Medicanteion Misadventures Jeanne Frenzel

Medication
Misadventures
Jeanne Frenzel, PharmD
Heidi Eukel, PharmD
Rebecca Focken, PharmD, BCACP, CGP
College of Health Professions
North Dakota State University
NDPhA Annual Convention 2016
Disclosures
 The speakers have not actual or potential conflicts of
interest in relation to this presentation
Objectives
1. Identify strategies to reduce the rate of medication errors
2. Identify resources available to pharmacists and patients
regarding the identification, prevention, and tracking of
medication errors
3. Understand North Dakota Pharmacy Statute 61-02-01-19
(Continuous Quality Improvement) and its application to
pharmacy practice
4. Utilize root cause analysis to identify contributing factors
to medication errors
5. Identify types of medication errors in long term care,
community, and institutional pharmacy practice settings
What is a medication error?
"A medication error 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 health care professional,
patient, or consumer. Such events may be related to
professional practice, health care products, procedures, and
systems, including prescribing, order communication, product
labeling, packaging, and nomenclature, compounding,
dispensing, distribution, administration, education, monitoring,
and use."
http://www.nccmerp.org/about-medication-errors
Causes of Medication Errors
A Systems Approach
1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
Role of Drug Names in Medication Errors
 After reports of errors, Food and Drug Administration (FDA)
and Institute for Safe Medication Practices (ISMP)
recommended a medication name change
Losec (omeprazole) vs Lasix (furosemide)
Similar brand names
Same dose 20 mg
Name look similar when handwritten
Role of Drug Names in Medication Errors
https://www.ismp.org/tools/tallmanletters.pdf
Role of Drug Names in Medication Errors
https://www.ismp.org/tools/confuseddrugnames.pdf
Role of Drug Names in Medication Errors
 FDA requires each new formulation of a drug to be
distinguished by a suffix
 Inconsistent use of suffixes may cause errors
Wellbutrin SR – twice daily
Wellbutrin XL – once daily
Error Prone Abbreviations and Dose
Expressions
https://www.ismp.org/tools/errorproneabbreviations.pdf
High Alert Medications
https://www.ismp.org/tools/highalertmedications.pdf
Recommendations for Preventing Drug
Name Mix-ups
 Maintain awareness of look alike and sound alike drug names
 Determine medication indication before dispensing
 Accept spoken orders only when necessary
 Computerize prescribing
 When possible, list brand and generic names on medication
administration records and automated dispensing cabinet
computer screens
 Affix name alert stickers to areas where look alike or sound
alike products are stored
 Store products with look alike or sound alike names in different
locations in pharmacies
 Use independent double checks in dispensing process
Preventing Dispensing Errors
 Errors related to the work environment
Twenty-four hour service in hospitals
Workload
Work area and workflow
Cognitive and social factors
Storage
Nomenclature and packaging
Preventing Dispensing Errors
 Errors related to dispensing methods
Unit dose dispensing
Dispensing multiple tablets
Independent double checks before dispensing
Self checking
Reducing calculation errors
Verifying compounded products
Using Technology to Prevent Medication
Errors
 Pharmacy computer systems
 Automated dispensing cabinets
 Point of care bar code medication administration
 Smart pumps
 Stand alone data monitoring technology
Medication Error Reporting Systems
 Purpose of reporting systems
 Responsibility for reporting
 Reportable events, conditions, and priorities
 Reporting mechanisms
 When to report
 What information to report
Disclosing Medication Errors to Patients
and Families
 An expression of regret and apology
 The nature of the accident, including time, place, and circumstances
 The proximate cause, if known
 Definite and potential consequences to the patient
 Actions taken to treat any consequences of the accident
 Who will oversee the ongoing care of patient
 Plans for investigation or review of the incident
 Actions taken to identify systems related causes and preventative efforts
 Who will oversee ongoing communication with the patient or representative
 Contact information for individuals at the facility who can answer questions
 Contact information of agencies with which the patient or representative
can communicate about the event
 The process for obtaining support
 The process for discussing compensation for harm
Managing Medication Risks Through a
Culture of Safety
 Strategic emphasis on safety
 Mindfulness and resilience
 Just culture
 Teamwork and localized decision making
 Error defying systems and redundancy
 Proactive focus and community involvement
 Learning culture and safety measurement
Continuous Quality Improvement
“Each pharmacy permittee shall establish continuous quality
improvement program for the purpose of detecting,
documenting, assessing, and preventing incidents, near
misses, and unsafe conditions.”
 North Dakota Pharmacy Statute 61-02-9-01
 Effective April 2, 2016
Continuous Quality Improvement
 Definitions
Actively reports
Analysis
Dispensing error
Incident
Near miss
Unsafe condition
Federally Listed Patient Safety
Organization (PSO)
“PSOs serve as independent external experts who can collect,
analyze, and aggregate Patient Safety Work Product to
develop insights into the underlying causes of quality and
patient safety events.”
 Listed on the Agency for Healthcare Research and Quality
(AHRQ) website, searchable by state and PSO specialty
Institute for Safe Medication Practices (ISMP)
Pharmacy Quality Commitment® (PQC)
Continuous Quality Improvement
 A pharmacy permittee meets the requirements if:
Maintains and complies with the policies and procedures
Pharmacy reports incidents, near misses, and unsafe
events through either:
 A contracted patient safety organization
 An internal program to the pharmacy
 Must include provisions to:
Designate an individual or individuals
Initiate documentation of incidents ≤ 7 days from
discovery
Continuous Quality Improvement
 Policies and Procedures
Training
Identify and document incidents and near misses
Minimize impact of incidents on patients
Analyze data
Respond to findings
Review findings with pharmacy personnel at least
quarterly
 Quality self-audit
Conducted at least quarterly
Upon change of pharmacist-in-charge
Continuous Quality Improvement
 Protection from discovery
Records from quality assurance program are not subject
to subpoena or discovery
Records are confidential and may not be released,
distributed, or communicated in any manner
 This does not affect discoverability of any records not
generated solely for the pharmacy’s QA program
Continuous Quality Improvement
 The board's regulatory oversight activities are limited to
inspection of the pharmacy's policies and procedures and
enforcing the pharmacy's compliance with these
 An analysis or summary of findings is evidence of compliance
Pharmacy Quality Commitment® (PQC)
 A continuous quality improvement program available
through the Alliance for Patient Medication Safety
 Allows collection of errors and near misses in order to easily
analyze and detect trends
 Web-based portal
 Information is completely protected from public knowledge
and is not available for any litigations.
Pharmacy Quality Commitment® (PQC)
 PQC can assist pharmacies to:
Comply with Quality Assurance requirements found in
network contracts, Medicare Part D, and state regulations
Protect patient safety data and quality improvement
work
Save money by improving workflow and decreasing
potential harmful events
Establish a strong team oriented patient safety culture
 Cost
$350 for first year
$250 each year thereafter
Institute for Safe Medication Practices
(ISMP) Tools
 Medication Safety Tools and Resources available for
Pharmacists
High-Alert Medication Modeling and Error-Reduction Scorecards
(HAMMERS™)
 Five Scorecards to evaluate errors relating to prescribing, data entry
(patient or medication data), wrong medication/dose selection, and
point of purchase.
 http://www.ismp.org/tools/HAMMERS/default.asp
ISMP Medication Safety Self Assessment for Automated
Dispensing Cabinets (ADC)
 https://www.ismp.org/selfassessments/ADC/Login.asp
ISMP Assess-ERR ™ and ISMP ASSESS-ERR™ Community Pharmacy
 These tools include worksheets that can be used to investigate errors in
both health system and community pharmacies.
 http://www.ismp.org/tools/AssessERR.pdf
 http://www.ismp.org/Tools/Community_AssessERR/default.asp
Institute for Safe Medication Practices
(ISMP) Tools
 Medication Safety Tools and Resources available for
Pharmacists
National Patient Safety Foundation (NPSF) RCA2:
Improving Root Cause Analyses and Actions to Prevent
Harm
 http://www.npsf.org/?page=RCA2
Root Cause Analysis Workbook for Community/Ambulatory
Pharmacy
 https://www.ismp.org/tools/rca/RCA-Complete.pdf
Root Cause Analysis
 An analysis that occurs retrospectively that investigates and
identifies the factors that either resulted in and/or have the
potential to result in either an adverse and/or sentinel event.
https://www.ismp.org/tools/rca/RCA-Complete.pdf
Root Cause Analysis Steps
 Gather an investigative team
 Review documentation related to the adverse/sentinel event
and/or near miss
 Consider how the physical environment may have contributed to
event/near miss
 Consider how products are labeled and packaged
 Conduct interviews of those involved in the adverse/sentinel event
and/or near miss
 Describe how the event unfolded using a flow chart
 Consider why an event and/or near miss could have occurred
 Consider factors that lead to the event/near miss and identify
primary causes
 Determine a plan to address each of the identified primary causes
 Evaluate the effectiveness of the plan to prevent future
events/near misses
 Share results
Cause and Effect Diagram: Fishbone
References
 Benefits of AHRQ Patient Safety Organziations (PSOs): Success
Stories from Hospital PSO Members. June 2015.
https://pso.ahrq.gov/sites
/default/files/wysiwyg/OnDemand%20Webinar%20Slides%20%20June%2010%202015.pdf
 Cohen, Michael Richard. Medication errors. American
Pharmacist Association, 2007.
 ISMP Root Cause Analysis Workbook for Community/Ambulatory
Pharmacy. https://www.ismp.org/tools/rca/RCA-Complete.pdf
 North Dakota Pharmacy Statute 61-02-901. http://www.legis.nd.gov/information/acdata/pdf/61-0201.pdf Accessed March 28, 2016.
 Pharmacy Quality Commitment. Alliance for Patient
Medication Safety. https://medicationsafety.org Accessed
April 10, 2016.