ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management Matthew Fricker, RPh, MS, FASHP Program Director, ISMP Rebecca Lamis, PharmD, FISMP Medication Safety Analyst, ISMP May 22, 2014 Objectives Discuss strategies to enhance the content of orientation and educational programs and staff competency evaluations Recognize the importance of a culture of safety within your organization and provide methods for identifying and analyzing risk Review the ICAHN aggregate self assessment results for these areas 2 Key Elements Key Element Mean % VI Drug Device Acquisition, Use, Monitoring 51% VIII Staff Competency and Education 55% I Patient Information 56% II Drug Information 56% IX Patient Education 63% X Quality Processes and Risk Management 63% IV Drug Labeling, Packaging, Nomenclature 65% III Communication of Drug Orders and Other Drug Info. 70% V Drug Standardization, Storage, Distribution 73% VII Environmental Factors, Workflow, Staffing Patterns 81% Total 63% 3 1
Rank Order of Error Reduction Strategies Strategy Fail safes and constraints Forcing functions Automation and computerization Standardization Redundancies Reminders and checklists Rules and policies Education and information Suggestions to be more vigilant Power (Leverage) High ( Blunt end ) Medium Low ( Sharp end ) 4 Staff Competency and Education Although staff education is a weak error reduction strategy alone, it plays an important role when combined with system based error reduction strategies Activities with the highest leverage include: Ongoing assessment of healthcare providers baseline competencies Education about new medications, non formulary medications, high alert medications, and medication error prevention 5 Problems with Staff Competency and Education Inadequate orientation process and baseline competency validation Competencies inconsistent throughout organization Lack of standardized, interdisciplinary education Inconsistent credentialing, training, and certification Lack of sharing information about errors (internal and external), their causes, and prevention 6 2
Core Characteristic #14: Practitioners receive orientation to medication use and undergo competency evaluations (57%) 7 What Should be Included in Orientation? Understanding of the entire medication use process Nurses spend time in the pharmacy Pharmacists spend time on patient care units Specific processes and procedures related to the provision of care, treatment, and services Technology training and assessment of use Medication errors and risk reduction strategies Staff is oriented to the key safety content before providing care, treatment, and services 8 Nurses Spend Time in the Pharmacy 173 During orientation, nurses spend time in the pharmacy (and with clinical pharmacists) to become familiar with the order entry and/or verification process, drug preparation and dispensing, availability of drug information resources, ways to access these resources, and various medication safety initiatives. 43% 50% 7% 9 3
Pharmacists Spend Time in Care Units 174 During orientation, pharmacists spend time in patient care units to become familiar with drug prescribing practices, unit stock storage conditions, medication administration procedures, and patient education processes. 29% 29% 43% 10 Pharmacists Participate in Medical Staff Orientation 175 Pharmacists actively participate in the orientation process for new medical staff (including medical students, medical residents, and attending physicians). 57% 29% 14% 11 Teamwork Training 183 The organization provides formal teamwork training (e.g., TeamSTEPPS) to all staff that incorporates elements of information sharing, conflict resolution, communication and teamwork skills, and clarification of team roles and responsibilities. 71% 21% 7% 12 4
Medication Error Information Provided During Orientation 172 During orientation and on a routine basis, staff participating in the medication use process, receive information about the hospital s actual error experiences as well as published errors that have occurred in other facilities; and they are educated about system based strategies to reduce the risk of such errors. 36% 50% 14% 13 Specialty Pharmacists/Nurses Undergo Training 176 All prescribers, pharmacists, and nurses who work in specialty areas (e.g., critical care, pediatrics, oncology) undergo extensive training and/or obtain certification if available in that specialty before working independently. 7% 57% 36% 14 Qualified and Trained Specialty Pharmacists 167 The organization has an adequate complement of well qualified and trained pharmacists to work in specialty areas or provide services to specialty populations (e.g., critical care, pediatric, neonatal, and oncology patients) that represent a substantial portion of the organization's patient population. 0% 21% 79% 15 5
Qualified and Trained Specialty Nurses 168 The organization has an adequate complement of well qualified and trained nurses to provide care to specialty populations (e.g., critical care, pediatric, neonatal, and oncology patients) that represent a substantial portion of the organization's patient population. 7% 7% 86% 16 Baseline Competency Evaluation 171 All new staff participating in the medication use process, including agency staff, undergo baseline competency evaluation before working independently. 29% 14% 57% 17 Topics to Include in Orientation and Baseline Competency Safe practices around medication use At risk behaviors Technology Error reporting/risk identification 18 6
Topics to Include in Orientation and Baseline Competency System based causes of medication errors High leverage strategies for risk reduction Examples of medication errors Internally reported Externally reported 19 Examples of Competencies for Nurses Consistently measure and document height and weight using the metric system (only) Demonstrate ability to communicate effectively, e.g., SBAR (situation, background, assessment, recommendation) i.e., verbalize the importance of sharing essential patient information between practitioner groups 20 Examples of Competencies for Nurses Order clarification process Utilize drug information resources as necessary Consistently use two unique patient identifiers Understand and utilize the correct procedure for an independent double check 21 7
Examples of Competencies for Pharmacists Verify all orders using the patient s complete profile before entering new orders or adjusting current medications Utilize laboratory parameters to evaluate the proper dosing of drug therapy Recognize appropriate (and inappropriate) therapy for patients based on their disease states and past history 22 Examples of Competencies for Pharmacists Clarify any incomplete or inappropriate orders with the prescriber Complete all steps in the checking process for IV preparations Additional checks required for high alert products? Technology Compounders Robotics Carousels 23 Examples of Competencies for Prescribers Need for complete orders Avoidance of dangerous abbreviations and dose expressions for all orders Use of mg/kg and total dose for pediatric/neonatal orders Formulary control Benefits of standardization Technology CPOE 24 8
Examples of At Risk Behaviors Accepting incomplete orders (verbal and written) Only repeating back telephone orders (not writing down/reading back) Administering medications without orders Not taking the MAR to the ADC or bedside Borrowing another patient's medications Not labeling syringes, bowels, etc. Mathematical calculations of doses not independently checked Use of dangerous abbreviations 25 Items on Error Reporting Organization s definition of a medication error What is reportable in your organization? Sentinel event Medication errors (reaching the patient) Close calls Error reporting procedures Reporting mechanism 26 Items on Error Reporting Methods for responding to errors Root cause analysis Proactive risk reduction activity (FMEA) Error reduction strategies How information is used 27 9
Core Characteristic #15: Provide ongoing education about medication error prevention and the safe use of drugs to staff (53%) 28 Identifying and Reducing Risk 194 Senior leaders, management, and frontline staff receive formal training in identifying risk within the system and incorporating high leverage errorreduction strategies to help eliminate the risk. 36% 36% 29% 29 Human Factors 193 Human factors and the principles of error reduction (e.g., standardization, use of constraints, redundancy for critical functions) are introduced during practitioner orientation, and used as the foundation for an annual mandatory educational program for all practitioners involved in the medication use process. 57% 29% 14% 30 10
Widespread Education 190 When errors occur, educational efforts are widespread among all practitioners who could make a similar error, rather than remedial and directed at only those practitioners who were involved in an error. 21% 36% 43% 31 Ongoing Medication Error Information 186 Practitioners receive ongoing information about medication errors occurring within the organization, error prone conditions, errors occurring in other healthcare facilities, and strategies to prevent such errors. 14% 43% 43% 32 Methods of Education Periodic medication safety tips via email Safety updates on the intranet or a medication safety website Storyboards or other poster formats to describe medication safety initiatives and results (often used at an annual skills day/employee updates) 33 11
Methods of Education Communication logs used to share safety tips in patient care areas Videos and computer based training courses Weekly multidisciplinary safety rounds with frontline staff and management involvement Simulation exercises 34 Simulations/Role Playing of Error Prone Conditions 192 Simulations of error prone conditions (e.g., problematic medication packages and labels, mock transcription/order entry of problematic orders) and/or role playing (e.g., to teach effective communication skills, inquiry skills, conflict resolution) are used as methodologies to orient and educate practitioners and other staff about medication/patient safety. 71% 29% 0% 35 Examples of Topics for Staff Education Safety strategies with high alert medications, for example opioids Opioid equianalgesic dosing (e.g., HYDROmorphone) Transdermal patch safety PCA safety New drugs added to the formulary Practice guidelines for using newly implemented technology safely 36 12
Key Elements Key Element Mean % VI Drug Device Acquisition, Use, Monitoring 51% VIII Staff Competency and Education 55% I Patient Information 56% II Drug Information 56% IX Patient Education 63% X Quality Processes and Risk Management 63% IV Drug Labeling, Packaging, Nomenclature 65% III Communication of Drug Orders and Other Drug Info. 70% V Drug Standardization, Storage, Distribution 73% VII Environmental Factors, Workflow, Staffing Patterns 81% Total 63% 37 Culture eats strategy for lunch everyday! That s the way we do things around here. Organizational safety culture is the most critical, underlying predictor of accomplishments related to safety. 38 Culture of Safety Achievement of sustainable medication safety goals requires lasting culture change Two strong predictors that healthcare workers will adopt patient safety behaviors Observed behaviors of professional peers Genuine belief in the safety outcomes of the behaviors Work in progress in most organizations Marathon not a sprint, but sense of urgency needed 39 13
Leaders Demonstrate Commitment to Patient Safety 222 224 There is a visible commitment to patient safety within the organization that is evident in the behaviors of hospital leaders and managers. The Board of Trustees/Directors actively demonstrates its commitment to patient safety (and safe medication practices) by approving a safety plan, rewarding practitioner error reporting, approving system design enhancements, including technology, that are likely to reduce errors, and incorporating patient safety and quality as a routine and significant component of each board meeting. 0% 43% 57% 7% 43% 50% 40 Safety Structure Components Culture Medication safety committee Strategic plan Medication Safety Practitioner 41 Factors Affecting Error Reporting Culture Anonymously survey practitioners Provides valuable insight Identify strengths and weaknesses in current culture Level of anxiety and fear with making errors and reporting error Ease of reporting errors and receiving feedback Online incident reporting Hotline available Timely feedback; follow up is key to any system 42 14
Culture Surveys 220 Practitioners are anonymously surveyed at least annually to assess the organization s safety culture. 64% 29% 7% 215 Practitioners and other staff report and openly discuss errors without embarrassment or fear of reprisal from the hospital/organization. Scoring guideline: If possible, choose A through E based on staff surveys as noted in item 220 7% 36% 57% 43 Internally Reported Errors are Analyzed 234 A convened interdisciplinary team, which includes at a minimum, risk management/quality improvement professionals, pharmacists, nurses, physicians, clinical information technology staff, and hospital leadership, meets at least monthly to review internal medication error/hazard reports, sentinel events, and other medication safety data, to identify the system based causes of error, and to facilitate the implementation of system design enhancements that make it difficult or impossible for practitioners to err. 14% 36% 50% 44 Feedback about Reported Errors 244 Prescribers, pharmacists, and nurses are provided with regular feedback about reported errors, hazardous situations, and error reduction strategies that are being implemented. 7% 50% 43% 45 15
Tip of the Iceberg Incident reports (Medication errors reported) Retrospective analysis Observation (Medication errors occurring) 46 Not Just Using Error Reports to Measure Medication Safety 247 An effective means of measuring medication safety (e.g., random chart review using triggers, tracking risk priority numbers from FMEAs, observational methods of error detection, measuring compliance with new medication protocols, drug use evaluations), which does not rely on practitioner reported data, has been designed and implemented to uncover systembased problems and to demonstrate sustained improvement after implementation of risk reduction strategies. 14% 64% 21% 47 Methods of Data Collection Proactive risk assessment Self assessments Failure Mode and Effects Analysis (FMEA) External sources of data ISMP s Quarterly Action Agenda The Joint Commission Sentinel Event Alert FDA alerts Concurrent risk assessment Pharmacy interventions Triggers and markers 48 16
Medication Use Process is Analyzed 233 The entire medication use process is analyzed at least annually (e.g., using a proactive risk assessment tool such as this self assessment) to identify potential risk factors for medication errors. 50% 43% 7% 49 Team Analyzes Outside Errors 240 A convened interdisciplinary team routinely analyzes and uses published error experiences from other organizations to assess the organization s vulnerability to similar errors and proactively target improvements in the medication use process. 43% 29% 29% 50 Dispensing and Prescribing Errors are Analyzed 242 Drug selection, preparation, and labeling errors identified during routine checking processes are reported and collected for the purpose of identifying system design issues and developing error prevention strategies. 14% 29% 57% 243 Prescribing errors that are detected by pharmacists and nurses are recorded, analyzed, and used in conjunction with medical staff quality improvement activities for system redesign 0% 50% 50% 51 17
Use of Triggers 241 In addition to practitioner reporting systems, computer markers or triggers for selected drug orders (such as antidotes) and laboratory tests (such as aptt greater than 100) are used to enhance detection of potential adverse drug events (both medication errors and adverse drug reactions). 14% 64% 21% 52 Methods of Data Collection Retrospective risk assessment Observational methodology WalkRounds Data from technology Smart pumps, ADCs, pharmacy system Chart reviews Rapid Response Teams Fall data Internal, voluntary reporting Close calls and good catches 53 Leadership WalkRounds 228 Senior leaders (administrative staff, board members when possible) participate in frequent, structured visits (e.g., WALKROUNDS to patient care units, the pharmacy, and laboratories to talk to frontline staff about safety and quality issues, learn first hand about day to day challenges that staff face when providing care and services, and show their support for staff reported errors. 29% 43% 29% 54 18
Off the Record Discussions 232 Trusted nurse, pharmacist, and physician representatives facilitate periodic, announced, focus groups of frontline practitioners for off the record discussions to learn about perceived problems and risks with the medication use system. 36% 36% 29% 55 Questions? 56 19