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 purpose of this activity is to evaluate the institution s performance regarding medication management and use processes related to several Joint Commission (TJC) standards. One focus is on the management of intravenous promethazine, which is on the Institute for Safe Medication Practices high alert list and a Joint Commission high alert standard 1 (MM.01.01.03). Patient safety issues and outcomes resulting from implementation of the intravenous (IV) promethazine use policy were reviewed. The utilization of medication reconciliation forms was reviewed to assess the accuracy of communicated patient medication information (NPSG.03.06.01). Standards related to clear and accurate medication orders (MM.04.01.01) were reviewed including the use of inappropriate abbreviations (MM.02.02.01), therapeutic duplications (MM.05.01.01), patient identifiers (NPSG.01.01.01), time interval range orders (e.g. q4 6h), and dose range orders (maximum dosage on range orders limited to 3x the minimum dose). In accordance with the standard that pharmacists must review appropriateness of orders, multiple PRN orders which may be viewed as therapeutic duplication (MM.05.01.01) were reviewed. Background The University of Mississippi Medical Center (UMHC) has developed policies and procedures to ensure that it meets the accreditation standards required by TJC. TJC standards must be met for hospital accreditation and review of these help institutions identify areas of the medication use process that may require improvements. 2 One of the recent policies effective April 2010 was created to help meet TJC standard (MM.06.01.01) regarding safe administration of medications. UMHC created a policy restricting IV promethazine use due to the addition of a FDA black box warning regarding potential serious tissue injuries with the use of IV promethazine. UMHC has developed pre printed order sets that limit IV doses of promethazine to 12.5mg. Per the protocol, any doses greater than 12.5mg on the order set will be regarded as 12.5 mg by pharmacy. Doses greater than 12.5mg must be handwritten with the max single dose being 25 mg. All promethazine must be diluted with at least 10mL of normal saline and given over 1 2 minutes via a large vein at or above the elbow or knee. This review determined if the policy is effective in reducing risk of potential harm to patients. Appropriate use of medication reconciliation (Med Rec) forms is necessary to improve patient safety by preventing medication errors and improving communication and continuity of care between providers. This aligns with TJC s National Patient Safety Goal (NPSG.03.06.01) to record and pass along correct information about a patient s medicines. Also, reconciliation is needed to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions and should be performed at each transition of care. UMHC utilizes a variety of three forms to accomplish this goal: inpatient admission Med Rec form, inpatient transfer/discharge Med Rec form, and outpatient/emergency Department Med Rec form.
Page 2 of 9 According to NPSG.01.01.01, TJC requires at least two patient identifiers when providing care, treatment, and services. Also, TJC requires that medication orders be clear and accurate (MM.04.01.01); therefore, UMHC has policies and procedures to reduce medication errors such as a list of inappropriate abbreviations (Table 1), to eliminate time range orders by processing time ranges as the shortest duration, and to restrict dose range orders to 3x the minimum dose. All inappropriate abbreviation and time or dose range orders must be clarified with the physician. Inappropriate orders that were clarified by a pharmacist were recorded. TJC discourages therapeutic duplications which may be viewed as multiple PRN orders with the same indication. Often there are several pain and/or nausea medications available as PRN orders on a patients medication administration record. Reviewing PRN medications within patients charts for indications will help to identify if physician orders differentiate between multiple PRN pain or nausea medications so that nurses can easily determine which medication to select. Appropriate patient identification, abbreviations, and orders are needed to eliminate medication errors. TJC utilizes a scoring system (Table 2) to determine an institution s compliance with its standards. Evaluation of UMHC s compliance with our own policies and procedures, as well as accordance with TJC Standards, will help our institution to improve medication utilization and patient safety. Table 1: UMHC Inappropriate Abbreviations 3 Abbreviation Potential Problem Preferred Term U, u Mistaken as zero, four or Write unit Cc IU Mistaken as IV Write international unit (intravenous) or 10 (ten) Q.D., QD, q.d., qd, Q.O.D., QOD, q.o.d., qod Mistaken for each other. The period after the Q can be mistaken for an I and the O can be mistaken for I Write daily and every other day Trailing zero (X.0), Lack of Leading zero (.X) MS, MSO4, MgSO4 Decimal point is missed Confused for one another. Can mean morphine sulfate or magnesium sulfate Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal Write morphine sulfate or magnesium sulfate Table 2: TJC Scoring Scale 4 0 3 or more occurrences Insufficient compliance 1 2 occurrences Partial compliance 2 1 or no occurrences Satisfactory compliance
Page 3 of 9 Methods From December 2 nd 29 th, a total of 100 charts were reviewed for the following within the first 96 hours of medication orders: inappropriate abbreviations, use of time/range orders, prn order duplications (specifically for pain and nausea), and patient identifiers. Also, whether incorrect orders were clarified was noted. Patient charts were included from all areas of the hospital, excluding the Emergency Department (ED) and Day Surgery. Charts were randomly obtained to establish data by selection of 2 charts per area including: 2N, 2S, 3N, 3S, 4N, 4S, 5N, 5S, MICU, SICU, CCU, BMT floor and each Batson floor with admitted patients (PICU, 2 nd, 3 rd, 4 th, 5 th ). Charts were selected by choosing the lowest and highest floor numbers occupied at selection time, and excluded if the patient had not been admitted for greater than 96 hours. The ED was excluded from review since it has stricter guidelines for promethazine use and patients will not be admitted in this area for > 96 hours. Also, day surgery areas were excluded because patients may receive promethazine from the dispensing unit without a written order. If the first 96 hours of patient stay were not found within the chart, this chart was excluded and the next lowest or highest number chosen. Also, medication orders for the first 2 weeks were viewed to evaluate medication reconciliation forms. Proper promethazine use per the UMHC policy was evaluated using a Meditech report run for all active promethazine orders written on specified days (December 20, 27, and January 10). A maximum of 17 orders/day were evaluated each day until 50 charts were reviewed. On December 20, there were 81 eligible IV orders; therefore, every 4 th order was selected to evaluate. On December 27, there were 54 eligible IV orders; therefore, every 3 rd order was selected to evaluate. On January 10, there were 80 eligible IV orders; therefore, every 4 th order (up to 16 orders) was selected to evaluate. Results The results of this medication use evaluation (MUE) are displayed in the following tables and figures. Joint Commission Standards Figure 1: Joint Commission Standards Evaluated (n = 100) 2 Patient Identifiers Dose Range Orders Time Range Orders* Correct Charts Inappropriate Charts Number Clarified Abbreviations 0 20 40 60 80 100 *Three time range orders found in two charts
Figure 2: Inappropriate Abbreviations by Type and Location (n = 100) 16 TJC Standards for Medication Management MUE Page 4 of 9 # of Inappropriate Abbreviations 14 12 10 8 6 4 2 Peds ICU Adult Wiser 0 u, U, IU Q.D., QD, qd QOD Trailing zero Leading zero MS, MSO4, MgSO4 Abbreviation Type Table 3: Medication Reconciliation (Med Rec) Forms* (n = 100) Charts Reviewed ED Med Rec Only No Med Reconciliation Charts eligible for Screening 100 A Completed Information Received From 66/94 B Medication List Marked Complete 63/94 C Charts with No Meds 17/94 D Charts with Unavailable/Unresponsive 2/94 Complete Charts with Meds 75/94 E Charts with Meds Circled to Continue *Appendix A UMHC inpatient Med Rec Form 71/75 1 5 94
Figure 4: Charts with PRN Med listed on Med Rec Form (n = 42) TJC Standards for Medication Management MUE Page 5 of 9 15 PRN reason listed PRN reason not listed 27 *Appendix A UMHC inpatient Med Rec Form Figure 5: Nurse Verified Last Dose on Med Rec Form (n=75) Nurse Completed Section of Med Rec 22 RN verified last dose RN did not verify last dose 53 *Appendix A UMHC inpatient Med Rec Form
Figure 6: Physician and Nurse Verified Med Rec (n=94) TJC Standards for Medication Management MUE Page 6 of 9 Physician verfified 89 5 Yes No RN verified 85 9 0 20 40 60 80 100 *Appendix A UMHC inpatient Med Rec Form Table 4: Number of Charts with Active PRN medications for Nausea and Pain (n=45) >1 PRN pain med 32 Including APAP orders for pain or fever >1 PRN nausea med 13 # of PRN meds that had an indication 27/45 # of PRN meds that had a differing indication 13/27 indications # of PRN meds that were appropriately 13/45 documented within order section a a. Progress notes were not reviewed for indications
Page 7 of 9 Promethazine (n = 50) Figure 7: Pharmacy Compliance with Policy 25 20 23 22 15 10 Honored Correctly Honored Incorrectly 5 0 Order Set (n=27) 4 1 Handwritten Orders (n=23) *Appendix B Promethazine policy In accordance with the policy, pharmacists honored most non handwritten orders as 12.5mg; however, there were 4 of the 27 non handwritten ordered as 25mg and entered as 25mg (3 incorrectly honored in Wiser and 1 incorrect in the Adult hospital). Out of 23 handwritten orders, only 1 was handwritten as 25mg but honored as 12.5mg in the CCU. Figure 8: Promethazine Administration* (n=50) 40 35 36 30 25 27 20 15 10 5 0 14 Central Line 9 Peripheral at or above AC Yes No *Appendix B Promethazine policy
Page 8 of 9 Upon independent review of Meditech, there were 9 patients charged for promethazine out of 27 pts with incorrect peripheral IV access. Because the medication was retrieved, these nine patients were potentially administered promethazine incorrectly. Of note, all patients with incorrect peripheral IV access that were charged for promethazine were located in the adult hospital. Conclusion This evaluation reveals that there were some errors occurring that involve TJC accreditation standards. Upon review of UMHC s compliance with TJC standards, UMHC is noncompliant in regards to inappropriate abbreviations, time range orders, utilization of Med Rec Forms. These areas have more than 0 to 1 occurrence in each category and are thus noncompliant according to TJC. Specifically, there were a total of 16 inappropriate abbreviations (14 U s, 1 qd, and 1 lacking a leading 0) found in 100 charts. Also, there were three time range orders found in two charts. Only one chart was found to have an order sheet lacking two patient identifiers. None of the abbreviations, range orders, or patient identifier errors were clarified in the chart by pharmacy. There were several problems utilizing Med Rec forms and PRN indications. Overall, the appropriate inpatient Med Rec Forms are being printed and added to charts; however, only about 70% of these are being marked with who the information was received from and as complete, incomplete, unavailable, or no medications. Of the 94 complete charts, 80% had medications listed with 95% of these circled to continue or discontinue. There were only 32 charts with multiple active pain medications and 13 with multiple active nausea medications. Of the 45 charts with multiple PRN medications, there was an indication listed 60% of the time. However, only 29% had differing indications. UMHC is in accordance with TJC standards regarding patient identifiers and dose range orders as there were only 1 and 0 errors, respectively. Upon review of UMHC s compliance with the promethazine policy, there were errors made with interpretation of medication order and administration. In the adult hospital, there were nine patients that were potentially administered promethazine incorrectly (not all of the nursing staff in the adult hospital were interviewed). Despite some noncompliance with the administration of promethazine, there were no adverse events reported during the review period. The promethazine policy regarding order entry by pharmacy was not fully compliant. Recommendations Based on these results, the Department of Pharmacy Services recommends actions to improve compliance in several areas. Recommendation Additional education for providers to decrease the number of inappropriate abbreviations Additional education for pharmacy to get orders clarified and corrected CPOE order sets should have unique indications (i.e. for mild, moderate, or severe) for medications used for PRN indications Standardized, formal process to help nursing staff determine when to use medications with similar therapeutic indications is needed Action Dept of Pharmacy plans to share these findings with providers of UMHC Dept of Pharmacy to provide education to staff In progress Dept of Pharmacy plans to share these findings with Dept. of Nursing For instance, when both oral and IV route are available, then we recommend that oral be deemed as the preferred method unless otherwise indicated.
Page 9 of 9 Label comments for IV promethazine to improve communication for administration Warning label regarding appropriate administration to appear when promethazine removed from MedSelect Additional education for nurses on appropriate promethazine administration Complete The label comments state must only be given via large patent veins at or above the elbow or knee and infusions via the scalp are not allowed. Complete The warning label states must only be given via large patent veins at or above the elbow or knee and infusions via the scalp are not allowed. Dept of Pharmacy plans to share these findings with Dept of Nursing Dept of Pharmacy plans to share these findings with Nursing Dept. so that appropriate education can be accomplished References: 1. Institute for Safe Medication Processes: High Alert Medication List [Internet]. Horsham (PA): Institute for Safe Medication Practices; c2011. ISMP s List of High Alert Medications; 2008 [cited 2011 Sept 21]; [about 2 screens]. Available from: http://www.ismp.org/tools/highalertmedications.pdf 2. ASHP guidelines on medication use evaluation. Am J Health Syst Pharm. 1996; 53:1953 5. 3. The Joint Commission: National Patient Safety Goals [Internet]. Washington (DC): NPSG Additional Resources; c2011. Official Do Not Use Abbreviations List; 2011 Jun [cited 2011 Sept 21]; [2 p.]. Available from: http://www.jointcommission.org/assets/1/18/official_do_not_use_list_6_111.pdf 4. The Joint Commission: National Patient Safety Goals [Internet]. Washington (DC): Certification Fact Sheets; c2011. Facts about scoring and certification decisions for 2011; 2011 Aug [cited 2011 Sept 21]; [2 p.]. Available from: http://www.jointcommission.org/assets/1/18/scoring_accreditation_decisions_2011.pdf