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MEDICATION SAFETY Administration of Medications Meeting HFAP Accreditation Standards for Pharmacy Services and Medication Use Part Three MEDICATION SAFETY Administration of Medications • HFAP Chapter 25 keeps you in compliance with the Medicare Conditions of Participation Medication Safety Series 1. 2. 3. 4. 5. Using CPOE: Challenges and Solutions to Address HFAP Standards Procurement, Preparation and Dispensing Administration of medications – timing, unit dose, bedside medication verification Monitoring of therapy, Medication Use Evaluations TBD The 6 rights Collaborative Process (nurses, RT, pharmacists, physicians) Routes of administration BMV Advantages Disadvantages What to do if you see medication errors (wrong patient, wrong drug, wrong time) Patient process Hand hygiene Identification Education of the patient Verification of the medication (double verification) Medications at the bedside and self-administration Observe for reactions Oral: sublingual, buccal Parenteral: intradermal, subcutaneous, intramuscular, intravenous Topical Inhalation Intraocular Metric Apothecary (grains) Household Grams (g), milligrams (mg), kilograms (kg) Liters (L), milliliters (ml) Tablespoons Teaspoons Ounces Cups Pints Quarts Conversions within systems Conversions between systems Six rights Triple-check before administration Patient assessment Right medication Right dose Right patient Right route Right time Right documentation Information Refusal Careful assessment Informed consent Safe administration Supportive therapy No unnecessary medications Collaborative process Nurses Pharmacists Respiratory Therapists Psychiatric Technicians Physicians Infants and children Older adults Polypharmacy Self-prescribing Over-the-counter medications Misuse Noncompliance Patient response to medications Patient and family ability to administer medications Presence of GI alterations Ability to swallow Use of gastric suction Positioning Skin applications Use of gloves or applicators Preparation of skin Thickness of application Assessment of nares Patient instruction and self-administration Positioning Drops, ointments, disks Assessment of eyes Asepsis Positioning Assessment of ear canal Warming of solution Straightening of canal for children and adults Positioning Metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) Patient assessment and instruction Use of spacer Determination of doses in canister Medications used to wash out a body cavity delivered with a stream of solution (sterile water, saline, or antiseptic) Asepsis Equipment Syringes: sizes (volume), types Needles: length, gauge Disposable units: Tubex, Carpuject Ampules Vials Mixing medications Determine compatibility of the medications Do not contaminate one medication with another Ensure the final dose is accurate Maintain aseptic technique Insulin Syringes and needle sizes Types of insulin Mixing of insulins Rotation of vials before withdrawal of solution Minimize discomfort Use smallest suitable needle Position client comfortably Select proper site Divert client’s attention Insert the needle quickly and smoothly Hold the syringe steady Inject the medication slowly and steadily Subcutaneous injections Sites: condition of area, rotation of use Amount of solution Length and gauge of needle Pinch or spread skin Angle of insertion Intramuscular injections Sites: landmarks, condition of area Amount of solution Length and gauge of needle Angle of insertion Aspiration Air-lock method Z-track technique Sites Ventrogluteal Vastus lateralis Deltoid Intradermal injections Skin testing Sites Length and gauge of needle Angle of insertion Formation of small bleb Needleless devices Sharps disposal One-handed recapping technique Large volume infusions Bolus injection Volume-controlled infusions Piggyback Tandem Volume-control set Mini-infusor pump Hand hygiene Identification Education of the patient Verification of the medication (double verification) Medications at the bedside and self-administration Observe for reactions Wash hands with soap and water or with waterless hand sanitizer before and after patient contact Gloves Must use at least two patient identifiers whenever administering medications. Acceptable identifiers may be the person’s name, an assigned identification number, a telephone number, a photograph, or another personal identifier. If bar code scanning is available, scan the patient’s armband Scan barcode Verify that this is the correct medication Verify dose Double verify High risk medications (heparin, insulin) Controlled substances More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999 Ordering 56% Administration 34% Transcription 6% Dispensing 4% Bates, Cullen, Laird, et al. “Incidence of Adverse Drug Events and Potential Adverse Drug Events.” JAMA, 1995, 274, 29-34. Why barcode medications? Nationally 2 of every 100 admissions experienced a preventable adverse drug event, resulting in increased hospital costs of $4,700 per admission. This is $2.8 million annually for a 700-bed teaching hospital. Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999 *Barcode Medication Administration (BCMA) in VA Medical Centers*: Right drug Right dose Right patient Right time Missed meds 75% improvement 62% improvement 93% improvement 87% improvement 70% improvement *Johnson, Carlson, Tucker, & Willette Using BCMA in VA Medical Centers Journal of Healthcare Information Management-Vol 16, No.1 *Eastern Kansas Health Care System (VA) 1994-2001*: 8,000,000 doses dispensed 549,000 errors prevented 0 documented errors Physician order received Order faxed to Pharmacy Pharmacists edit and verify electronic orders into patient profile Pharmacy dispenses ordered medications in BarCoded packages Nurse accesses BMCA software on computer via log on Nurse scans unique patient bar-coded ID band Nurse utilizes two unique patient identifiers to verify armband Nurse verifies patient profile medications as per order Nurse scans bar-code on medications Nurse administers medications •Reduction in medication errors •The FDA estimated that over a 20 year period the number of medication errors would be reduced by 50% and up to 500,000 adverse events would be avoided by utilizing BCMA (Food and Drug Administration, 2004). •Ease of checking the five rights of medication administration •Automatic MAR creation •Lab results can be displayed at the point of care •Alerts for missed medications Estimated to cost $1,799 per bed to implement BCMA, with an additional $1,000 yearly for maintenance No universally accepted bar codes Bar codes that are unable to be scanned Equipment malfunction Over reliance on BCMA to catch errors Stat medication turnaround time (ZIH, 2006) Over 15 types have been identified that could potentially lead to errors For example: Nurses override alerts for 4.2 % of patients cared for and for 10.3% of meds charted (Karsh, Koppel, Telles, & Wetterneck, 2008) Require special order from physician Must be stored in a secure manner Avoid using home medications unless they are unavailable from the hospital pharmacy If using home medications, they must be stored in and dispensed from the hospital pharmacy only upon positive identification Patient education on self-administration Example: inhalers Assessment Vital signs Blood glucose Pain level Education What drug is for Side effects Reassessment Types of errors: Omissions Drug administration without a physician’s order Wrong drug Wrong dose Wrong time Failure to follow manufacturer specifications Do not crush Shake well Inadequate fluids Administration without adequate fluids Administration through enteral feeding tube: Example: phenytoin Administration of eye drops Contact time with eye Inhalers Administration with regard to meal times Monitoring of Therapy Medication Use Evaluations Trending of medication errors
