Failure Modes Effects Analysis of Morphine Prescribing

Transcription

1 Failure Modes Effects Analysis of Morphine Prescribing Hilary Writer MD FRCPC Elaine Wong BScPhm CPSI Patient Safety and Quality Improvement Forum,14 April 2010

2 Outline Rationale Medication Incidents with Morphine Morphine Administration Failure Modes Effects Analysis CHEO team and process Findings Recommendations and Future Plans

3 Why look at Morphine in Paediatrics In the paediatric literature, the reported prevalence of morphine adverse events ranges from 1% to 43% Esmail Z, Montgomery C, Courtrn C, Hamilton D, Kestle J. Efficacy and complications of morphine infusions in postoperative paediatric patients. Paediatric Anaesth. 1999; 9 (4):

4 Why look at Morphine in Paediatrics? Year 2008 Number of Patients <18 MORPHINE MEPERIDINE HYDROMORPHONE OXYCODONE METHADONE OXYMORPHONE Total Inpatients Receiving Opiate Agonists Brogan CHEO Brogan CHEO Brogan CHEO Brogan CHEO Brogan CHEO Brogan CHEO Brogan CHEO Brogan CHEO Brogan Narcotic Hospital Utilization

5 Why look at Morphine in Paediatrics? Anesthesia Patient Safety Foundation (APSF) There is still a low but unpredictable incidence of lifethreatening, opioid-induced respiratory depression in young healthy patients No patient shall be harmed by opioid-induced respiratory depression in the post-operative period Healthcare providers should have zero tolerance of respiratory morbidity and mortality associated with opioid use in the post-operative period because these events should be completely preventable

6 Why look at Morphine in Paediatrics? Medication Incidents ISMP 11 CAPHC member organizations found 305 reported incidents with an outcome of harm. Top 5 Medications with reports of incidents causing harm in a paediatric population Medication # Incidents (%) (Total n = 294) Morphine 26 (8.8) Potassium chloride 14 (4.8) Insulin 11 (3.7) Fentanyl 10 (3.4) Salbutamol 10 (3.4) ISMP Canada Safety Bulletin. Volume 9. Number 6. August 31 st, 2009

7 Why look at Morphine in Paediatrics? Because Accreditation Canada says so..

8 CHEO Internal Data 2406 safety reports posted (Jan 2007 Apr 2009) Of these, 671 (27.98%) were medication incidents 3.5% 5.7% Other medication incidents Other Opioids related Morphine related

9 Making Morphine Administration Safer Storage IDC Prescribing Monitoring Guidelines Monitoring

10 Overview of CHEO initiatives FMEA Pharmacy preparation of epidurals (2006) Morphine monitoring study (2006) Standard dose concentrations and calculation tool (2006) FMEA Epidural pump programming (2007) Development of PPO for PCA, continuous opioid infusions epidural infusions (2007) Independent Double Check/Double Check policy (2008) CAPHC/ISMP National Collaborative participation (2008) Late Career Nurse Initiative Morphine Administration (2009) Morphine IV bolus administration and Human Factors (2009)

11 FMEA Morphine Prescribing Team-based systematic and proactive approach for identifying the ways that a process or design can fail, why it might fail, the effects of that failure and how it can be made safer FMEA focuses on how and when a system will fail, not IF it will fail Practitioners in the system know the vulnerabilities and failure points

12 FMEA Process 1. Select a high risk process and assemble a team 2. Diagram the process 3. Brainstorm potential failure modes 4. Identify causes of failure modes 5. Prioritize failure modes 6. Re-design the process 7. Analyze and test the new process 8. Implement and monitor the new process Canadian Failure Mode and Effects Analysis Framework ISMP

13 FMEA Multidisciplinary Team Representation from Physicians (Critical Care Physician, Emergency Care Physician, Palliative Care, Chronic Pain & Symptom Management Physician, Anaesthesia & Acute Pain, Medical Resident, Surgery) Nursing Pharmacy Human Factor Engineering (Professor from Carleton University & Master s level student) Physicians were the core of the team Meetings did not take place without at least 3 physicians

14 Process Diagram Failure Modes Morphine prescribing Decision Information gathering MD Dose calculation Prescription written Order sheet/ppo available Reassess

15 Written Prescription Trailing zeros Allergies, wt Correct chart Math Legible Sig. Route Do not use Frequency, duration Drug name Legible order Correct pen Units, dose, range Signature quality ink Adjunct orders

16 FMEA: Morphine Prescribing 6 large category failure modes 8 total sub-categories of each failure mode 74 total causes across all failure modes Panel focused on the written prescription

17 Failure Modes Single Point Weakness A step so critical that its failure will result in a system failure or adverse event Prioritise Failure Modes: Severity (Score 1-5) Detectability (Score 1-4) Frequency (Score 1-5) Assign Risk Priority Number (RPN) where: RPN = Severity x Detectability x Frequency RPN > 48 Severity 5

18 Single Point Weaknesses

19 Severity 5 Weaknesses Severity 5 weaknesses

20 Risk Priority Number (RPN) 48 RPN 48

21 Strategies & Recommendations Development of corporate dosing guidelines Development of a verbal order policy Promotion of pre printed orders hospital wide Support for computerized physician order entry with forcing functions.

22 Possible Solutions: SPWs

23 Possible Solutions: Severity 5 Weaknesses Severity 5 weaknesses

24 Possible Solutions: Risk Priority Number (RPN) 48

25 Corporate Dosing Guidelines Development and dissemination of corporate dosing guidelines Audit of pharmacist interventions Review of safety reports Historical peak in July with new housestaff

26 Verbal Order Policy Development of corporate Policy Audit compliance with policy (including written documentation of read back ) Review of Safety reports Should Verbal Orders be allowed..?!

27 Promotion of Pre-Printed Orders Hospital Wide Audit of compliance with use of the pre-printed orders based on unit Initiate new PPO s where necessary

28 Computerized Aids Build prescribing templates with dosing guidelines, max/min alerts within computer systems Physician order entry IV infusion pumps Audit overrides in ordering/administering outside usual dosing guidelines

29 Future Directions Educational Programs In-person Web-based with testing Chart Audits Eg compliance with no dosing/duration range Pain scores E-clin Doc Monitoring data Human Factors Analysis

30 Hawthorne Effect? Reports to SRS April 09-Dec 09 Key Word Morphine 11 of 332 events 3.3%

31 CHEO Internal Data 2406 safety reports posted (Jan 2007 Apr 2009) Of these, 671 (27.98%) were medication incidents 3.5% 5.7% Other medication incidents Other Opioids related Morphine related

32 Comments or Questions?