Download Error Reduction Strategies for High

Error Reduction Strategies for
High-Alert Medications
Kelly Besco, Pharm.D., FISMP, CPPS
Medication Safety Officer | OhioHealth Pharmacy Services
Conflict of Interest Disclosure
Kelly Besco declares no conflicts of interest, real or
apparent, and no financial interests in any company,
product, or service mentioned in this program,
including grants, employment, gifts, stock holdings, and
honoraria.
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Objectives
• Describe troublesome process designs that often
impact the safe use of high alert medications.
• Identify three key safety principles to use in
medication error prevention.
• Differentiate between high leverage and low leverage
error reduction strategies.
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Principles of Safe Use of Medications
• Three principles to promote the safe use of
medications
1) Reduce or eliminate the possibility of error
2) Make errors visible
3) Minimize the consequence of error
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Reduce of Eliminate Possibility of Error
• Limit the number and
variety of medications
available for use.
• Examples:
– Isolate storage of
medications to Pharmacy
– Ban on OTC sale of
pseudoephedrine, which is
used to make
methamphetamine
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Make Errors Visible
• Making errors visible can prevent patient harm from
occurring.
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Minimize Consequences of Error
• Practices can be changed to reduce effect of errors
that occur.
• Closer monitoring can improve early detection of
errors and prompt remedial action.
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Error Reduction Strategies
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Rank Order of Error-Reduction Strategies
Strategy
– Fail-safes and Constraints
– Forcing Functions
– Automation and
computerization
-----------------------------------– Standardization
– Redundancies
– Reminders and checklists
------------------------------------– Rules and policies
– Education and information
– Suggestions to “be more
vigilant”
Power (Leverage)
Car won’t start if
alcohol is
detected on
breath
Reminder
signs and
checkpoints
Rule/Law: It’s
illegal to drive
over the
allowable alcohol
limit
– High
– Medium
– Low
Fail-safes
Feature which, in the
event of failure, responds
in a way that will cause
no harm or at least a
minimum of harm.
It is automatically
activated in the event of
failure.
Fail-safes
Bubble detector: A
safety device that
detects air bubbles
in the tubing,
indicating that air
was drawn into the
line and a decreased
delivery of the
ingredient could
result.
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Constraints
The state of being checked, restricted, or
compelled to avoid or perform some action.
Forcing Functions
• Aspect of a design that prevents the user from taking
an action without consciously considering information
relevant to that action.
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Standardize and Simplify
• Standardization reduces reliance on human memory
and vigilance.
• Simplification of processes reduces load on memory,
planning and problem solving.
• Standardization and simplification reduce variation
and complexity.
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Available Heparin Vial Concentrations
• 10 units/mL
• 100 units/mL
– 1 mL vial
– 10 mL vial
• 1,000 units/mL
–
–
–
–
1 mL vial
2 mL vial
10 mL vial
30 mL vial
• 5,000 units/mL
– 1 mL vial
– 10 mL vial
• 10,000 units/mL
–
–
–
–
1 mL vial
4 mL vial
5 mL vial
10 mL vial
• 20,000 units/mL
– 1 mL vial
– 5 mL vial
• Order stated “Cytoxan 4 g/m2 days 1-4
(over 4 days)
• Given as 4 g/m2 EACH DAY for four days
Benefits of Standardized
Work
Before implementing daily
goals sheet:
Less than 10% nurses and
residents understood goals for
care for the day
After implementing daily goals
sheet:
Greater than 95% of nurses and
residents understood the goals
for care for the day
ICU LOS decreased from a
mean of 2.2 days to 1.1
Simplify
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Differentiation
• Need to draw attention to
differences between lookalike products.
• Strategies:
1) Remove one of the look-alike
medications from use
2) Purchase one of the products
from a different
manufacturer
3) Use auxiliary warning labels
4) Barcode scanning
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Reminders
• Examples:
– Warning labels
– Computerized warnings
– Visual aids
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Redundancies
• A system of redundancies in which one person
independently checks the work of another individual
is essential to embed in processes involving high-risk
medications and populations (e.g., pediatrics).
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Case Study: Concentrated U-500 Insulin
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Concentrated U-500 Insulin: Common Errors
• Dose Translation—
– Incorrect doses translated when dose written as
corresponding units on U-100 insulin syringe.
• Many “good catches” made by hospital with established
Pharmacist verification protocol.
• Omissions—
– Protocol was to use patient’s own supply resulting in
missed doses until medication brought in by patient’s
family.
• Patient Administration Events—
– Patient administered own supply without physician
order.
U-500 Insulin Safe Use Protocol
• Standardized
order set
• Endocrinology
consult
• Pharmacist
double check
• Patient Interview
Prescribing
Administration
• Nursing
education
• Patient specific
doses
Transcribing
Storage/
Dispensing
• Separate storage
• Dispense in
tuberculin syringe
• Product double
check
Safe Use Protocol– Prescribing
Safe Use Protocol– Prescribing
Safe Use Protocol– Prescribing
Safe Use Protocol– Prescribing
Safe Use Protocol– Prescribing
• Additional Ordering Parameters—
– If an order is NOT completed on the order set, the
reviewing Pharmacist contacts the prescriber.
– Pharmacists may complete the order as a telephone
order if desired by the prescriber.
Safe Use Protocol– Transcribing
• As an additional layer of safety, a
process was approved for
Pharmacists to interview the
patient to verify their home dose
of U-500 insulin.
• A kit was developed for use during
the interview.
• The kit features a U-100 and
Tuberculin syringe as well as an
interview checklist.
• Orders are not transcribed by the
Pharmacist until the interview is
conducted.
Safe Use Protocol– Transcribing
• During interview patient is asked
which syringe they use to administer
their insulin and demonstrate using
the identified syringe, the dose they
draw up into the syringe.
• A progress note is completed by the
Pharmacist once the verification is
completed.
• A standardized template was
developed for the progress note.
• Pharmacist additionally updates
electronic medication reconciliation
list with home dose and notes the
equivalent dose on a U-100 syringe.
Safe Use Protocol– Transcribing
• Order Entry—
– U-500 process checklist available
to pharmacists
– Link in pop-up box in Pharmacy
information system.
– Computer entry listing designed
to reduce risk of incorrect
selection.
– Default route to subcutaneous in
computer system.
– Independent double check
required to verify accuracy.
Safe Use Protocol– Storage/Dispensing
• Storage—
– U-500 vials are separated from other types of insulin in
the Pharmacy.
• Vials are NOT stored in patient care areas.
– Stored in red “high alert” medication bins.
– Auxiliary labeled— “high potency”
Safe Use Protocol– Storage/Dispensing
• Dispensing—
– Pharmacy dispenses
individual doses to the
units
• Tuberculin syringes
• Each dose labeled will
“high potency”
auxiliary sticker
• Each syringe requires a
two Pharmacist double
check prior to
dispensing.
Safe Use Protocol– Administration
•
Since orders for U-500
insulin are rare, a
Nursing Education
sheet is sent with each
dispensed syringe to
remind Nursing staff of
required safe
practices.
Validate Effectiveness!
• Review was completed of patients that received U500 insulin over a 6 month period.
– 22 patients included in the review.
• Results of the review showed that overall, we are
doing a GREAT job in following our safety protocol.
– Example: The Humulin Regular U-500 Insulin Order Set
was completed in 100% of patients!
• There was 1 opportunity identified from the review
related to completion of the Pharmacist Progress
Note subsequent to the patient interview.
Opportunities
• Completion of Progress Note—
– Pharmacist feedback was that the initial template
provided for the progress note was too long and
detailed; therefore, it was not being used 100% of the
time.
– SOLUTION: A streamlined/shorter version of the
progress note template was developed.
Process Improvement
Revised Progress Note Template—
PHARMACOTHERAPY NOTE: INSULIN U-500 VERIFICATION
Pharmacist has evaluated patient’s home dose of insulin U-500
during an interview with the patient and/or caregiver and:
___ Verified dose has been correctly ordered OR
___ Physician has been contacted to correct order
Please call with any questions.
Pharmacist Name:
Contact Number:
Rank Order of Error-Reduction Strategies
Strategy
– Fail-safes and Constraints
– Forcing Functions
– Automation and
computerization
-----------------------------------– Standardization
– Redundancies
– Reminders and checklists
------------------------------------– Rules and policies
– Education and information
– Suggestions to “be more
vigilant”
Power (Leverage)
– High
– Medium
– Low
Risk Management Plan Design
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Risk Control
• Error prevention strategies are not mutually
exclusive.
• The fastest and easiest solution may not always be
the best . . . may introduce new sources of error.
• People cannot be expected to compensate for weak
systems
• Do not rely on education alone!
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Prioritize Risk-Control Efforts
• High impact (for severity)
– Effect which has the greatest potential to cause harm
• Actionable
• Streamlines and simplifies, does not add complexity
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