A case of omissions - WiHCA/WiCAL · Slide 28 © 2016 MMIC/UMIA. All rights reserved 10² 12% of residents in LTC facilities are on anticoagulant therapy Time spent in therapeutic

Slide 1

© 2016 MMIC/UMIA. All rights reserved

Preventing Medication Errors

Steven DuBois, RN, BSN, CPHRM, CHEM

Manager, Sr. Risk and Patient Safety Consultant

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Learning objectives

1. Identify the incidence and root causes of

preventable adverse drug and medication

error-related injuries.

2. Discuss how to implement a system-based

approach to preventing medication errors.

3. Utilize evidence-based tools, resources and

guidance for appropriate medication

management and medication reconciliation.

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Slide 3


A case of

omissions

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Slide 4


… 24 of them

Orders included three two-tablet doses

potassium daily

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Slide 5


Preventing medication errors

PART ONEIncidence and

harm

PART TWOCommon errors

and root causes

PART THREEReducing risk

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Slide 6


Medication errors and

adverse drug events

Any preventable event that may

lead to or cause harm

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Slide 7


Incidence of medication errors

1.5 million Americans injured every year in

various settings -including nursing

homes

800,000 preventable medication errors in

nursing homes annually

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Slide 8


Incidence of medication errors

Error rate:

• Higher in nursing facilities than in hospitals

• Higher in assisted living than in nursing facilities

Most common errors:

• Omission

• Wrong time

• Failure to monitor

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Slide 9


2014 OIG Report: Adverse events in SNFs

22% suffered adverse events

59% of events preventable

50% readmitted

$2.8 billion in 2011

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Slide 10


Adverse events in skilled nursing facilities

Types of adverse events Percentage*

Events related to medication 37%

• Medication-induced delirium or other change

in mental status 12%

• Excessive bleeding due to medication 5%

• Fall or other trauma with injury secondary

to effects of medication 4%

• Constipation, obstipation and ileus related to medication 4%

• Other medication events 14%

* The percentages for conditions listed within the clinical categories do not sum to 100 percent because of rounding.

Source: OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011.

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Slide 11


Harm caused by medication errors

• Falls and fractures

• Malnutrition

• Dehydration

• Delirium

• Over-sedation

• Behavior problems

• Hospitalization

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Slide 12


Hospital readmissions

19% of discharged

patients experience an adverse event

2/3 attributed to medication

errors

Med errors cause

significant proportion of

hospital readmissions

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Slide 13


Hospitalization causes harm

Medication errors

Infections

Confusion

Poor nutrition

Skin breakdown

Deterioration in condition

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Slide 14


• Polypharmacy

• Frail, elderly

• Transitions of care

High-risk profile

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Slide 15


Common medications involved in errors

0%

2%

4%

6%

8%

10%

12%

14%

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Slide 16


Medication errors: stage of process

Ordering

Transcribing

Administration

Monitoring

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• Wrong drug

• Wrong dose

• Errors at transitions of care

– Omission of hospital meds

– Continuation of hospital meds

Ordering errors

Ordering

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Slide 18


Ordering errors

• Discrepancies at transition

• Mismatch between discharge summary and referral form

• Error rate at transition

Ordering

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Slide 19


Medication Common error type(s) during transition

warfarin Communication error regarding dose,

failure to order INR

insulin Communication error regarding dose

oxyCODONE with Name confusion with HYDROcodone

acetaminophen with acetaminophen

HYDROcodone with Name confusion with oxyCODONE with

acetaminophen acetaminophen

enoxaparin Dosing errors and delays in administration

Common errors identified by ISMP

ISMP Medication Safety Alert July 25, 2013

Ordering

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Slide 20


Transcribing errors – illegible orders

Transcribing

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Slide 21


Transcribing errors – illegible orders

Transcribing

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Slide 22


Transcribing errors – unclear orders

Transcribing


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Transcribing errors – dangerous abbreviations

Transcribing

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Slide 24


• Omitted medication

• Wrong – med, time, dose, route,

preparation, technique, resident

– Discontinued med

– Duplicate doses

Administration errors

Administration

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Slide 25


• Frequent delays in administration

– Mean delay: 12.55 hours

– Mean omitted meds: 3.4

Administration errors at transitions of care

Administration

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Slide 26


Monitoring errors

Inadequate

monitoring of

medication

Inadequate

monitoring for

change of

condition

Monitoring

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Slide 27


High-alert medications

• Anticoagulants

• Antipsychotic agents

• Diuretics

• Antiepileptics

Monitoring

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Slide 28


• 10–12% of residents in LTC facilities are on

anticoagulant therapy

• Time spent in therapeutic range < 50%

Anticoagulant therapy

Monitoring

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Slide 29


Root causes of medication errors

Breakdowns in communication:

• Unclear orders

• Illegible orders

• Dangerous abbreviations

• LASA (look-alike/sound-alike medications)

• Verbal orders

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Slide 30


Contributing factors

Lack of:

• Evidence-based medication policies

• Compliance with medication policies

• Education and training

• Appropriate staffing

• Continuity of caregivers

• Teamwork training

• Multidisciplinary approach

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Slide 31


Goal:prevent the

preventable

Studies show

42–51% of

events preventable

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Slide 32


Systems approach to

preventing medication errors

1 2 3

4 5

Assess

your safety

culture

Implement

adverse

event

reporting

Update

medication

management

policies

Review and

redesign

medication

processes

Analyze

your

data

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Slide 33


Systems approach to

preventing medication errors

10

Utilize

health IT

Provide

high-alert

medication

monitoring

services

Enhance

medication

reconciliation

process

Enhance

medication

regimen

review

Provide

education

and training

6 7 8

9

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Slide 34


Analyze

your data

1


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Slide 35


Medication error rates

• What is an “acceptable” error rate?

• Is 95% accuracy OK?

• Is 99.9% accuracy OK?

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Slide 36


Potential

error

Implications of

99.9% error rate

Unsafe airplane landings 84 per day

Lost mail 16,000 pieces per hour

Bank errors 32,000 errors per hour

American Society of Health-System Pharmacists Annual Meeting 1996, B.F. Shea

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Slide 37


Implement

adverse

event reporting2


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Slide 38


Medication error reporting

• How easy is it for staff to report medication errors?

• How safe is it for them to report?

• Your actual medication error rate may be higher than

the rate indicated in your reports …

you only know what your staff is willing to tell you

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Slide 39


Barriers

to reporting


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Barriers to reporting

• Under-recognition of event

• Confusion about what to report

• Concerns about confidentiality

• Fear of blame and punishment

• Burden of time and effort

• Belief that reporting will make no difference

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Incentives to reporting

• Clarity about what to report

• Confidentiality and respect

• Belief that reporting will make a difference

• Feedback

• Ease of reporting

• Expectation of culture

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Assess your

culture of

safety

3


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Slide 43


Assess your culture of safety

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Slide 44


AHRQ culture of safety survey

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AHRQ’s 2014 culture of safety survey

Strengths:

• Overall perceptions of resident safety

• Feedback and communication about incidents

Weaknesses:

• Punitive response to mistakes

• Staffing issues

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Review and

redesign

processes

4


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Review and redesign processes

• Map medication processes

• Conduct FMEA

• Redesign medication

processes

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Slide 48


Update

medication

management

policies

5


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Slide 49


Update medication management policies

• Medication orders

– Components of appropriate order

– Verbal order; read back process

– Order clarification

• Administration policy – 5 rights; timeliness

• High-alert medications

• Lab level tracking/monitoring

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Slide 50


Update medication management policies

• Do Not Use list – dangerous abbreviations

• Do Not Crush list

• LASA (look-alike/sound-alike) precautions

• Medication reconciliation process and tool

• Medication competency and skills assessment

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Slide 51


Utilize Health IT

6


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Utilize health IT

• CCD (continuity of care document)

• CPOE and CDS

– Drug doses, routes, frequency

– Corollary orders

– Automated reminders

• eMAR (electronic med administration record)

• Barcode administration

• Test management and follow-up

• Transfer information

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Slide 53


Provide

anticoagulation

services

7


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Slide 54


Prescribing and

monitoring errors

most common


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Slide 55


Anticoagulation services

• Monitor VS daily

• Monitor for bleeding/bruises

• Monitor for dyspnea, chest pain, extremity

color/temperature change

• Use system for drug monitoring and communication:

– INR labs drawn per order

– INR results to physician in a timely manner

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Slide 56


Enhance

medication

reconciliation

8


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Slide 57


Lessons learned

Amaryl

Ramipril


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Slide 58


• Person’s lack of knowledge of

their medications

• Physician and nurse

workflows

• Lack of integration of patient

health records across

continuum of care

Causes of MR failure

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Slide 59


Reliable medication reconciliation

Home Hospital

Post-

acute

care

MD visit

MR MRMR

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Slide 60


Reliable medication reconciliation

• Define the steps

• Identify accountabilities

• Identify time frame for completion

• Educate staff

• Educate residents and family caregivers

• Implement a monitoring system

• Use a standard form

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Slide 61


Medication reconciliation worksheet

Part 1: Hospital recommended medications needing clarification

Medications recommended by hospital

discharge for which clarification is neededClarification needed*

Resolution for final orders

(continue, stop, change)

*Examples: unclear diagnosis or indication, uncertain dose or route of administration, stop date, hold parameter, lab tests needed for monitoring, dose different than before hospitalization, medication duplication

Part 2: Medications prior to hospitalization needing clarification

Medications taken before hospitalization not currently

on hospital recommended list

Comments (e.g. reason for the medication

before hospitalization and reason it was

stopped

in the hospital, if known)

Resolution for final orders

(continue, stop, change)

Medication reconciliation worksheet for post-hospital care


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Slide 62


Enhance

medication

regimen review

9


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Slide 63


Medication regimen review

Documented

indications for

med use

Identified

allergies,

potential side

effects and

medication

interactions

Documented

progress

toward goals

Acted upon

lab results and

diagnostic

studies

Acted upon

possible

medication-

related causes

of worsening in

the resident’s

condition

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Slide 64


Evidence-based tools

• Beers Criteria

• STOPP Criteria

• START Criteria

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Slide 65


Provide education

and training

10


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Slide 66


Provide education

Long-term care staff:

• Medication error root causes

• Medication processes/policies

• Medication error reporting

• Root cause analysis findings

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Slide 67


Provide education

Residents and family care-givers:

• Medication purpose, side effects, regimen

• Resident and family care giver role in medication

error prevention

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Slide 68


National Action Plan for

Adverse Drug Event Prevention

Initial targets are:

• Anticoagulants - bleeding

• Diabetes agents - hypoglycemia

• Opioids - accidental overdoses, over-sedation,

respiratory depression

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Slide 69


Questions? Contact us

[email protected]

952.838.6709

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Documents

A case of omissions - WiHCA/WiCAL · Slide 28 © 2016 MMIC/UMIA. All rights reserved 10² 12% of residents in LTC facilities are on anticoagulant therapy Time spent in therapeutic