ICAHN Aggregate Results ISMP Medication Safety Self Assessment for Hospitals Matthew Fricker, RPH, MS, FASHP Rebecca Lamis, PharmD, FISMP January 23, 2014 1 Objectives Report the demographic characteristics of the participating ICAHN hospitals Summarize the aggregate ICAHN selfassessment results Identify opportunities for improvement in medication safety Describe how to prioritize areas in need of improvement 2 Demographics: Type and Services Total Number of Participants = 14 critical access hospitals Primary Type of Service Provided General medical and surgical n = 14 Other Services Provided Oncology n = 8 Pediatrics n = 14 Trauma n = 11 3 2014 1
Demographics: Practitioners Employ Hospitalists time coverage n = 4 Part time coverage n = 3 Clinical Informatics Practitioner (full or part time) Yes n = 3 Medication Safety Officer/Manager (full or part time) Yes n = 2 4 Demographics: Pharmacist Availability 122a 122b 122c At least one pharmacist is physically present onsite 24 hours a day, 7 days a week. A pharmacist at a remote location is available for questions and to enter and screen medication orders before the drugs are removed or dispensed. A night cabinet has been established for when the pharmacy is closed, and a pharmacist is oncall for questions and to come into the hospital if needed. 1 0 0 0 2 4 1 3 3 5 Demographics: Technology CPOE Barcoding (Pharmacy) emar ADCs Barcoding (Bedside) Smart Infusion Pumps 13 7 13 12* 7 11 10 *Ten (10) hospitals have profiled ADCs 6 2014 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% 7 8 Core Characteristics Core Characteristic Mean % 11 15 Carefully procure, maintain, use, and standardize devices used to prepare and deliver medications Provide ongoing education about medication error prevention and the safe use of drugs to staff 51% 53% 3 A controlled drug formulary system is established 54% 1 2 Essential patient information is obtained, readily available, and is considered Essential drug information is readily available and considered 56% 57% 9 2014 3
Core Characteristics 14 5 17 19 16 Core Characteristic Mean % Practitioners receive sufficient orientation to medication use and undergo competency evaluations Strategies are taken to minimize errors with look and/or sound alike drug names/packaging A Just Culture of shared accountability is in place and supported by management/administration Redundancies or an automated verification process are used for vulnerable parts of the medication system Patients are included as active partners in their care through education about their medications 57% 60% 61% 62% 63% 10 Core Characteristics Core Characteristic Mean % 18 Practitioners detect and report adverse events/errors, and teams regularly analyze these reports and reports of errors 63% that occurred in other organizations 9 Unit stock is restricted 67% 4 6 12 Methods of communicating drug orders/information are streamlined, standardized, and automated Readable labels are on all drug containers, and drugs remain labeled up to the point of actual administration Medications are prescribed, transcribed, prepared, dispensed, and administered within an efficient and safe workflow and in an environment with adequate space and lighting and without distractions 70% 73% 74% 11 Core Characteristics Core Characteristic Mean % 8 7 13 10 20 Medications are provided to patient care units in a safe and secure manner and within a time frame that meets patient needs IV solutions, drug concentrations, doses, and administration times are standardized The complement of qualified, well rested practitioners matches the clinical workload Hazardous chemicals are safely sequestered from patients and not accessible in drug preparation areas Proven infection control practices are followed when storing, preparing, and administering medications 81% 83% 85% 86% 86% 12 2014 4
13 Scoring Guidelines C. ly implemented in some or all areas D. y implemented in some areas E. y implemented throughout Low Scoring Areas 15 2014 5
Key Element VI: Drug Device Acquisition, Use, and Monitoring (51%) 16 Risk Assessment Performed for New/Replacement Medication Devices 130 Error potential for all new and replacement medication devices is identified through a literature search and a failure mode and effects analysis (FMEA); and potentially harmful error potential is documented and addressed before a decision is made to purchase and use the device. 71% 14% 14% 17 Smart Pump Technology 18 2014 6
Smart Pump Technology: General Infusion Pumps 143 General infusion pumps with smart pump technology are in use in all hospital areas (including the ED, pediatrics, oncology, operating room). 29% 29% 43% 4 hospitals are not utilizing smart pumps 4 hospitals have partially implemented smart pump technology 6 hospitals have fully implemented smart pump technology 19 Smart Pump Technology: PCA and Syringe Infusion Pumps * * * 144 PCA and syringe infusion pumps with smart pump technology are in use in all hospital areas (including the ED, pediatrics, oncology, operating room). 42% 17% 42% 5 hospitals have not implemented smart pump technology 2 hospitals have partially implemented smart pump technology 5 hospitals have fully implemented smart pump technology 2 hospitals do not have PCA or syringe infusion pumps *Based on the number of hospitals that have PCA and syringe infusion pumps (n=12) 20 Pumps Use Wireless Technology * * * 148 The drug library is updated via wireless technology. 80% 0% 20% *Based on the number of hospitals that have smart pump technology (n=10) 21 2014 7
Drug Library: Development/Testing * * * 147 An interdisciplinary team develops and tests the drug library, and reviews and updates the library at least quarterly. 60% 40% 0% *Based on the number of hospitals that have smart pump technology (n=10) 22 Use of Smart Pump Data * * * 145 The percent of infusions with medications that are administered using full functionality of the safety software is monitored, and the findings are used to increase compliance. 60% 30% 10% 146 An interdisciplinary team reviews data for soft and hard dose and volume limits that have been bypassed, and the findings are used to take action to reduce the number of bypassed warnings or to modify dosing limits. 90% 0% 10% *Based on the number of hospitals that have smart pump technology (n=10) 23 Tubing, Catheters, Administration Sets 24 2014 8
Risk Assessment: Medical Tubing, Catheters, Fittings 134 An initial risk assessment has been performed to determine the various types of medical tubing, catheters, and fittings in use, identify the possibility for misconnections, assess the potential severity of misconnections, and address process changes that need to be made, and this assessment is updated prior to the purchase of any new medical tubing, catheters, and fittings. 71% 29% 0% 25 Epidural Administration Sets 139 The administration set used for epidural infusion pumps does not contain any access ports (Y connectors), can be distinguished from all other administration sets and medical tubing (e.g., a yellow stripe running the length of the tubing), and is not used for anything other than epidural infusions. 50% 0% 50% 26 Key Element VIII: Staff Competency and Education (55%) 27 2014 9
Core Characteristic #15: Provide ongoing education about medication error prevention and the safe use of drugs to staff (53%) 28 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% 29 Error Reduction Strategies 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 2014 10
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% 31 Core Characteristic #14: Practitioners receive orientation to medication use and undergo competency evaluations (57%) 32 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% 33 2014 11
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% 34 Specialty Training/Certification 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% 35 Deep Sedation 178 The hospital only allows practitioners who are trained in the use of drugs causing deep sedation, qualified to rescue patients from general anesthesia or severe respiratory depression, and not simultaneously involved in a procedure, to administer medications which could lead to deep sedation (e.g., propofol, ketamine, etomidate) of non ventilated patients. (Advanced cardiac life support [ACLS] certification alone is not sufficient.) 7% 21% 71% 36 2014 12
Key Element I: Patient Information (56%) 37 Patient Weight 38 Weight is Measured and Documented in Metric Units 25 All weights and heights are measured and documented in written and electronic systems in metric units (i.e., grams or kilograms for weight, centimeters for height). 14% 36% 50% 26 Scales used to weigh patients only measure in metric units or default to metric units. 64% 21% 14% 39 2014 13
Source of Patient Weight is Documented 27 All documented weights and heights in written and electronic systems are designated as actual, estimated by practitioners, or stated by patients. 7% 36% 57% 40 Patient Allergies 41 Patient Allergy Field is a Hard Stop 11 Medication orders cannot be entered into the computer order entry system until the patient s allergies have been entered and coded (i.e., orders cannot be entered until the allergy field has been populated). 29% 29% 43% 42 2014 14
Computer Alerts for Allergies 12 Computer order entry systems automatically screen and detect drugs to which patients may be allergic (including cross allergies), provide a clear warning to staff during order entry, and require practitioners to enter an explanation to override the warning. 14% 43% 43% 43 Readily Accessible/Real Time Patient Data 44 Recent Lab Values Displayed 5 Recent inpatient and outpatient laboratory values are automatically displayed on computer order entry system screens for medications that typically require dose adjustments based on pending laboratory results (e.g., if warfarin is ordered, the most recent INR is displayed). 43% 43% 14% 45 2014 15
Patient Identification / Selection 46 Use of Barcoding and Two Patient Identifiers 20a 20b Machine readable coding (e.g., bar coding) is used to verify patient identity during drug administration. Two patient identifiers (not the patient s room number or location) from the MAR (paper or electronic) or the original order are manually verified against the patient identification bracelet and/or when possible, with the patient, before medications are administered. 0 6 1 1 2 4 47 Key Element II: Drug Information (56%) 48 2014 16
Core Characteristic #3: A controlled drug formulary system is established (54%) 49 Order Entry Systems Tested for Clinical Alerts 56 Computer order entry systems are tested after adding a new drug to the formulary to verify that important clinical warnings (e.g., serious drug interactions, allergies, cross allergy alerts, maximum dose limits) are functional; and if a serious alert is not yet functional through the drug information system vendor, a temporary free text alert or similar mechanism is added so that it appears on the screen during order entry. 43% 36% 21% 50 Potential for Error is Investigated 52 Before a decision is made to add a drug to the formulary, the potential for error with that drug is investigated by searching the literature and performing an internal risk assessment that includes staff who are involved in the prescribing, storage, preparation, dispensing, and administration of the medication; and the results of this assessment are documented in the drug monograph submitted to the pharmacy and therapeutics committee (or a similar voting body). 7% 57% 36% 51 2014 17
Safety Strategies for Drugs with Heightened Error Potential 54 When drugs with heightened error potential are approved for addition to the formulary, safety enhancements such as standardized order sets, prescribing guidelines, check systems, reminders, administration guidelines, monitoring protocols, and/or limitations on use, administration, and storage of drugs are established and implemented before initial use. 14% 36% 50% 52 Core Characteristic #2: Essential drug information is readily available and considered (57%) 53 Dose Range Checks 42 Computer order entry systems perform dose range checks and warn practitioners about overdoses and underdoses for all high alert drugs and for most other medications. 29% 50% 21% 54 2014 18
Serious Alert Overrides 43 Computer order entry systems require practitioners to enter an explanation upon overriding a serious alert (e.g., exceeding a maximum dose for a high alert drug, a serious drug interaction, an allergy). 29% 43% 29% 55 Overridden Warnings 44 A designated pharmacist routinely reviews, for quality improvement purposes, reports of selected computer order entry system warnings (e.g., maximum dose alerts, serious drug interactions, allergy alerts) that are overridden. 71% 21% 7% 56 Drug Protocols / Charts / Guidelines 57 2014 19
Equianalgesic Dosing Charts 36 Equianalgesic dosing charts for oral, parenteral, and transdermal (e.g., fentanyl patches) opioids have been established and are easily accessible to all practitioners when prescribing, dispensing, and administering opioids. 71% 29% 0% 58 Next Steps 59 Where Do We Begin? May seem overwhelming Keep in mind: You can t tackle everything at once This is an ongoing process Important that you at least begin taking action and start making improvements 60 2014 20
Create a Work List Columns to consider including: Self assessment item/item number Numerical and alphabetical score (A E, N/A) Maximum weighted score Reason for selected letter score Barriers to implementation Responsible department or individual Cost/resources required Goal/Timeframe for completion (or partial completion) 61 62 63 2014 21
How to Sort the Work List There is no right or wrong way Consider implementing by: Lowest scoring Key Elements Lowest scoring Core Characteristics Lowest scoring self assessment items or items that your organization has identified as a priority 64 Prioritize Consider: Items with the highest maximum weighted score Greatest impact on safety Clear, documented evidence or Expert consensus regarding their effectiveness 65 Items Weighted Based on Impact S Y S T E M H U M A N Strategy Forcing functions Barriers and fail safes Automation and computerization Standardization Redundancies Reminders and checklists Rules and policies Education and information Suggestions to be more vigilant Power (Leverage) High ( Blunt end ) Scale: 10 16 Medium Scale: 6 10 Low ( Sharp end ) Scale: 4 6 2014 22
Lab Values Automatically Display Weight 5 Recent inpatient and outpatient laboratory values are automatically displayed on computer order entry system screens for medications that typically require dose adjustments based on pending laboratory results (e.g., if warfarin is ordered, the most recent INR is displayed). 12 43% 43% 14% 67 Prioritize Consider: Maximum weighted score Ease of implementation Begin with items you know you can achieve without considerable delay ( low hanging fruit ) Can help ensure early success and establish momentum 68 Equianalgesic Dosing Charts Cost/ Difficulty 36 Equianalgesic dosing charts for oral, parenteral, and transdermal (e.g., fentanyl patches) opioids have been established and are easily accessible to all practitioners when prescribing, dispensing, and administering opioids. Low 71% 29% 0% 69 2014 23
Prioritize Consider: Maximum weighted score Ease of implementation Successful small scale implementation Building upon items that scored C or D is a natural progression of effort 70 Verbal Orders (C) (D) 68 Verbal (face to face) orders from prescribers who are onsite in the hospital are never accepted, except in emergencies or during sterile procedures where ungloving would be impractical. 21% 50% 21% 7% 71 Prioritize Consider: Maximum weighted score Ease of implementation Successful small scale implementation Resource considerations (financial, time/personnel) Do not hesitate to include a resource intensive strategy high on your priority Making a resource intensive strategy a priority helps to ensure that the planning work begins 72 2014 24
122a 122b 122c Pharmacist Availability At least one pharmacist is physically present onsite 24 hours a day, 7 days a week. A pharmacist at a remote location is available for questions and to enter and screen medication orders before the drugs are removed or dispensed. A night cabinet has been established for when the pharmacy is closed, and a pharmacist is on call for questions and to come into the hospital if needed. Cost/ Difficulty High 1 0 0 Moderate 0 2 4 Low 1 3 3 73 Prioritize Consider: Maximum weighted score Ease of implementation Successful small scale implementation Resource considerations Motivation Successful change begins with acquiring staffs buy in Strategies that incite enthusiasm strengthen the commitment to achieving a shared goal 74 Other Considerations Are there items that relate to other efforts? The Joint Commission, CMS, Illinois Department of Health Internal medication safety initiatives Incorporate planning into existing committee meetings Engage staff and senior leadership Storytelling is powerful Important to have support of board of directors 75 2014 25
Upcoming Four Webinars Lowest scoring Key Elements Patient Information (Key I) February 27 th Drug Information (Key II) March 27 th Drug Devices/Technology (Key VI) April 24 th Staff Competency and Education (Key VIII) May 22 nd Low scoring items from other Key Elements Standardization, Storage, Distribution (Key V) Patient Education (Key IX) Quality Processes and Risk Management (X) 76 Questions? 77 2014 26