Medication Safety Kim Donnelly, RPh Assistant Director, Pharmacy Services University of Washington Medical Center Affiliate Associate Professor University of Washington School of Pharmacy Objectives Review medication errors and pharmacy law. Review systems approach for analyzing and improving safety in the medication use process. Review recommendations from IOM report and Department of Health report. Safety Freedom from accidental injury Not all errors result in harm BOSTON GLOBE MARCH 23, 1995 DOCTOR S ORDERS KILLED CANCER PATIENT DANA-FARBER ADMITS DRUG OVERDOSE CAUSED DEATH OF GLOBE COLUMNIST, DAMAGE TO SECOND WOMAN 1995 Leape and Bates Incidence of Adverse Drug Events Prospective cohort study 6 month study (4031 admissions) Self reporting via RN s and RPh s, daily chart review by RN investigators. RICHARD KNOX, GLOBE STAFF Small Steps to a Safer Medication System 1
1995 Leape and Bates - Results Over 6 months, 247 ADE s and 194 potential ADE s identified 6.5 Adverse Drug Events per 100 non-obstetrical admissions 28% ADE s were preventable. Prescribing errors most common preventable error. Prescriber Defensive Layers in the Medication System Pharmacist Nurse Latent Medication System Errors Latent Error and the Preventable ADE Latent Errors handwriting incomplete information MAR transcription unclear labeling high workload etc Proximal Causes of Medication Errors Preventable ADE s Lack of knowledge of the drug Lack of information about the patient Violation of rules Slips and memory lapses Transcription Errors Faulty checking of identification Faulty interaction with other services Faulty dose checking Infusion pump & parenteral delivery problems Inadequate monitoring Drug stocking and delivery problems Preparation errors Lack of standardization Leape, Bates et al. JAMA 1995 Order Written (56%) Interpreted by Nurse Interpreted by Pharmacist Transcribed to MAR (6%) Prepared and dispensed (4%) Administered to patient (34%) Bates Data in Red Small Steps to a Safer Medication System 2
WAC 246-873-080 1999 Institute of Medicine Report Hospital Standards Drug Errors. All drug errors shall upon discovery be recorded in an incident report and reported to the prescribing practitioner and to the pharmacy. To Err is Human: Building a Safer Heath System. 44,000-98,000 hospital deaths per year in the US were due to medical errors. Call to health care organizations to give high priority to implementing safer medication-use systems. 1999 IOM Report Leapfrog Group Provide leadership Respect human limits in process design. Promote effective team functioning. Anticipate the unexpected. Create a learning environment. Large U.S. Health Care purchasers Develop a set of purchasing principles that promote patient safety and health care value. Physician order entry Evidence-based hospital referral Physician staffing in ICU 2000 Department of Health Report Increase prescription legibility Prescription drug labeling and packaging. Medication error reporting plans. Implement proven medication safety practices. (automation) Sound alike drugs. Patient education. JCAHO Patient Safety Standards Hospitals need to have integrated patient safety programs. Ongoing, proactive program for identifying risks to patient safety and reducing medical errors. Patients are informed about the outcomes of care including unanticipated outcomes. Small Steps to a Safer Medication System 3
JCAHO Standards Blame and move on approach Pharmacist must review all medication orders before nursing administration of drug. Formulary selection criteria includes: Potential for error in prescribing, preparation, dispensing and administration. Find out who did it. Blame the employee. Sanction the employee. Retrain the employee. Move on. Same error will happen again. Systems Approach Medication systems are extremely complex. Most errors occur when more than one step in the process breaks down. System analysis digs deep into the process to identify and understand what went wrong. Human Component to Error Humans make mistakes. Humans tend to err when relying heavily on memory and observation. System Oriented Approach to Med Error Reduction Multi-faceted approach Proactive Learning environment Track and analyze data Sentinel Event An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Root cause analysis a process for identifying the basic or causal factors that underlie variation in performance. Small Steps to a Safer Medication System 4
Standardization Physician Order Entry Preprinted order sets Avoid abbreviations Spell out units Equipment (infusion pumps) Verbal orders Prevents misinterpretation of handwritten orders. Provides decision support. Avoid double entry systems. DOH recommends eliminating all handwritten prescriptions by 2005 Automation Systems Automation Drug interactions Automated dispensing systems Allergy alerts Bar-code technology Duplicate therapy alerts Hand held devices Dose-range checking Drug therapy alerts High Risk Drugs Unit-Dose Medications Chemotherapy Neonatal\Pediatric doses Warfarin\Heparin Insulin Standardize and limit number of drug concentrations available. Avoid dispensing bulk items Do not floor stock concentrated electrolyte solutions. Small Steps to a Safer Medication System 5
Look-a-like medications Pharmacist on Patient- Care Team Leape, 1999 Rate of preventable prescibing ADE s decreased by 66% when pharmacist on ICU service. Look-a-Like\Sound-a- Like Medications Order entry alerts dopamine vs dobutamine Alert stickers Review storage of known sound-alike medications. Access to Patient Information Allergies Weight Labs Electronic chart Small Steps to a Safer Medication System 6
Patient Talk to patients about their medications. Involve patients in verifying or clarifying allergies. Give patients written/verbal information about medications. Listen to your patients. Pharmacy A key in medication safety Small Steps to a Safer Medication System 7