MedSafetyandQuality_RX Prep 2020_1-4.pdf

PHARMACY FOUNDATIONS PART 2 CHAPTER CONTENT Background Medication Errors System- Based Causes 988 988 988 989 Response 989 . . . . Reporting • •Organizations that Specialize in Error Prevention 989 990 Evaluation and Quality Improvement ... 990 The joint Commission (TjC) .. National Patient Safe...

PHARMACY FOUNDATIONS PART 2 CHAPTER CONTENT Background Medication Errors System- Based Causes 988 988 988 989 Response 989 . . . . Reporting • •Organizations that Specialize in Error Prevention 989 990 Evaluation and Quality Improvement ... 990 The joint Commission (TjC) .. National Patient Safety Coals 990 Select National Patient Safety Coals 990 Methods Reduce Medication Errors 991 to Common Avoid "Do Not Use" Abbreviations 991 Tall Man Lettering 991 Do Not Use Abbreviations .... . 991 991 High Alert Drugs Medication Therapy Management 992 Medication Reconciliation . 992 Indications and Proper Instructions 993 on Prescriptions 993 Use of The Metric System Do Not Identify Medications Based on 993 Packaging Alone Avoid Multiple - Dose Vials 993 Safe Practices For Emergency Medications / Crash Carts 994 Dedicate Pharmacists To High Risk Areas 994 994 Monitor for Drug-Food Interactions Education 994 Five Rights of Medication Administration 994 Use of Technology and Automated Systems 995 Computerized Prescriber Order Entry and Clinical Decision Support 995 Barcoding... 995 Automated Dispensing Cabinets . 995 Patient Controlled Analgesia Devices 9% Infection Control in Hospitals 9% Common Types of Hospital- Acquired 9% ( Nosocomial) Infections Universal Precautions to Prevent Transmission 997 Catheter -Related Bloodstream Infections 997 Hand Hygiene... 997 Safe Injection Practices 998 Sharps Disposal 998 ' * ** * • « • — CHAPTER 76 MEDICATION SAFETY & QUALITY IMPROVEMENT BACKGROUND A study from the Institute of Medicine (IOM ) , To Err is Human (1999 ) , increased awareness of the prevalence of medical errors. This study found that up to 98,000 Americans die each year in U.S. hospitals due to preventable medical errors, 7,000 from medication errors alone. These numbers understated the problem because they did not include preventable deaths due to medical treatments outside of hospitals. Since the release of the IOM study, there has been a greater focus on the quality of healthcare provided in the U.S. The Joint Commission (T]C) and the Institute for Safe Medication Practices (ISMP) are two organizations actively involved in improving medication safety. MEDICATION ERRORS The formal definition of a medication error developed by the National Coordinating Council for Medication Error Reporting and Prevention ( NCC MERP) is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.” This can include errors made in prescribing, order communication , product labeling and packaging, compounding, dispensing, administration, education and monitoring. Do not confuse medication errors with adverse drug reactions ( ADRs). ADRs are generally not avoidable, although they may be more likely to occur if the drug is given to a patient at high - risk for certain complications. Refer to the Drug Allergies & Adverse Reactions chapter for a discussion of ADRs. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. When a sentinel event occurs, it is important to find out what went wrong and implement measures to prevent it from happening again. CONTENT LEGEND t ; * Study Tip Cal 18 SYSTEM- BASED CAUSES Experts in medication safety agree that the most common cause of medication errors is a problem with the design of the medical system itself , not usually an individual making an error. Instead of blaming the ist ” or the "lazy technician” ( or the prescriber ) , RxPrep Course Book | RxPrep 02019, RxPrep 02020 healthcare professionals should find ways to improve the system. Errors will always occur, but the goal is to design systems to prevent medication errors from reaching the patient. Some "at risk" behaviors that can compromise patient safety are included below. ERRORS OF OMISSION AND COMMISSION Error of Omission Something was left out that is needed for safety Example: failing to warn a patient about an important side effect with a new medication AT- RISK BEHAVIORS THAT CAN COMPROMISE PATIENT SAFETY Error of Commission Drug and Patient- Related Failure to check/reconcile home medications and doses Example: prescribing bupropion to a patient with a history of seizures Something was done incorrectly Dispensing medications without complete knowledge of the medication Not questioning unusual doses REPORTING Not checking/ verifying allergies Medication errors, preventable adverse drug reactions, hazardous conditions and "close calls" or "near misses" should be reported. Medication errors are reported to the appropriate bodies so that changes can be made to the system to prevent similar errors in the future. Without reporting, these events may go unrecognized and will likely happen again because others will not learn from the incident. Communication Not addressing questions/concerns Rushed communication Technology Overriding computer alerts without proper consideration Not using available technology Work Environment Trying to do multiple things vs.focusing on a single complex task Inadequate supervision and orientation/ training RESPONSE Institutions should have a plan in place for responding to medication errors. The plan should address the following: Internal notification: who should be notified within the institution and within what time frame? External reporting: who should be notified outside of the institution? Disclosure: what information should be shared with the patient /family? Who will be present when this occurs? Investigation: what is the process for immediate and long term internal investigation of an error? - Improvement: what process will ensure that immediate and long- term preventative actions are taken? EXAMPLE OF AN ADR (NOT A MEDICATION ERROR ) A 55 - year- old female has a history of herpes zoster. She has no other known medical conditions. The patient reports considerable "shingles pain” that "runs from my back through my left breast." She received a prescription for pregabalin. The patient returned to the clinic with complaints of ankle swelling, which required drug discontinuation. This problem would not be attributable to a medication error made by the prescriber of pregabalin or by the pharmacist who dispensed it. Rather, this is a side effect that can occur with the use of this drug. In a pharmacy, the staff member who discovers the error should immediately report it using the established reporting structure to the appropriate office (e.g., corporate office, the owner of an independent pharmacy, designated hospital office). Many state boards of pharmacy require quality assurance programs to promote pharmacy processes to prevent medication errors. Error investigations need to take place quickly (often as soon as within 48 hours of the incident ) so that the sequence of events remains clear to those involved. Many states mandate the ethical requirement that errors be reported to the patient and the prescriber as soon as possible. Many medication error reporting systems within hospitals are electronic; however, some hospitals still maintain a paper reporting system. The hospital's Pharmacy and Therapeutics ( P&T) committee and Medication Safety Committee (or similar entity ) should be informed of the error. ORGANIZATIONS THAT SPECIALIZE IN ERROR PREVENTION Organizations that specialize in error prevention can analyze the system - based causes of errors and make recommendations. The ISMP National Medication Errors Reporting Program ( MERP ) is a confidential national voluntary reporting program that provides expert analysis of the system causes of medication errors and provides recommendations for prevention. Medication errors and close calls can be reported on the ISMP website ( www.ismp.org). Professionals and consumers should be encouraged to report medication errors using this site even if the error was reported internally. When there are _ 76 I MEDICATION SAFETY & QUALITY IMPROVEMENT many reports of a particular error, the manufacturer may be required to take measures to increase safety (e.g., REMS program , name change, packaging change) . met. These will be included in the institution's protocol. The Study Tip Gal and text describe some of the most important 2019 hospital NPSGs related to medication safety. Every pharmacist should make it a practice to read medication error reports and use the information to improve their own NPSG 03.05.01: Reduce the likelihood of harm associated anticoagulant therapy practice setting. EVALUATION AND QUALITY IMPROVEMENT A root cause analysis ( RCA ) is a retrospective investigation of an event that has already occurred which includes reviewing the sequence of events that led to the error. The information obtained in the analysis is used to design changes that will hopefully prevent future errors. The RCA can be of great value in capturing both the big picture perspective and the details of the error. Targeting corrective measures at the identified root cause is the best way to prevent similar problems from occurring in the future. A single intervention is not likely to prevent all future errors. Thus, RCA is often considered to be a repetitive process, and is frequently viewed as an important continuous quality improvement (CQl ) tool. An analysis can also be done prospectively to identify pathways that could lead to errors and to identify ways to reduce the error risk . Failure mode and effects analysis ( FMEA ) is a proactive method used to reduce the frequency and consequences of errors. FMEA is used to analyze the design of the system in order to evaluate the potential for failures, and to determine what potential effects could occur when the medication delivery system changes in any substantial way or if a potentially dangerous new drug will be added to the formulary. , There are many important elements to this goal including the requirements to use standardized dosing protocols and programmable pumps for heparin and to provide education to patients and families. Protocols should include starting dose ranges, alternate dosing strategies to address drug-drug interactions, communication with the dietary department to address drug-food interactions, requirements for a baseline INR , frequency of INR monitoring and monitoring for bleeding and HIT. NPSG 03.06.01: Maintain and communicate accurate patient medication information. This includes medication reconciliation, providing written information to the patient and conducting discharge counseling. The medication name, dose, frequency, route and indication ( at the minimum ) should be confirmed . Refer to the section on Medication Reconciliation later in this chapter. NPSG 07.03.01; 07.04.01; 07.05.01; 07.06.01: Implement evidence- based practices to reduce healthcare associated infections. These include recommendations to prevent healthcare associated infections with multidrug- resistant organisms SELECT NATIONAL PATIENT SAFETY GOALS J Appropriate identifiers: name, medical THE JOINT COMMISSION ( TJC) The Joint Commission on Accreditation of Healthcare organizations (TJC ) is an independent, not -for- profit organization that accredits and certifies more than 17, 000 healthcare organizations and programs in the U.S., including hospitals, healthcare networks, long- term care facilities, home care organizations, office - based surgery centers and independent laboratories. TJC focuses on the highest quality and safety of care and sets standards that institutions must meet to be accredited . An accredited organization must undergo an on-site survey at least every three years and surveys can be unannounced. NATIONAL PATIENT SAFETY GOALS o National patient safety goals ( NPSGs) are set annually by TJC for different types of healthcare settings (e.g., ambulatory care, behavioral health, hospital ) . Each goal includes defined measures called " Elements of Performance" that must be v? NPSG 01.01.01: Use at least two patient identifiers when providing care, treatment and services. record number, date of birth ® Inappropriate non- patient specific identifiers: zip code, physician name, room number **** NPSG 02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. Includes lab and blood culture results: protocols must include acceptable length of time for reporting. NPSG 03.04.01: Label all medications, medication containers and other solutions on and off the sterile field in perioperative and other procedural settings. Numerous errors have been associated with removing medications from their original containers and placing them into unlabeled containers. NPSG 03.05.01: Reduce the likelihood of harm associated with anticoagulant therapy (see text). NPSG 03.06.01: Maintain and communicate accurate patient medication information (see text). NPSG 07.01.01: Comply with the Centers for Disease Control (CDC) hand hygiene guidelines . RxPrep Course Book | RxPrep © 2019, RxPrep © 2020 ( e.g., MRSA, C. difficile, VRE , multidrug- resistant gram negative bacteria ). The elements of performance address care of central lines, bloodstream infections, post -surgical infections and catheter -associated urinary tract infections. up should be labeled with tall man letters ( the letters that are different are tall man ). Here are two examples: COMMON METHODS TO REDUCE MEDICATION ERRORS Using tall man letters, which mix upper and lower case letters, draws attention to the dissimilarities in the drug names. The letters that are upper cases are the ones that are different between the two look -alike, sound -alike drugs. Safety -conscious organizations (e.g., ISMP, FDA, TJC ) have promoted the use of tall man letters as one means of reducing confusion between similar drug names. The FDA's and ISMP's approved tall man lettering information is available at: http:// www.ismp.org / tools / tallmanletters.pdf. AVOID “DO NOT USE” ABBREVIATIONS Abbreviations are unsafe and contribute to many medical errors. TJC standards include recommendations against the use of unsafe abbreviations. The minimum list of "Do Not Use" abbreviations per TJC is shown in the table. ISMP also publishes a list of error - prone abbreviations, symbols, and dosage designations which includes those on TJC's list and many others. All institutions accredited by TJC are required to have a list of abbreviations that may not be used in the facility. This list must include all of the abbreviations from the TJC “ Do Not Use" list, and any additional abbreviations selected by the institution (e.g., those that have resulted in significant errors at the site in the past ). The unapproved abbreviation list should be readily accessible in the institution (e.g., wall charts, pocket cards) . It is best to try to avoid abbreviations entirely. Electronic prescribing can virtually eliminate errors associated with poor handwriting. Despite this, handwritten prescriptions and progress notes are still used in many settings. See Study Tip Gal. DO NOT USE . U u (unit) POTENTIAL PROBLEM USE INSTEAD Mistaken for “0" Write "unit" (zero), the number “4" (four) or “cc" IU (International Unit) . . Q.O.D. QOD. q.o.d., Q.D., QD q.d. qd (daily) , Mistaken for IV (intravenous) or the number 10 (ten) Write "International Unit" Mistaken for each other Write "daily " Write “every other Period after the Q mistaken for “I" and the "O " mistaken for "I" day " Decimal point is missed resulting in a 10- fold dosing error Write X mg MS Can mean morphine sulfate or magnesium sulfate Write "morphine sulfate” MS04 and MgSC> 4 Confused with one another Write “magnesium sulfate” qod (every other day) CeleXA , CeleBREX predniSONE, prednisoLONE Drug dictionaries within computer systems and automated dispensing cabinets (ADC) often have alerts that prompt the provider to confirm that the correct medication is being ordered or withdrawn. For example a warning may appear on the screen of the ADC which will state: “This is DILAUDID . Did you want hydroMORPHONE ? ” to avoid confusion with morphine. DO NOT USE ABBREVIATIONS 0 How often should the potassium be given? Is that 8 or 80 units of Lantus? Coumadin 1or 10 mg? Once daily or four times per day? HIGH- ALERT DRUGS TALL MAN LETTERING Drugs with a heightened risk of causing significant patient harm if used in error, should be designated as high-alert. See the box on the following page for some examples from multiple The settings. patient -care at: “ high -alert" available list is ISMP http:// www.ismp.org /Tools/ highAlertMedicationLists.asp. ISMP's list represents the most common agents that are high risk, but an institution's list may include additional drugs based on experience in that setting. Look-alike, sound -alike medications are a common cause of medication errors. Poor handwriting and similar product labeling aggravate the problem. Drugs that are easily mixed High -alert medications can be used safely by developing protocols or order sets for use, using premixed products whenever possible, limiting concentrations available in Trailing zero (X.O mg) Lack of leading zero ( X mg) Write O.X mg