Constant Pursuit of Medication Safety Geraldine Koh Chief Pharmacist 1
Alexandra Hospital 400 beds Multi discipline except Paeds & ObGyn Restructured in Oct 2000
Transformation
Creating A Safety Culture Patients are our primary focus Patients have ready access to quality care Standards of practice are safe, effective and efficient Embrace continuous improvement Prevent adverse outcomes through risk management patient safety measures
Swiss Cheese Model Some medication errors: Typing medications wrongly Not familiar with drug names ipharm system down Packing wrong medication Not detected Harm to patient
Potential Errors Before Prescription Reaches Pharmacy 1. Two patients with similar names 3. IMR with drug orders left at the nursing station by the doctor ERRORS HARM 2. Patients next to each other in the ward 4. Both patients are discharged and prescription mixed up All these mistakes can occur before the prescription is sent to the pharmacy
Safety in Standardization Standard Abbreviations List Reduce / Separate Look Alike and Sound Alike Medication Protocols Insulin, Dilution of GTN, Dopamine, Dobutamine, Heparin IV Administration Dilution and Infusion Charts Use of Programme able Pumps for Infusions
Safety in Proper Labelling TALL man lettering on drug labels Colour coded drug labels Drug Allergy labels Do Not Crush labels Central vs Peripheral TPN
Safety in Harnessing IT Encourage use of Electronic Prescriptions Drug Allergy Alerts Drug Interaction Alerts
Safety in Continuous Improvement Improvements to Inpatient Medication Record
Safety in Reporting Medication Error Reporting Near Misses Reporting Monthly Reports to Nursing Admin on various nursing interventions ADR Reporting
About 60 Drug Allergy reports monthly linked to National Central Database
Safety in Education Active involvement in training course for nurses e.g. orientation, induction, continuing education programmes to improve drug knowledge and reduce medication errors
Safety in Pharmacist Review Medication Reconciliation Dedicated ICU Pharmacist Pharmacists Review of Medication Orders Anticoagulation Service Outpatient and Inpatient
Safety in Restricting Access Removal of Conc KCl from General Wards Introduced premixed KCl infusion bags Removal of concentrated electrolytes from General Wards Drug Allergy Status
Dr to TICK if no drug allergies. SN will not serve meds if allergy box NOT indicated
Safety in Audits Medication Audits Wards and SOCs Medication Use Evaluations Antithrombotic Workgroup Oversee anticoagulation use in the hospital Peri procedural bridging of anticoagulants
Medication Reconciliation Poor communication of medication information at transition points 50% of all medication errors in the hospitals up to 20% of adverse drug events
Medication Reconciliation Obtain complete and accurate list of each patient s current home medication Compare doctor s admission, transfer and discharge orders Discrepancies brought to attention of the prescriber Changes made accordingly
Before Patients are interviewed for medication history Doctors rely on previous discharge notes or electronic records for reference References may not be updated May not include any medication ordered by other doctors outside the hospital e.g. GPs
Pilot Started Jul 2005 Medication reconciliation interviews were conducted Within 24 hours of admission (weekends and PH excluded) At discharge, physical reconciliation of drugs also done
Results a) Total no. of medication reconciliation done 194 b) Total no. of new admissions in the same period 344 c) Number of drugs/line items missed by Dr 64 d) Number of errors in dosage/dose /frequency 101
Impact a) Potential adverse drug events (ADEs) prevented 18 b) Medication errors detected and prevented (165 / 344) 48% c) Potential ADEs detected and prevented (18 / 244) 5.2%
Critical Meds Missed Out Insulins* Tolbutamide* Hyzaar Metformin Lovastatin Enalapril Prazosin Combivent MDI* Galantamine Baclofen* Fludrocortisone* Midodrine* Digoxin Simvastatin ISDN Becotide MDI Salbutamol MDI* Prednisolone* Benzhexol* Losartan Amlodipine Glibenclamide* Amitriptylline Fluvoxamine Aspirin
At Discharge
Patient s own meds from home Dr s discharge prescription Staff working out the balance quantity to supply
BEFORE
TODAY Paper, 28 Jun 07
Innovations Conducting physical reconciliation upon discharge ensures patients go back with sufficient drugs and updating correct dosing Sorting out old medication and topping up adequate supply till next appointment reduce medication costs due to excess medication
Innovations Ziplocking old and new supplies together to reduce confusion Bedside dispensing and advising patients on which medication to continue or discard Developing inclusion criteria for patients with high risks for medication errors
Achievements Improve med safety, reduce potential harm Greater accuracy in medication history taking upon admission and discharge Prevented potential medication errors by 48% Prevented potential ADEs by 5.2% Direct savings on medication up to 50% by reducing excess supply Indirect cost savings on potential ADE reduction
Achievements Raised awareness of importance of effective communication between HCP Development of med recon model GP liaison ensure safe transfer of patient care Potential problems associated with incorrect med hx Closer collaboration between disciplines
Pilot Medication Reconciliation in an Outpatient Setting How to Improve Safety of Medication Administration in the HOME setting Started Aug 2008
OMR Workflow How to get patients to bring home meds? How to set up workflow to do physical reconciliation? Sees doctor Outpatient Visit Patient comes to the hospital Patient comes to Pharmacy Patient goes home
Sort! Re Label! Re labeling of medicines As is To be
Communication to Patient Patient Medication List Info carried by patients to other HCP
Results Cost Savings Through OMR Total Cost Savings (S$) 5000 4000 3000 2000 1000 0 Average savings: $2,739.85 per month Total savings: $13,699.27 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Month
Post OMR Survey Patients' Satisfaction on OMR Service (N=51) Percentage 70 60 50 40 30 20 10 0 1 2 3 4 5 Scale Very Useful
Post OMR Survey Patients' Willingness to Pay for OMR Service (N=51) Percentage 50 40 30 20 10 0 Free <$2 $3-5 >$5 (Any Amount) FREE!! Amount of Fees
Moving Forward Medication List Patients to PRE COUNT their balance medication Pictures of medication and dosage instructions Different languages SMS patients to bring their home medication
Communicate Value of OMR Automatic calculation of cost savings Show patients upon dispensing
Individualized Patient Medication List
Self Administration of Medication Allows selected patients to administer their medication on their own, under supervision of staff nurses during their stay in the hospital.
Targeted Approach Targeting 2 groups of patients Patients who are relatively FIT and on simple medication Patients who are admitted for newly diagnosed conditions which need multiple chronic medication e.g. stroke, TIA AIMS: Patient Education Familiarize with medication regime improve compliance when return home
Workflow SN identify the patients and obtain consent Inform Pharmacy by noon Pharmacists involved have designated hour in the afternoon to do beside patient education and counselling
Short Term Goal Moving forward, to target Patients who are admitted for newly diagnosed condition who needs multiple chronic medication Benefits this group of patients the most Joint collaboration between Nursing and Pharmacy department
Khoo Teck Puat Hospital 550 beds Multi discipline INCLUDING Oncology, Paediatrics & Women s Health Opened 28 Mar 2010
Medication Safety A JOURNEY
NURSES CAREGIVERS DOCTORS PHARMACISTS PATIENTS / CUSTOMERS OTHER HCPS
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