Medication Safety & Quality Improvement PDF

76 | MEDICATION SAFETY & QUALITY IMPROVEMENT HIGH ALERT MEDICATIONS Acute Care, Community/Ambulatory and/or Long-Term Care Settings Anesthetics, IV or inhaled (e.g., propofol) Antiarrhythmics, IV (e.g., amiodarone) Anticoagulants /Antithrombotics (e.g., heparin, warfarin) . Chemotherapeutics (e...

76 | MEDICATION SAFETY & QUALITY IMPROVEMENT HIGH ALERT MEDICATIONS Acute Care, Community/Ambulatory and/or Long-Term Care Settings Anesthetics, IV or inhaled (e.g., propofol) Antiarrhythmics, IV (e.g., amiodarone) Anticoagulants /Antithrombotics (e.g., heparin, warfarin) . Chemotherapeutics (e.g , methotrexate) Epidural/intrathecal drugs Hypertonic saline (greater than 0.9%) Immunosuppressants (e.g., cyclosporine) Inotropics (e.g. digoxin) . Insulins (e.g., insulin aspart, insulin U- 500) Magnesium sulfate injection Opioids Oral hypoglycemics (e.g., sulfonylureas) Parenteral nutrition Potassium chloride and phosphates for injection Sterile water for injection the institution and stocking high-alert products only in the pharmacy. See an example of safe use precautions for insulin and potassium chloride on the next page. Protocols for high risk drugs increase appropriate prescribing and reduce the chance of errors from inappropriate prescribing. Examples of Safe- Use Precautions DRUG PRECAUTIONS Insulin If U - 500 is stocked, specify conditions under which it is to be used, which product will be stocked (vials and U- 500 syringes vs. pens), and how doses will be supplied Standardize all insulin infusions to one concentration Develop protocols for insulin infusions, transition from infusion to SC and sliding scale orders; use standard orders for management of hypoglycemia Do not use "U" for units; always label with “units" or "units = mL", but never just "mL" Do not place insulin in automated dispensing cabinets; all insulin orders should be reviewed by a pharmacist visual alert to the person pulling the medication. The bin can be labeled with warnings and include materials ( placed inside the bin ) that should be dispensed with the drug (such as oral syringes or MedGuides ) . In the hospital setting, certain drugs are classified as “ high -alert" and these can be placed in bins labeled with dispensing requirements. MEDICATION THERAPY MANAGEMENT Errors may be discovered during a comprehensive medication review ( CMR ) , through the process of medication therapy management ( MTM ). A personal medication record ( PMR ) is prepared , and a medication - related action plan ( MAP) is developed , preferably by a pharmacist -led team. The next steps involve interventions, referrals, documentation and plans for follow - up. Patients targeted for MTM include those with multiple chronic conditions who are taking multiple drugs and are likely to incur annual costs for covered drugs that exceed a predetermined level. Computer databases are used to identify patients with certain high - risk conditions (such as heart failure or uncontrolled diabetes) who are generally using many medications (some systems tag patients taking many chronic medications daily) and assign a pharmacist ( preferably ) to review profiles for proper use. The pharmacist can form a partnership with the patient and prescriber to remedy any issues or lapses. Often, these reviews identify missed therapy such as lack of an ACE inhibitor or ARB in patients with diabetes and albuminuria , missing beta blocker therapy post -MI, missing bisphosphonate therapy with high-dose chronic steroids, and others, since these are easily searchable in databases. A popular MTM initiative is to improve nonadherence in heart failure patients due to the high - rate of ED visits due to decompensated heart failure. MTM is also used to identify cost -savings, by promoting switches to generics or more affordable brands, or by suggesting patient assistance programs or low income subsidies for eligible members. prior to dispensing Potassium Chloride Remove all KCI vials from floor stock; all KCI infusions prepared in the pharmacy Use premixed containers Use protocols for KCI delivery which include indications for IV administration, maximum rate of infusion, maximum allowable concentration, guidelines for when cardiac monitoring is required, stipulation that all KCI infusions must be given via a pump, prohibition of multiple simultaneous KCI solutions (e.g., no IV KCI while KCI is being infused in another IV) Allow for automatic substitution of oral KCI for IV KCI, when appropriate Label all fluids containing potassium with a "Potassium Added’ sticker Any drug that is high- risk for significant harm if dispensed incorrectly can be placed in a medication bin that provides a are often actively involved in documenting home MEDICATION RECONCILIATION Medication reconciliation involves comparing a patient’s medication orders to all of the medications that the patient has been taking ( home medications including OTC and dietary supplements). This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors or drug interactions. Medication reconciliation (" med rec ” ) was previously done on paper forms, but it is now usually performed within the electronic health record ( EHR ). Prescribers can view sideby-side lists of home medications and ordered medications and address any discrepancies. This process is most effective when complete and accurate information is entered into the patient’s medical record. For this reason, pharmacy nts . RxPrep Course Book | RxPrep © 2019 RxPrep © 2020 medication use and performing medication reconciliation. In many hospitals, admission orders for a patient cannot be entered into the electronic system until medication reconciliation is completed by a physician , pharmacist or nurse. Medication reconciliation should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions of care include changes in setting, service, practitioner or level of care. Common examples are hospital admission, transfer into or out of an ICU and at hospital discharge. This process comprises five steps: 1. Develop a list of current medications 2. Develop a list of medications to be prescribed 3. Compare the medications on the two lists 4. Note discrepancies and make clinical decisions based on the comparison 5. Communicate the new list to appropriate caregivers and to the patient Discharge medication reconciliation is an opportunity for the prescriber to address any of the patient's home medications that were “on hold ” during the hospitalization and which medications used during the hospitalization should be continued when the patient goes home. Discrepancies are addressed and the patient is educated. Though most often discussed in the hospital context, medication reconciliation can be equally important in ambulatory care, as many patients receive prescriptions from more than one outpatient provider and may go to several pharmacies. EXAMPLE OF THE BENEFIT OF MEDICATION RECONCILIATION Ann is an 82- year-old female. Her only medication for the previous ten years has been atenolol 25 mg daily. Ann recently developed influenza She began to have trouble breathing and was taken to . the hospital. It was discovered that Ann had pneumonia and heart failure. She was prescribed lisinopril, carvedilol and furosemide. Ann was discharged to transitional care and received the new medications plus her home medication (atenolol). The consultant pharmacist conducted a medication review to reconcile the medications and, after discussion with the physician, the pharmacist wrote an order to discontinue the atenolol. INDICATIONS AND PROPER INSTRUCTIONS ON PRESCRIPTIONS An indication for use that is written on the prescription (such as lisinopril 10 mg once daily for hypertension) helps pharmacists ensure appropriate prescribing and drug selection. Using the term “as directed ” is not acceptable on prescriptions because the patient often has no idea what this means and the pharmacist cannot verify a proper dosing regimen. Occasionally, this term is used on the bottle along with a separate dosing calendar, such as with warfarin. It would be preferable to write “ use per instructions on the dosing calendar ” since the patient may not understand how to take the medication and may not be aware that a separate dosing calendar exists. USE OF THE METRIC SYSTEM Measurements should be recorded in the metric system only. Prescribers should use the metric system to express all weights, volumes and units. Computer systems generally have a drop-down menu for selecting the correct units (e.g., lb vs. kg) and easily converting between units. It is critical to record the correct units, since many calculations (CrCl or eGFR ) and dosing checks are performed automatically by the EHR system based on the height and/or weight recorded for the patient. With the increasing prevalence of overweight and obesity in the U.S., it is not uncommon to care for patients weighing 100 kg (or more); but serious errors can occur if this weight was intended to be 100 lb. DO NOT IDENTIFY MEDICATIONS BASED ON PACKAGING ALONE Look -alike packaging can contribute to errors. If unavoidable, separate look-alike drugs in the pharmacy and patient care units, or repackage. Never rely on the package to identify the right drug product. Pharmacies frequently have to purchase products from different manufacturers ( and these may look vastly different ) . EXAMPLE OF AN ERROR DUE TO MISIDENTIFICATION OF A CONCENTRATION BASED ON THE PACKAGING The intravenous catheters of three neonates in a NICU unit were flushed with the adult therapeutic dose of heparin (10,000 units / mL) rather than the heparin flush dose of 10 units/ mL. This accident did not result in fatalities although two of the babies required the reversal agent protamine. Three babies died from a similar incident the previous year at a different hospital. The overdose was administered because the nurse thought she was using a lower concentration of heparin. Due to the high-risk associated with heparin overdose, high concentration heparin vials should not be present in patient care areas. Instead, therapeutic doses should be sent by the pharmacy department. AVOID MULTIPLE- DOSE VIALS Multiple -dose vials pose risk for cross-contamination ( infection ) and over -dosing. If used , they should be (ideally) designated for a single patient and labeled appropriately. Discard the remainder when the patient is done with the medication , or is discharged. 76 | MEDICATION SAFETY & QUALITY IMPROVEMENT SAFE PRACTICES FOR EMERGENCY MEDICATIONS/CRASH CARTS Staff must be properly trained to handle emergencies and use crash cart medications. The medications should be unit dose and age -specific, including pediatric - specific doses. A weight - based dosing chart can be placed in the trays used in the pediatric units. If a unit dose medication is not available, it is best to have prefilled syringes and drips in the cart ( to the extent possible) because it is easy to make a mistake under the stress of a code. The emergency medications should be stored in sealed or locked containers in a locked room and replaced as soon as possible after use ( through a cart exchange so that the area is not left without required medications) . Monitor the drug expiration dates. Trained pharmacists should be present at codes when possible. Patients can play a vital role in preventing medication errors when they have been encouraged to ask questions and seek satisfactory answers about their medications before drugs are dispensed at a pharmacy. If a patient questions any part of the medication dispensing process, whether it is about the drug’s appearance, dose or something else, the pharmacist must be receptive and responsive ( not defensive ). All patient inquiries should be thoroughly investigated before the medication is dispensed. The written information about the medications should be at a reading level that is appropriate for the patient. It may be necessary to provide pictures or other means of instruction to patients who do not speak English or are unable to read English. Attempts must be made to communicate to the patient in their language, using on-site staff or dial - in translation services. CODE BLUE A code blue refers to a patient requiring emergency medical care, typically for cardiac or respiratory arrest. The overhead announcement and /or paging system will provide the patient's location. The code team (often including a pharmacist) will rush to the room and begin immediate resuscitative efforts. DEDICATE PHARMACISTS TO HIGH RISK AREAS The intensive care unit ( ICU) , pediatric units and emergency departments are units with a high incidence of preventable medication errors. Pharmacists working in these units can assist in identifying and preventing medication errors by developing process improvements designed to reduce errors. FIVE RIGHTS OF MEDICATION ADMINISTRATION One recommendation is to use the "five rights" when administering medications to help prevent medications errors. The "five rights" are a quick double check that should be performed by a healthcare professional every time when giving a medication (see figure) . The "five rights ” are an example of a best practice in medication safety, but cannot prevent errors aloneand must be combined with other system based error prevention methods. Barcoding (discussed later in this chapter ) is an example of a technological tool that has been implemented in medication administration to assist in ensuring the "five rights." MONITOR FOR DRUG- FOOD INTERACTIONS Check for drug-food interactions routinely and involve the nutrition department ( also called "dietary ” ) when the profile includes drugs with a high rate of food interactions (e.g., warfarin) , or medications that interact with enteral feedings (i.e., tube feedings) . For example phenytoin administration via feeding tube requires that enteral feeding be held for 1 - 2 hours before and after the dose. EDUCATION Staff education programs such as "in -services ” should be provided whenever new high-alert drugs are being used in the facility, to introduce new procedural changes aimed at preventing medication errors and to introduce any new guidelines. The information provided in these "in services” should be unbiased and should not be provided in a skewed manner by drug company representatives. Many hospitals now limit access of pharmaceutical companies and representatives due to the inherent bias. THE 5 " RIGHTS" . RxPrep Course Book | RxPrep C> 2019 RxPrep USE OF TECHNOLOGY AND AUTOMATED SYSTEMS COMPUTERIZED PRESCRIBER ORDER ENTRY AND CLINICAL DECISION SUPPORT Computerized physician / provider order entry (CPOE ) is a computerized process that allows direct entry of medical orders by prescribers. Directly entering orders into a computer has the benefit of reducing errors by minimizing the ambiguity resulting from handwritten orders. A much greater benefit is seen with the combination of CPOE and clinical decision support (CDS) tools. Clinical guidelines and patient labs can be built into the CPOE system and alerts can notify a prescriber if the drug is inappropriate, or if labs indicate that the drug could be unsafe (such as a high potassium level and a new order for a potassium -sparing agent ) . CPOE can include standard order sets and protocols. An example of an on -screen alert from a CDS system is shown below. This alert appears when a prescriber attempts to order citalopram with a dose greater than 40 mg /day. In addition to medication orders, CPOE is used for laboratory orders and procedures. In most hospitals, pharmacists are actively involved in creating, updating and monitoring the CDS tools. One aspect of CQ1 is monitoring, reporting trends and addressing alert overrides. CITALOPRAM DOSE RANGE FDA notified healthcare professionals and patients that the antidepressant Celexo (citalopram) should no longer be used at doses greater than 40 mg per day because it can cause abnormal changes in the electrical activity of the heart. In addition, studies did not show a benefit in the treatment of depression at doses higher than 40 mg per day. Read the MedWotch safety alert by clicking "References* linked to the FDA Drug Safety Communication. Thank you > 2020 IV that are not meant to be administered in this manner. When a medication is scanned and administered using barcode technology, the administration can automatically populate on the medication administration record ( MAR ) , thus avoiding the time associated with manual charting of medication administration. AUTOMATED DISPENSING CABINETS Most pharmacy interns will have seen automated dispensing cabinets ( ADCs) while on clinical rotations. Common names are Pyxis, Omnicell , ScriptPro and AccuDose. Over half of the hospitals in the U.S. now use ADCs. In many hospitals, they have replaced patient cassettes that had to be filled at least once daily and exchanged. Practical Benefits of ADCs The drug inventory and medication can be automated when drugs are placed into the cabinet and removed. Controlled drug security can be improved (versus the previous method of keeping the controlled drugs locked in a metal cabinet or in a drawer in the nurses’ station) . The drugs are easily available at the unit and do not require individual delivery from the pharmacy. ADCs provide alerts, usage reports and work well with barcoding. Alert Action Methods to Improve ADC Safety TIC requires that the pharmacist review the order before O Cancel citalopram O Override ( References ) OK BARCODING Barcoding may be the most important medication error reduction tool available right now. The barcode follows the drug through the medication use process to make sure it is being properly stocked (such as in the right space in the pharmacy or in the right pocket in the dispensing cabinet ) , through compounding (if required ) and to the patient. The barcode is used at the bedside to identify that the correct drug ( by scanning the barcode on the drug's packaging) is going to the right patient ( by scanning the barcode on the patient's wristband ) and confirms that the dose is being given at the right time. The nurse may have a badge barcode to track who administered the dose. Barcodes are now on many pumps and can prevent errors involving medications being given the medication can be removed from the ADC for a patient, except in special circumstances ( an override ) . The override function should be limited to true emergencies and all overrides should be investigated. The most common error associated with ADC use is giving the wrong drug or dose to a patient. The patient's MAR should be accessible to practitioners while they are removing medications from the ADC. Barcode scanning improves ADC safety. The drug can be scanned to make sure it is going into the right place in the cabinet and can ensure that the right drug is being pulled. Prior to administration, the patient's wristband can be scanned to make sure the drug is going to the right patient.