Medication Safety 2013: Stony Brook Medicine Joseph D DeCristofaro, MD Assistant Medical Director for Patient Safety and Quality joseph.decristofaro@stonybrookmedicine.edu
Why is this topic so important? Medical Errors are common and often preventable Institute of Medicine Report (IOM) 1999: Estimated that 44,000-98,000 annual deaths are a result of medical errors Medication errors top this list Two percent (2%) of admissions experience an adverse drug event (ADE) that results in an increased length of stay and nearly $4,700 for the cost of each event
IOM: 2006 Updated report from IOM: Estimated that 1.5 MILLION people are harmed each year as a result of a Medication Error Focus ought to be on PREVENTION
Definition of Medication (Joint Commission) Any prescription medications Sample medications Herbal remedies Vitamins Nutriceuticals Over-the-counter drugs Vaccines Radioactive medications Respiratory therapy treatments Blood derivatives Parenteral nutrition Intravenous solutions (plain, with electrolytes and/or drugs) Diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions Any product designated by the Food and Drug Administration (FDA) as a drug. This definition of medication does not include enteral nutrition solutions which are considered food products, oxygen, and other medical gases.
What Is A Medication Error? Adverse Drug Event (ADE) = Medication Error: Any preventable event that may cause or lead to an inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. At Stony Brook, ADE s are reported on the patient safety net (PSN) website. Every medication error is reviewed and changes have been made to processes or systems to prevent future errors.
Why are Medication Errors so Common? The process of medication ordering and dispensing is complicated. There are many steps: The medication order is written Nurse transcribes the order Delivered to the pharmacy Pharmacist transcribes the order Pharmacist prepares the medication Delivered to the point of care Administered to the patient With many hands along the way
CPOE Prevents Medication Errors by Eliminating Steps in the Medication Process: The medication order is ordered by computer Nurse transcribes the order Delivered to the pharmacy Pharmacist transcribes the order Pharmacist prepares the medication Delivered to the point of care Administered to the patient
Examples of Medication Errors Prescribing incorrectly (most common before CPOE) Omission Wrong time Wrong administration technique Wrong patient Wrong route Wrong dosage form Wrong drug preparation Improper dose/quantity Unauthorized drug Source: USP Pharmacopeia
What is an acceptable error rate? No benchmarks in medicine, but zero is the goal Relate safe to other industries 99.9% safe means: 84 unsafe plane landings per day 16,000 lost pieces of mail per hour 32,000 bank errors per hour
Paradox Regarding Error in Medicine Zero error standard Inherent toxicity with medication use Unwillingness to accept that healthcare workers are human and make mistakes Errors result in a paralysis of the healthcare workersreports are inconsistent and often go unreported. Unwilling to report to avoid trouble Prevention strategies are difficult to develop and sustain
The biggest challenge is to get people in hospitals physicians, pharmacists, nurses and administrators to recognize that errors are system problems NOT people problems. -----Lucian Leape Professor, Harvard School of Public Health
How do we prevent errors? Standardize the medication system Simplify the process Evaluate processes at risk before an error occurs (human factors engineering, redesign, use failure mode effects analysis [FMEA]) Make it difficult to err Report all errors to see where systems failed and make improvements on these processes
Cerner and CPOE Computerized physician order entry (CPOE) was implemented in 2009 The Cerner system involves several components including the pharmacy section (Pharmnet), the nursing section (e-mar), CPOE, surgical section (surginet), and powernotes. The paperless medical record is the goal, linking the ambulatory and hospital record computerized.
Commonly Used Cerner Order Functions 1. Cancel/Reorder 2. Copy 3. Delete 4. Cancel D/C 5. Modify 6. Suspend 7. Resume
Cerner Tutorials CPOE is not always self-explanatory The physician portal intranet page, bottom left under Education/Instructions Education / Instructions» CME Saturday: Lung Cancer Update 2011» CME Online (Continuing Medical Ed.)» Documentation Improvement Updts» EPR/STARS Cerner PowerChart»Education Videos»Job Aides» HANYS ACOG Fetal monitoring materials» Remote access setup instructions» Tracheostomy PowerPlan Cerner Educational Videos: How to order
Ordering Medications in Cerner Enter Patient Factors on admission before entering medication orders. If not, your orders will be rejected. Always use an order sentence or PowerPlan. You can modify these orders (dose, frequency). If you use an order sentence pick the drug name and route desired. Do not change the route, change the dose or frequency! Resources are available on line to check dosing (Lexi-Comp, Micromedex, NeoFax) and references may be available in the reference tab in Cerner
Frequency After finding the DRUG & ROUTE, choose a frequency from the drop down menu There are hospital standard times for dosing frequency Know what the standard times are when you order a medication BID is not the same as every 12 hours Now means at the time of order entry (STAT)
STAT MEDS When ordering any Medication STAT you must also notify the nurse or it may not be seen until the next round of care When you order the first dose now the second dose will follow the hospital frequency unless you change the time of the second dose. If you order Imuran now and q6h, the first dose is due immediately and the next dose could be due in the next hour following the hospital q6h schedule.
CPOE Alerts Cerner offers many different types of alerts for prescribers as they order medications. These many alerts can result in alert fatigue and result in the prescriber ignoring an important alert and result in a critical error. Read the alert before passing through it
Medication Reconciliation Admission medication orders starts with an accurate home medication list The Cerner system was designed to turn the list of home medications into new admission medication orders When medication orders are placed prior to the home medications, complete the admission medication reconciliation as soon as possible to avoid missing critical home medications (eg. patient with Myasthenia admitted for acute chest pain but Mestinon not ordered)
Medication Reconciliation The Joint Commission requires that medications are reconciled across the continuum of care This means a complete medication history is obtained upon entry into the organization The medications are reconciled with every transfer in level of care and between services Medications are reconciled at time for discharge A final list of medications is given to the patient and communicated to the next provider of care.
Safe Medication Use Medication safety processes in place: Look-alike Sound-alike (LASA) medications, found on the pharmacy website, are reviewed every year Tall man lettering is used to help distinguish between LASA medications (DOPamine and DOBUTamine) LASA meds are stored separately throughout the hospital Label all medications administered to patients ACLIPS is our list of high risk medications (Anti-coagulants, Calcium IV, Lanoxin IV, Insulin IV, Potassium IV rapid replacement, Sodium Chloride 3% IV) require additional attention Prohibited abbreviations cannot be used anywhere in the medical record (see next slide) Verbal orders are not accepted
Prohibited Abbreviations - 2013 Must Use: No zero after a whole number (e.g., 2 mg) Zero for all numbers less than one (e.g., 0.2 mg) Metric system (mg, grams, or g, etc.) Micrograms (written out), mcg µg Never Use: Trailing zero after a whole number (e.g., 2.0 mg) Decimal point without a leading zero (e.g.,.2 mg) Apothecary symbols (drams, grains, etc.) Units (written out) International Units Twice a week (designate days of week) Three times a week (designate days) Once Daily Every other day Morphine Sulfate U IU BIW TIW QD, Q.D., qd, q.d. QOD, Q.O.D., qod, q.o.d. MSO 4, MS Magnesium Sulfate MgSO 4
Patient Safety Concerns about Patient Safety should be reported to: - Immediate Supervisor - Department Head - Associate Director for Area - AD Patient Safety & Regulatory (4-1956) - CEO Office (4-2701 or fax 4-8925) - Patient Safety Officer Safety Hotline (4-Care) If your concerns have not been addressed, or if you prefer, you may contact the Joint Commission (TJC) at 1-800-994-6610 No disciplinary action will be taken because an employee reports safety or quality concerns to TJC *For concerns related to workplace safety please contact Jill Kavoukian EH&S 4-6783 24
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