICINES SUPPORTED BY FAMILY/INFORMAL CARERS OF PATIENTS IN COMMUNITY NURSING CLINICAL PROTOCOL SELF - ADMINISTRATION OF MEDICINES AND ADMINISTRATION OF MEDICINES SUPPORTED BY FAMILY/INFORMAL CARERS OF PATIENTS IN COMMUNITY NURSING RATIONALE Medication errors can cause unnecessary

More information

WHAT are medication errors?

WHAT are medication errors? Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. webinars@thinkreliability.com www.thinkreliability.com Office 281-412-7766

More information

CRAIG HOSPITAL POLICY/PROCEDURE

CRAIG HOSPITAL POLICY/PROCEDURE CRAIG HOSPITAL POLICY/PROCEDURE Approved: P&T, MEC, NPC, P&P 03/09 Effective Date: 02/95 P&T, MEC, P&P 08/09; P&P 08/10; P&T, MEC 10/10, P&T, P&P 12/10 ; MEC 01/11; P&T, MEC 02/11, 04/11 ; P&T, P&P 12/11

More information

To prevent harm to patients from adverse medication events involving high-alert medications.

To prevent harm to patients from adverse medication events involving high-alert medications. TITLE MANAGEMENT OF HIGH-ALERT MEDICATIONS DOCUMENT # PS-46-01 PARENT DOCUMENT LEVEL LEVEL 1 PARENT DOCUMENT TITLE Management of High-alert Medications Policy APPROVAL LEVEL Alberta Health Services Executive

More information

Adverse Drug Events: A Focus on Anticoagulation Steve Meisel, Pharm.D., CPPS Director of Patient Safety Fairview Health Services, Minneapolis, MN

Adverse Drug Events: A Focus on Anticoagulation Steve Meisel, Pharm.D., CPPS Director of Patient Safety Fairview Health Services, Minneapolis, MN Adverse Drug Events: A Focus on Anticoagulation Steve Meisel, Pharm.D., CPPS Director of Patient Safety Fairview Health Services, Minneapolis, MN Fairview Health Services 6 hospitals, ranging from rural

More information

H2H Mind Your Meds "Challenge. Webinar #3- Lessons Learned Wednesday, April 18, :00 pm 3:00 pm ET. Welcome

H2H Mind Your Meds Challenge. Webinar #3- Lessons Learned Wednesday, April 18, :00 pm 3:00 pm ET. Welcome H2H Mind Your Meds "Challenge Webinar #3- Lessons Learned Wednesday, April 18, 2012 2:00 pm 3:00 pm ET 1 Welcome Take Home Messages Understand how to implement the Mind Your Meds strategies and tools in

More information

Objectives MEDICATION SAFETY & TECHNOLOGY. Disclosure. How has technology improved the way we dispense and compound medications AdminRx AcuDose Rx

Objectives MEDICATION SAFETY & TECHNOLOGY. Disclosure. How has technology improved the way we dispense and compound medications AdminRx AcuDose Rx MEDICATION SAFETY & TECHNOLOGY Objectives Identify technology that can improve medication safety and decrease medication errors Identify ways that technology can cause medication errors if used inappropriately

More information

The Impact of CPOE and CDS on the Medication Use Process and Pharmacist Workflow

The Impact of CPOE and CDS on the Medication Use Process and Pharmacist Workflow The Impact of CPOE and CDS on the Medication Use Process and Pharmacist Workflow Conflict of Interest Disclosure The speaker has no real or apparent conflicts of interest to report. Anne M. Bobb, R.Ph.,

More information

Moving the Green Medicines Bag from the Safety Agenda to QIPP

Moving the Green Medicines Bag from the Safety Agenda to QIPP Moving the Green Medicines Bag from the Safety Agenda to QIPP Jane Hough (ESEE Specialist Pharmacy Services) Fiona Eccleston (PSF Project Manager) Ed England ( Ambulance Service) Facts and figures 97%

More information

Supplementary Appendix

Supplementary Appendix Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology

More information

Electronic Prescribing and emar. Jonathan Sheldon Consultant Physician and Clinical Lead for Electronic patient records

Electronic Prescribing and emar. Jonathan Sheldon Consultant Physician and Clinical Lead for Electronic patient records Electronic Prescribing and emar Jonathan Sheldon Consultant Physician and Clinical Lead for Electronic patient records AIMS To discuss the support needed for the successful conclusion of this project To

More information

Medication Management Policy and Procedures

Medication Management Policy and Procedures POLICY STATEMENT This policy establishes guidelines for ensuring safe and correct management of client medications in accordance with legislative and regulatory requirements and professional practice competency

More information

4/28/2017. Medication Management for Improved Compliance & Home Care Satisfaction PREPARED FOR NEHCC Presenter. Overview

4/28/2017. Medication Management for Improved Compliance & Home Care Satisfaction PREPARED FOR NEHCC Presenter. Overview Medication Management for Improved Compliance & Home Care Satisfaction PREPARED FOR NEHCC 2017 Presenter Debra Demar, MS is the Community Liaison for White Cross Pharmacy, serving RI, MA and CT. She has

More information

National Patient Safety Goals from The Joint Commission

National Patient Safety Goals from The Joint Commission National Patient Safety Goals from The Joint Commission Objectives After completion of this module, participants will be able to: List at least five National Patient Safety Goals that are required in a

More information

Re-Engineering Medication Processes to Capitalize on Technology. Jane Englebright, PhD, RN Vice President, Quality HCA

Re-Engineering Medication Processes to Capitalize on Technology. Jane Englebright, PhD, RN Vice President, Quality HCA Re-Engineering Medication Processes to Capitalize on Technology Jane Englebright, PhD, RN Vice President, Quality HCA Who is HCA? % % % % U.K. % % % Switzerland % %% % % % % % %% % % % % % % % %% % % %

More information

PHARMACY IN-SERVICE Pharmacy Procedures for New Nursing Staff

PHARMACY IN-SERVICE Pharmacy Procedures for New Nursing Staff PHARMACY IN-SERVICE Pharmacy Procedures for New Nursing Staff OVERVIEW COMMUNICATION: THE KEY TO SUCCESS GOOD COMMUNICATION BETWEEN THE FACILITY AND THE PHARMACY IS ESSENTIAL FOR EFFICIENT SERVICE AND

More information

The Medication Safety Journey Natasha Nicol, Pharm. D., FASHP Director of Medication Safety June 4, 2009

The Medication Safety Journey Natasha Nicol, Pharm. D., FASHP Director of Medication Safety June 4, 2009 The Medication Safety Journey Natasha Nicol, Pharm. D., FASHP Director of Medication Safety June 4, 2009 About me I am someone s mother, wife, daughter, granddaughter, sister, aunt, cousin and niece. I

More information

POLICY AND PROCEDURE: MEDICATION

POLICY AND PROCEDURE: MEDICATION POLICY AND PROCEDURE: MEDICATION Cheshire does not administer medication. However, front line staff provide physical assistance with medication at the consumer/client s direction. (Exception: Cheshire

More information

2018 Hong Kong Pharmacy Conference. Strategic Planning for Pharmaceutical Services , Hospital Authority of Hong Kong

2018 Hong Kong Pharmacy Conference. Strategic Planning for Pharmaceutical Services , Hospital Authority of Hong Kong 2018 Hong Kong Pharmacy Conference Strategic Planning for Pharmaceutical Services 2017-2022, Hospital Authority of Hong Kong Ms Anna LEE Chief Pharmacist Hospital Authority Hong Kong 10 March 2018 Hospital

More information

High Returns Pharming COWS

High Returns Pharming COWS High Returns Pharming COWS HIC 2009 The Frontiers of Health Informatics * IM&TD, + Concord Repatriation General Hospital, Sydney South West Area Health Service, Sydney, NSW. Design & implementation of

More information

Completing the NPA online Patient Safety Incident Report form: 2016

Completing the NPA online Patient Safety Incident Report form: 2016 The National Pharmacy Association (NPA) Patient Safety Incident report form can be used within the community pharmacy to log patient safety incidents. The online form should not include any patientidentifiable

More information

Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use

Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use Our vision is to create a culture where patients and those who care for them are

More information

5th International Conference on Well-Being in the Information Society, WIS 2014, Turku, Finland, August 18-20, 2014

5th International Conference on Well-Being in the Information Society, WIS 2014, Turku, Finland, August 18-20, 2014 5th International Conference on Well-Being in the Information Society, WIS 2014, Turku, Finland, August 18-20, 2014 EVALUATION OF INTRAVENOUS MEDICATION ERRORS WITH INFUSION PUMPS Eija Kivekäs, MSc, RN,

More information

Mental Health Pharmacist Education. Medication Reconciliation Patient Safety Initiative

Mental Health Pharmacist Education. Medication Reconciliation Patient Safety Initiative Mental Health Pharmacist Education Medication Reconciliation Patient Safety Initiative August 2015 Introductions Agenda MedRec Project Overview Project Structure Implementation/Dates MedRec Basics What

More information

FIRST PATIENT SAFETY ALERT FROM NATIONAL PATIENT SAFETY AGENCY (NPSA) Preventing accidental overdose of intravenous potassium

FIRST PATIENT SAFETY ALERT FROM NATIONAL PATIENT SAFETY AGENCY (NPSA) Preventing accidental overdose of intravenous potassium abcdefghijklm Health Department St Andrew s House Regent Road Edinburgh EH1 3DG MESSAGE TO: 1. Medical Directors of NHS Trusts 2. Directors of Public Health 3. Specialists in Pharmaceutical Public Health

More information

Advanced Practice Provider (APP): Nurse Practitioner (NP) or Physician s Assistant (PA).

Advanced Practice Provider (APP): Nurse Practitioner (NP) or Physician s Assistant (PA). GEORGIA DEPARTMENT OF JUVENILE JUSTICE Applicability: { } All DJJ Staff { } Administration { } Community Services {x} Secure Facilities (RYDC and YDC) Transmittal # 17-15 Policy # 11.26 Related Standards

More information

Medication Error Reporting Program (MERP) Update. April 2010 *********************************************

Medication Error Reporting Program (MERP) Update. April 2010 ********************************************* Medication Error Reporting Program (MERP) Update April 2010 ********************************************* Overview and presentation of our readiness Opening PowerPoint completed and under review by Quality

More information

PURPOSE To establish a standardized process for the activity of an independent double check for medication administration.

PURPOSE To establish a standardized process for the activity of an independent double check for medication administration. PURPOSE To establish a standardized process for the activity of an independent double check for medication administration. POLICY STATEMENTS Health Care Providers will complete the independent double check

More information

UW HEALTH JOB DESCRIPTION

UW HEALTH JOB DESCRIPTION PHARMACY TECHNICIAN - PREPARATION Job Code: 510005 FLSA Status: Non-Exempt Mgt. Approval: B. Ludwig Date: 8-17 Department : Pharmacy HR Approval: CMW Date: 8-17 JOB SUMMARY The Pharmacy Technician Preparation

More information

Admission Medication History and Reconciliation Documentation. Froedtert Hospital, Milwaukee WI

Admission Medication History and Reconciliation Documentation. Froedtert Hospital, Milwaukee WI Overview of Medication History and Reconciliation Process 2 Overview of Icons Used in the Medication History 2 and Reconciliation Process The Admission Navigator 3 SureScripts Medication Reconciliation

More information