Medication Error Reporting Program (MERP) Update April 2010 *********************************************
Overview and presentation of our readiness Opening PowerPoint completed and under review by Quality Management Pharmacy has complied data and highlight success story of Hospital-wide medication error reduction efforts Vulnerabilities identified Pharmacy Performance Improvement Plan
Opening PowerPoint presentation Part 1 Hospital demographics, affiliations, services, goals (18 slides) Part 2 MUSS (SFGH MERP Committee), reporting structure, MUSS activities related to MERP (5 slides) Part 3 Technology implemented that impacted medication safety (1 slide) Part 4 Success stories related to the technology (4 slides) Part 5 INLP impact on medication safety (3 slides)
San Francisco General Hospital and Trauma Center ) 4
A California Public Hospital SFGH is one of 19 public hospitals in CA Today, just 6% of hospitals that Provide nearly half of the hospital care to the state s uninsured Operate almost 60% of CA s trauma centers Operate almost 45% of the burn centers Serve 2.5 million patients per year During the economic crisis, the need for services is growing
SFGH is for everyone Only Trauma Center in San Francisco Care for 100,000 patients per year Provides 20% of all inpatient care in SF Only Psychiatric Emergency & Rehabilitation Services Referral Center for Healthy San Francisco, the health access program for the uninsured
University of California, San Francisco (UCSF) SFGH has partnered with UCSF for over 130 years through our teaching and research affiliation. Over 160 UCSF Principal Investigators conduct research at SFGH with an annual budget of $143M Over 1,300 UCSF employees on campus.
Clinical training at SFGH University of California, San Francisco Schools of Nursing, Pharmacy, Dentistry, and Medicine 350 3rd or 4th Year Medical Students, 800 Residents, 60 Clinical Fellows 32% of intern/resident training in 17 academic departments 35% medical student clinical training California State University System, Community colleges, private universities and colleges place approximately 200 clinical nursing students for rotations at SFGH.
SFGH PATIENT DIVERSITY FY 2008-2009 Age N=98,698 Sex Over 64 9% Under 18 13% 45-64 33% 18-24 11% Female 49% Male 51% 25-44 34% Asian/PI 21% Oth/Unk 5% White 24% Race Nat Amer 0% Hispanic 32% Afric-Amer 18%
Dedicated interpreter staff at SFGH provide services in over 20 languages: Spanish Cantonese Mandarin Russian Vietnamese Tagalog Cambodian Thai Arabic Amharic (Ethiopia) Portuguese Polish Burmese and more
Top 10 Discharge Diagnoses FY 2008-2009 1. Schizophrenia 2. Normal Delivery 3. Pneumonia Organism 4. Congestive Heart Failure 5. Chest Pain 6. Alcohol Withdrawal 7. Leg Cellulitis 8. Shortness of Breath 9. HIV Disease 10. Obstructive Chronic Bronchitis with Exacerbation
SFGH Services FY 2008-2009 Outpatient: 529,098 visits Inpatient: 15,405 admissions 103,313 patient days Skilled Nursing: average census 30 LOS 34 days
Acute Care for the Elderly (ACE) Special dedicated unit for post-op, medical, surgical and rehab patients Trained inter-disciplinary team emphasizes socialization, exercise, discharge planning, reducing pharmaceutical dependence Only ACE unit in California Currently 35 beds on two units
San Francisco Behavioral Health Center FY 2008-2009 Mental Health Skilled Nursing Facility Average daily census of 57 Mental Health Rehabilitation Center Average daily census of 45 Adult Residential Care Facility Average daily census is 41
Surgical Services Ten operating rooms 6,872 procedures performed - of which 48% were emergency 1,118,100 surgical minutes
Baby Friendly Hospital FY 2008-2009 SFGH named by World Health Organization as Baby Friendly in May 2007 Only Baby Friendly hospital in San Francisco 1 of 63 hospitals in U.S. 1,334 babies were born at SFGH 1,966 women received prenatal care, 25% high-risk
Trauma and Emergency FY 2008-2009 Over 53,000 Emergency Room visits 15% are admitted Over 7,200 Psychiatric Emergency encounters 26% are admitted SFGH receives 29% of all ambulance traffic in San Francisco 3,559 adults and children are treated for injuries requiring the trauma activation.
SFGH Goals FY 2008-2009 Promote patient safety Enhance clinical care Promote staff retention & recruitment Maintain hospital infrastructure Comply with all regulatory standards & attain specialty certifications Maintain services during hospital rebuild
VIEW FROM 23RD STREET
Performance Improvement and Patient Safety Reporting Pathway
Committees Involved in Medication Management Pharmacy and Therapeutics Committee Medication Use and Safety (MUSS) Formulary Review Subcommittee (FRS) Pain Management Subcommittee Nutrition Subcommittee Antibiotic Review Subcommittee Procedural Sedation Committee Clinical Laboratory/Therapeutics Committee Performance Improvement Patient Safety Committee (PIPS) Nursing Quality Improvement Coordinating Council (NQICC) CALNOC Integrated Nursing Leadership Program (INLP) Joint Nursing Pharmacy Committee
Medication Use and Safety Subcommittee (MUSS) Membership comprised of: Medical Staff, Nursing, Pharmacy, Respiratory Care Services, Radiology, Quality Management, Risk Management Duties/Responsibilities: Oversees the Hospital s MERP Review adverse drug events and medication unusual occurrences Develops and maintains medication management policies Discusses medication management safety processes including opportunities for improvement. Develops safety strategies including staff education Review pre-printed physician order forms that contain medication orders.
2009-3 2009-4 2009-2 MUSS Committee activities ADR summary REPORTED ADR BY QUARTER 180 160 140 120 100 80 60 40 20 0 QUARTER 2006-1 2006-2 2006-3 2006-4 2007-1 2007-2 2007-3 2007-4 2008-1 2008-2 2008-3 2008-4 2009-1 # OF ADR
MUSS Committee activities Med Error Review summary Total # of Med Error UO's by quarter (2007-2009 total = 1816) 250 # of UOs 200 150 100 125 170 139 119 107 109 107 175 148 199 222 196 50 0 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 2007 2008 2009
MUSS Committee activities Med Error Review summary (con t) Total Ordering Errors (Total UOs Reported = 161) Total Preparation Errors (Total UO's Reported = 428) # of errors 25 20 15 10 5 0 12 15 20 8 10 10 5 12 12 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 17 21 19 # of errors 90 80 70 60 50 40 30 20 10 0 14 28 27 15 3 11 26 52 54 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 73 48 77 2007 2008 2009 2007 2008 2009 Total Administration Errors (Total UO's Reported = 1452) Total Communication Errors (Total UO's Reported = 788) # of errors 200 180 160 140 120 100 80 60 40 20 0 180 168 139 132 140 105 121 100 97 89 97 84 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr # of errors 100 90 80 70 60 50 40 30 20 10 0 90 87 88 79 74 70 61 60 47 48 45 39 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 2007 2008 2009 2007 2008 2009
Technology implemented at SFGH that impacted Medication Errors 1. Invision/Lifetime Clinical Record (LCR) Medication Reconciliation Laboratory values & reports Allergies & Clinical Alerts 2. Siemens Rx system Patient profiles in Omnicell ADMs 3. Medication Administration Check & Communication (MAK) 4. Omnicell-Automated Dispensing Machines (ADMs)
Invision/LCR - Medication Reconciliation Electronic System
Medication Administration Check & Communicate (MAK) Electronic Medication Record Integrated in the Siemens Pharmacy system to facilitate electronic medication administration process using wireless technologies. Project Aim: Increase patient safety Decrease medication errors by 50% utilizing the electronic medication administration (MAK) program Computerized documentation achieves the following: Elimination of all transcription Pharmacy-entered orders are visible in real time Electronic communication between Nursing & Pharmacy in MAK, reduces phone calls Drug information library Lab data High alert medications require 2 nurse logons Specific drugs require data entry: pain score, pulse, BP, glucose Reminders for pain reassessments Injection site charting 28
MAK Outcomes Study on 5C Medication Administration Accuracy Errors were reduced on Unit 5C after introduction of MAK in September 2008 Error rate was 57% lower than the average error rate on comparison non-mak units at SFGH Overall Error Rate: Before and After MAK Implementation 12 11.9 10 9.1 8 6 % Errors Before % Errors After 4 2 2.3 1.3 0 4D 5A 5D 6A % 5C % 2007 Q1-2008 Q3 2008 Q4 2009 Q4
MAK Outcomes Study on 5C 2500 2184 0.9 0.8 0.875 2000 1500 1000 500 844 316 524 Number Observed Doses before MAK Number Observed Doses after MAK 0.7 0.6 0.5 0.4 0.3 0.2 0.15 0.6 % Wrong Dose Before % Wrong Dose After 0 4D 5A 5D 6A 5C 0.1 0 4D 5A 5D 6A % 5C % 0 0.9 0.8 0.7 0.825 3 2.5 2.6 2.4 0.6 2 0.5 0.4 0.3 0.2 0.1 0 0.2 0.4 4D 5A 5D 6A % 5C % 0 % Extra Dose Before % Extra Dose After 1.5 1 0.5 0 1 4D 5A 5D 6A % 5C % 0.3 % Omission Before % Omission After
CALNOC Collaborative Alliance for Nursing Outcomes Voluntary quality outcomes monitoring benchmarked anonymously to other like-sized California hospitals. Indicators: Medication Administration Accuracy Study (Med Pass) Study: Observe 100 medication passes for the following: -Patient Identification -Allergies -Patient Teaching -Distraction during Med Pass -Compares to MD Order, Med Admin Record (MAR) & Omnicell -Hand Hygiene -Charting All nursing areas of SFGH conduct Medication Administration Accuracy Studies
Administration Omitted Administrations Reasons for Omitted Medication Administrations (N=35 patients) NPO 15% Patient nauseated 14% Patient Refused 15% IV Site Used No reason charted 11% 3% Pt Off Unit 9% Not indicated per clinical parameters 11% Dose Administered 11% Held per MD Order 11%
Integrated Nurse Leadership Program (INLP) in Med-Surg The Integrated Nurse Leadership Program (INLP) is funded by the Gordon and Betty Moore Foundation and is directed and administered by the Center for the Health Professions at the University of California, San Francisco. INLP aim is to transform the hospital work environment and improve nurse-related patient outcomes through developing nurses professionalism, while enhancing their capacity to create and lead sustainable systems change. SFGH the INLP focus has been on Medication Safety including this unit projects: 4B - Decrease high alert medication errors that could be prevented by 2 RN checks by 50% in 2009. 4D - Reduce medication errors related to antibiotics to 80% by Jan 2009. 5A - Increase and sustain number of medication administration without interruptions to 90% by June 30, 2009. 5C - Maintain 95% compliance of No Interruptions during Preparation and Administration of Medications Using the New MAK System by February 2009. 5D - Decrease medication error related to heparin SQ and IV administration by 100% and decrease interruptions during medication administration by 90% in six months. 6A - To conduct 100% allergy screening with every medication administration by June 30, 2009.
Potential vulnerabilities Policy and Procedures Revision to be completed by April 23, 2010. Timely review of UO Aim is 100% reviewed and addressed by April 23, 2010 Collation of all medication errors Have ME, ADR data but need more order entry errors Omitted dose Clinical pharmacists start reviewing charts for omitted dose on April 19, 2010
2010 Pharmacy Performance Improvement Plan 1. 100% of medication orders are entered in the correct patient s profile by April 2010 2. Reduce interruption by 50% during order entry by encouraging the use of RN-Pharmacy Communication form by Oct 2010 3. 90% of orders will have a 30 minutes turn around time by July 2010 4. Implement pop-up alert window in Omnicell to assist nurses prior to administration for all highalert meds by July 2010
2010 Pharmacy Performance Improvement Plan (con t) 5. 100% of units with clinical pharmacist assignment Verify pharmacy profile, MAR and MD orders for discrepancies starting May 2010 6. Implement medication alerts for 100% of MAK units for high alert meds by Sept 2010 7. Implement Omnicell biometrics feature sign-on in 50% of inpatient nursing units by Dec 2010 8. Implement TallMan lettering in Omnicell for 100% of ISMP medication list by April 2010 9. Increase order entry error data reporting by 50% by June 2010