Safety Way Beyond the 5 Rights JoAnne Phillips, MSN, RN, CCRN, CCNS, CPPS The University of Pennsylvania Health System Philadelphia, PA Current State. Of Chaos Prescriptions 12 per /person / year 4 BILLION / year Vaida Harm 1.3 million injuries year One death / day Adverse Drug Events (ADE) Definition an injury from a medicine (or lack of intended medicine) 1/7 $4 B 770,000 Ching, Ehlert 1
Adverse Drug Events Preventable? 56% of prescription related 34% administration related $4655 - $5857 Increase LOS: 3.23 4.6 Errors = Most common cause of harm during delivery of care Increasing complexity of certain medications Ubiquitous use of medications High rate of nonadherence with prescribed meds Increasing technology associated with medication administration Error Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Brady 2
Objectives. Need to go beyond 5 rights Identify the importance of complete patient information (height, weight, diagnosis, allergies, lab values, concurrent drug therapy, and literacy level) in safely administering medications. Discuss the impact of technology on safe medication administration, including computer provider order entry; automated dispensing machines; and IV/PCA pumps. Understand the impact of environmental issues, such as distractions and interruptions on safe medication administration and discuss strategies to mitigate these risks in their clinical environment. Cycle: Potential for Errors Administering Ordering Wrong dose Wrong drug Wrong route / form Transcribing Wrong: Dose Route Patient Time Drug Dispensing Wrong: Dose Route Patient Time Incorrect labeling Allergy / interaction Wrong Patient Dose Drug Time Route Infusion pump issue Pt. / Drug Info Staff Competency Orders Administration Environment Labeling Standard ization 3
Height & Weight Allergies Patient Information Lab values Literacy Concurrent therapy Source of truth Online Drug Info Pharmacists Apps ISMP Standards Drug Orders Emergencies Verbal Orders Write down, read back http://www.ismp.org/tools/guidelines/standardordersets.asp 4
Computer Provider Order Entry (CPOE) Formulary Support Basic Decision Support Advanced Decision Support Basic Decision Support Drug allergies Dosing guidelines 60% Rx errors dose and frequency Influencing factors: age, weight, liver & renal function Decreased variable dosing Choose from predefined lists Avoids mental slips Outpt may eliminate 42% of Rx errors, 53% of potential ADEs Advanced Decision Support Renal function Recommends decreased dosing when needed Age Cultures Assists with appropriate antibx ordering Labs Coags: prevents anticoagulation errors Chemistries: Prevents inappropriate electrolyte replacement orders 5
Formulary Decision Support Guide provider to formulary choices May only include meds on formulary Pop up for non-formulary choices Recommendations for meds in drug class Eg, H2 blocker Shortages Safety warnings from the FDA Kuperman Potential Risk CPOE Risks Result Entering a order can require dozens of clicks on a screen, increasing the amount of time required to complete an order Seems to add more work / take longer Providers may resist change Multiple screens increase chance of incorrect selection error Not enough computers Can create long lines, inefficiencies, increased opportunities for error due to miscommunication Server may be overloaded CPOE may crash, need down time plan TJC Perspectives on Safety, 2007 Look alike store separately Standard for labeling Labeling/ Packaging IV bags 2 sides Generic / brand name Ambulatory: reason for taking Unit dose 6
Concen trations High alert meds Standardize Meds in ADC Unit doses Interruptions Workflow Environment Orders to pharmacy? Med Room: Design, workflow Where are the medications? Med Calc Moderate Sedation Staff Competency Ongoing assessment New medications Technology 7
Literacy level Available in different languages Patient Education Who teaches? Resources written at appropriate level Why should I? QI & Reporting : how do I? Data to drive improve ments Feedback to reporter Solutions & Mitigating Strategies Technology Nursing Practice Systems Crew Resource Management Environment 8
Smart Pumps Safeguards Barcoding Check concentration, rate, time, dose and compliance with library Hard and soft limits Data reports on attempts to go beyond hard and soft limits Decision support Alerts, reminders, unit specific drug rates Smart Pumps Safeguards Eliminate free flow Enhanced programming Bolus feature Smart pumps aren t smart on their own!!! ISMP Med safety alert, April, 2007 Libraries: Key to Safety! Design and development is foundation of infusion pump safety Review of data to assess ongoing issues Key reason to encourage reporting of near misses Example: Alteplase 20 names 8 concentrations 7 variations in dosing units 8 variations in indications 9
Automated Dispensing Cabinets Advantages Easy access Decreased pharmacy request Disadvantages High rate of error Wrong dose, med, rate Inefficient stock control Pyxis Profile Only active medication orders that have been reviewed by a pharmacist can be removed from the machine by the nurse Prevents open access to medications by the RN Prevents errors with look alike sound alike medications Prevents wrong dosage form removal Enforces the 5 rights of medication administration Emergency Meds available through over ride Safety of Bar Code Scanning 14,041 medication administrations; reviewed 3082 order transcriptions Non BCMA Units BCMA Units 776 non timing errors 495 non timing errors 11.5% 6.8% 10
Safety of Bar Code Scanning 14,041 medication administrations; reviewed 3082 order transcriptions Non BCMA Units ADE 3.8% BCMA Units ADE 1.6% PCA Pumps: The Good, the Bad The Good Small frequent doses delivered as soon as the patient needs it The Bad. When PCA pumps are involved in med errors, chance for harm is 3.5 times greater The Ugly. PCA Errors Dosing errors (38%) a factor of 10 Wrong drug /wrong syringe (18%) Omission error (17%) Rx error (9%) Drug topics health system edition October 25, 2004 11
How PCA Errors Occur PCA by Proxy Improper patient selection Inadequate monitoring Inadequate patient education Drug product mix ups Practice related mixups Device design flaws Inadequate Staff Training Rx Errors ISMP Safety Alert, July 2003 Swiss Cheese Model Nurse A unsure how to program pump. Nurse A & B read directions, make 2 errors Programmed 0.5mg/ml not 5 mg/ml Connected tubing incorrectly Bupivicaine 0.125% Fentanyl mcg/ml Via epidural Demerol 25mg PACU Inadequate pain mgt Demerol 25mg x2 POD #1 POD #2: PCA (11:24AM) MS 5mg loading, max 15 PCA 2mg, 10 lockout, No 4 hour max 153 mg MS in 90 min Nurse C answers alarm, suspects problem, notifies nurse B. B changes conc to 5mg/ml. Pt still A/A/O with pain. Given extra 34mg MS Nurse D answers @17:00, change tubing set up, flushes IV with NS Pt immediately drowsy, pain 17:10 Anesthesia pain rounds Cyanotic, apneic, somnolent Narcan 0.4mg IV Patient recovered, transferred to PACU for further monitoring Data download, discovered error, disclosed to family Reason Technology: Not a Panacea!! Safe Admin & Technology CPOE Computer Provider Order Entry Robot Dispensing Infusion Pumps Automated Dispensing Cabinets Bar Coding PCA Pumps Clinical Decision Support Insulin Pain Chemo Patient / Epidural Pumps 12
Nursing Practice Distractions and interruptions Standardize Nurse Work Distractions and Interruptions Study on the relationship between interruptions and med errors Procedure failure (74.4% at least 1 procedural failure) Admin with no interruptions: 69.9% Admin with 3 interruptions: 84.6% Clinical error ( 25% had at least 1 clinical error) Admin with no interruptions: 25.3 % Admin with 3 interruptions: 38.9% Westbrook Distractions and Interruptions Distraction: Any interruption that is not safety or procedure related If the RN is giving a med and a another RN wants a double check Not distractions: Phone rings and you don t answer Someone asks you for a double check, you tell them you are giving meds Westbrook 13
Mitigation Strategies for Interruptions Sterile cockpit Using Crew Resource Management techniques errors decreased by 42.78% Do Not Disturb signs Vests, sashes, lights room management ADC management Challenge: All staff give their meds at the same time who is left to respond to other patient needs Need to plan for that Donahue; Fore Standardize Nurse Work 6 Steps 1. Compare medication with MAR / ADC a. Source of truth 2. Keep medication labeled from preparation through administration 3. Check 2 forms of patient ID 4. Explain the medication to the patient 5. Chart medication immediately after administering 6. Protect process from distractions Anything you can t do tomorrow? Ching Error Mitigation Strategies Ordering / Prescribing CPOE Allergy information Prohibit resume preop / home meds Unit based clinical pharmacists Dose adjustments for special populations Dispensing Bar code tracking Alerts built in Allergy documentation required before dispensing Pharmacist verification before dispensing Administering High risk (alert) medication policies in place Med admin records available at the bedside Bar code med administration Meds should not be removed from their containers before administration 14
Error Mitigation Strategies Monitoring Patient education to prevent errors after discharge Familiarity with monitoring of meds being administered Reporting 10-25% of medication errors are reported Keep staff informed of med error trends Encourage reporting of near misses Miscellaneous Keep staff informed of updates from ISMP, Sentinel event alerts, etc Evaluate medication administration process: environment, interruptions, etc Risk Reduction Strategies Forcing functions / constraints Automation / computerization Standardize and protocols Checklists and double check systems Rules and policies Education and information ISMP.org Environment room / storage location How does the nurse work flow match with the environment? Med carts Med rooms? 15
So Now What? What can you do tomorrow? Where do you stand with your data? Errors, near misses High alert meds? IV meds? Patterns with insulin, heparin, etc? Standardize nurse work: 6 steps Assess your environment Work with pharmacists, nurse leaders Incorporate nurse workflow Technology Evaluate data (eg, from smart pumps, PCA pumps, BCMA) Are you ready for the next level?? CPOE? BCMA? 1. Compare 2. Labels 3. Pt ID 4. Pt ed 5. Chart immediately 6. No distractions Questions? Thank you!! Joanne.Phillips@uphs.upenn.edu Safety Zone - Bibliography Brady, A., Malone, A., & Fleming, S. (2009). A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of nursing management, 17(6), 679-697. Cescon, D. W., Etchells, E. (2008). Barcoded medication administration: a last line of defense. Journal of the American Medical Association. 299, 2200-2202. Ching, J. M., Long, C., Williams, B. L., & Blackmore, C. C. (2013). Using Lean to Improve Administration Safety: In Search of the Perfect Dose. Joint Commission Journal on Quality and Patient Safety, 39(5), 195. Donahue, M., Brown, J. P., & Fitzpatrick, J. J. (2009). administration process assessment: applying lessons learned from commercial aviation. Journal of Nursing Administration, 39(2), 77-83. Ehlert, D. A., Rough, S. S. (2013) Improving the safety of the medication use process. In B. J. Youngberg (Ed). Patient Safety Handbook. (pp. 461 492). Burlington, MA: Jones and Bartlett. Fore, A., Sculli G.L., Albee, D., Neily, J. (2013). Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit based project. Journal of Nursing Administration, 21, 106-111. ISMP s Guidelines for Standard Order Sets: Retrieved from: http://www.ismp.org/tools/guidelines/standardordersets.asp. Kuperman, G. J., Bobb, A., Payne, T.H., et al. (2007). related clinical decision support in computerized provider order entry systems: a review. Journal of the American Medical Informatics Association. 14, 29-40. Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O.,... & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. Smart pumps are not smart on their own. (April 19, 2007) ISMP Safety Alert. Vaida, A. J., Lamis, R. L., Smetzer, J. L., Kenward, K., & Cohen, M. R. (2014). Assessing the State of Safe Practices Using the ISMP Safety Self Assessment for Hospitals: 2000 and 2011. Joint Commission Journal on Quality and Patient Safety, 40(2), 51. Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal medicine, 170(8), 683. 16