Medical and Medication Errors CE Program. Tom Johns, PharmD, BCPS Director, Pharmacy Services UF Health Shands Hospital

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1 Medical and Medication Errors CE Program Tom Johns, PharmD, BCPS Director, Pharmacy Services UF Health Shands Hospital

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5 RANK ORDER OF ERROR REDUCTION STRATEGIES Forcing functions and constraints Automation, computerization, bar code scanning Standardization and protocols Time out, checklists and double check systems Rules and policies Visual warnings (auxiliary labels) Education/information Be more careful, be vigilant 5

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7 The Power of the Story Stories. attract attention promote critical thinking are memorable create empathy inspire and incite change ISMP Medication Safety Alert! September 8,

8 Heparin Clarian Health System 1 ml heparin vials that contained 10,000 units/ml misplaced into NICU unit-based automated dispensing cabinets by pharmacy technician 3 fatalities 8

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12 Progesterone vaginal suppository Prostin E-2 vaginal suppository (prostanglandin E-2, dinoprostone) 12

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16 Who do you blame for the error? Person approach Blames the individual person Bad things happen to bad people Focuses on unsafe acts Forgetfulness Poor motivation Negligence System approach Humans are fallible and errors are to be expected Focus on defenses, barriers and safeguards Errors are viewed as consequences of upstream systemic factors 16

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18 Were the actions as intended? Unauthorized substance? Knowingly violate safe operating procedures? No No No Pass substitution test? Yes History of unsafe acts? Yes No Yes Yes No Were the consequences as intended? Medical condition? Were procedures available, workable, intelligible and correct? Deficiencies in training & selection or inexperience? Yes No Yes Sabotage, malevolent damage, suicide, etc. No Substance abuse without mitigation Yes Substance abuse with mitigation Yes Possible reckless violation No Systeminduced violation Diminishing culpability No Possible negligent error Yes Systeminduced error Blameless error but corrective training, counseling needed Blameless error Decision Tree for Determining Culpability of Unsafe Acts Reason, J., Managing the Risks of Organizational 18 Accidents

19 Medication Error Definition 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. 19

20 Stage of Errors 20

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24 Error Types Wrong drug Wrong patient Wrong dose Wrong time Wrong route Overdose Underdose Lack of drug Unnecessary drug 24

25 Most Common Drugs 25

26 Errors Contributing Factors Communication Look alike/sound alike medications Distractions and interruptions Knowledge deficit Calculation errors IV infusion pump administration errors Confirmation bias 26

27 Quantifying Adverse Drug Events Voluntary Medication Error Reporting 27

28 Voluntary Error Reporting Under-reporting of errors o o Estimated only 10-20% of actual errors are reported Should not use as a quantitative measure Many reasons for under-reporting o o o o You don t know what you don t know Fear Liability Time Value: learn what type of problems are occurring in your hospital from a qualitative perspective Goal: voluntarily reported medication error rates should increase over time o Indicates a positive culture of safety, where employees are encouraged and feel free to report errors 28

29 Medication Error Reporting 29

30 IHI Trigger Tool for Measuring Adverse Drug Events (ADEs) Using triggers to identify ADEs is an effective method for measuring the overall level of harm from medications Conducted through retrospective chart review with a multidisciplinary team Reported as a quantitative rate o ADEs per 1,000 doses o Percent of admissions with an ADE 30

31 Trigger Examples Vitamin K INR >6 Flumazenil Naloxone Glucose <50 Rising serum creatinine Over-sedation, lethargy, falls Abrupt cessation of medication 31

32 Medication Error Severity Definitions 32

33 Electronic Reporting 33

34 Healthy Root Cause Analysis A Structured (Reactive) Response to Medication Errors Everyone needs to play well in sandbox together: no finger pointing, no accusations, no passing judgment Multidisciplinary team including individuals involved in the error Importance of medical staff involvement Structured (semi) process - what happened, why did it happen (causes/contributing factors); what can be done to prevent it from happening again 34

35 A Framework for a Root Cause Analysis and Action Plan In Response to a Sentinel Event 35

36 Medication Error Analysis 36

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38 TRANSPARENCY 38

39 Sterile Product Observations Incorrect BUD applied to CSP prepared in LAFH SDV used on multiple patients MDV without expiration date MDV used beyond expiration date Assumption that vial stopper is sterile underneath protective cap Infusion bags used as multidose container for flushes Needles and syringes stored unwrapped Medication prep areas unclean and cluttered Pre-spiking IV bags Inappropriate syringe labeling (or no label) 39

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41 Avoid Unsafe Abbreviations Do not use any of the following: U,u - IU - Q.D., QD, q.d., qd - Q.O.D., QOD, q.o.d, qod - Trailing zero (X.0 mg) - Lack of leading zero (.X mg) - MS - MSO4 - MgSO4 41

42 Remove Concentrated Electrolytes from Patient Care Areas Concentrated potassium chloride (KCL) USP nomenclature changes 42

43 Labeling Syringes and Bowls 43

44 Identify and review a list of lookalike/soundalike drugs and take action to prevent errors involving the interchange of these drugs 44

45 Avoid Look-alike Products 45

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47 Oral unit dose syringe availability 47

48 Oral unit dose syringe availability 48

49 Medication Reconciliation 49

50 Home Medication Profile Form 50

51 Patient Safety Initiatives Standardization of care Insulin protocols Heparin protocols VTE prophylaxis protocol Evaluation of process improvements Are they being ordered appropriately? Are the orders being followed by nursing staff? 51

52 Shands UF Heparin Protocol 52

53 Shands UF Heparin Documentation Tool 53

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55 Insulin Ranks as #1/#2 in medication errors both internally and with external benchmarks Most common error types Look alike/sound alike mistakes Storage in original boxes IV infusion pump administration errors Dosage miscalculation withdrawing from vials 55

56 BEFORE AFTER Vials prefilled syringes Product/Name diversification 56

57 Heparin Shands UF evaluation Med Safety Committee All heparin products pulled for comparison Prevention strategy Utilize 10 unit/ml syringe instead of vial ($250,000 annual increase in drug budget) 57

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59 NMB Error Prevention Strageties Conduct a failure-mode and effects analysis (FMEA) Store separately from other medications Limit availability to the pharmacy and patient care areas that routinely care for mechanically ventilated patients All institutionally prepared syringes or infusion containers of should contain a clearly visible, brightly colored alert stating, Warning: Paralyzing Agent (Use Requires Mechanical Ventilatory Assistance). 59

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61 Promethazine ISMP Medication Safety Alert! August 10, 2006 Extravasation leading to amputation has occurred Contraindicated in children less than 2 y/o Potential to cause fatal respiratory depression Ensure 50 mg/ml vial is not stocked Created comment that appears on label and MAR.. dilute in 10 ml and infuse over 10 minutes 61

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64 Smart Infusion Pumps Multiple types of pumps with central brain Guard rail technology (hard/soft alerts) Drug library Library can change for different patient populations (eg, adult, pediatrics, critical care) wireless or manual change Track averted errors 64

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66 Alaris Smart Pump Alerts November 2009 Guardrails CQI Reporter Drug or Fluid Alerts by Times the Limit Ranges Count of Frequency Times Intended Dose Count

67 Insulin example Patient receiving Insulin infusion for tight blood glucose control in ICU Insulin infusion bag concentration is 0.5units/mL Intended rate was 2.4mL/hr Nurse programs the pump to run at 204mL/hr the Smartpump created a hard stop requiring the nurse to reprogram the pump. This was a keypad error as the decimal point is next to the zero on the face of the pump. This was a potentially lethal error that was avoided. 67

68 Medication Errors Captured by Alaris Smart Pump Insulin (Adult ICU) Programmed dose: 40 units/hr (80 ml/hr) Intended dose: 4 units/hr (8 ml/hr) NORepinephrine (Adult ICU) Programmed dose: 1.2 mcg/kg/min (189 ml/hr) Intended dose: 0.12 mcg/kg/min (18.9 ml/hr) FUROSemide DRIP (PICU) Programmed dose: 2 mg/kg/hr (3.4 ml/hr) Intended dose: 0.2 mg/kg/hr (0.34 ml/hr) 68

69 24 Hour Chronogram Reprogram Alerts 10 fold or greater only All Patients 22:00 23:00 0: :00 2:00 21: :00 20: :00 19: :00 18:00 0 6:00 17:00 7:00 16:00 8:00 15:00 9:00 14:00 13:00 12:00 11:00 10:00 69

70 Emergency Carts 70

71 Emergency Medication Tray 71

72 Risk reduction strategies to prevent medication errors during codes. 72

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