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Download Eschenbacher High Alert Medication Presentation October 2007
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Transcript
Safety in our System: High Alert Medications Lynn Eschenbacher, Pharm.D. Medication Safety Officer Duke University Hospital Case Study Physician ordered Norcuron (Vercuronium) for a patient via Computerized Physician Order Entry (CPOE) Ordered via remote location- not at the bedside Accidentally prescribed for a patient on a medical unit, meant for a patient in the ICU Case Study Pharmacist processed and prepared the infusion, failing to recognize that a neuromuscular blocking agent should never be sent to a medical unit Auxiliary labels placed on bag High Alert medication Paralyzing agent Pharmacy technician delivered to medical unit and didn’t question why not an ICU Case Study Independent double check performed by the nurses to verify Drug Pump settings Patient Infusion started and patient walked to the bathroom Patient fell to the floor once paralysis began to set in Case Study Patient called for help Rapid response team responded Nurse questioned if new drug hung could have done this Physician immediately stopped the infusion Patient treated and no long-term effects ISMP Medication Safety Alert! May 31, 2007 Volume 12 Issue 11 What Happened? Entered on wrong patient in CPOE No confirmation of correct patient or hardstop in CPOE for NMB outside of the ICU Unfamiliarity with the medication Didn’t ask for clarification or information about the medication Auxiliary labels not read Multiple providers involved 6 Rights Patient, drug, dose, route, time, response Others? How Do Errors Occur? The Swiss Cheese Model Medication Safety Defined Adverse drug event (ADE) Any incident in which the use of a medication (drug or biologic) at any dose, may have resulted in an adverse outcome in a patient (JCAHO 2001) Adverse Drug Reaction (ADR) A response to a drug that is noxious and unintended, and that occurs at doses normally used in man for the prophylaxis, diagnosis or therapy of disease, or for the modification of physiological function (WHO 1972) Near Miss/Close Call Errors that have the capacity to cause injury, but fail to do so, either by chance or because they are intercepted (Leape 1995) High Alert Medications How does a medication get tagged high alert? 1. 2. 3. 4. A medication that is notorious for causing a lot of medication errors. A medication that requires an intern who has worked for less than 10 hours in a row to write for it. A medication that requires special care because if an error occurs it has the potential to result in significant patient harm. I have no idea. Answer 1. A medication that is notorious for causing a lot of medication errors. 2. A medication that requires an intern who has worked for less than 10 hours in a row to write for it. 3. A medication that requires special care because if an error occurs it has the potential to result in significant patient harm. 4. I have no idea. What Does the Evidence Tell Us? Warfarin and insulins caused: One in every seven estimated adverse drug events treated in emergency departments More than a quarter of all estimated hospitalizations In the elderly, insulin, warfarin, and digoxin were implicated in: One in every three estimated adverse drug events treated in emergency departments 41.5% of estimated hospitalizations Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296:1858-1866. IHI 5 Million Lives Campaign Reducing Harm from High-Alert Medications The Goal: Reduce harm from high-alert medications by 50% by December 2008 IHI 5 Million Lives Focus Anticoagulants Heparin and Warfarin Narcotics/Opiates Patient-Controlled Analgesia Insulin Sedatives e.g., Midazolam IHI Recommended Measures ADEs: Related to Anticoagulant per 100 Admissions with Anticoagulant Administered Related to Insulin per 100 Admissions with Insulin Administered Related to Narcotic per 100 Admissions with Narcotic Administered Related to Sedative per 100 Admissions with Sedative Administered Percent of Patients Receiving: Anticoagulant with Treatment Appropriately Managed According to Protocol Heparin with aPPT Outside Protocol Limits Insulin with Blood Glucose Level Outside Protocol Limits Insulin with Treatment Appropriately Managed According to Protocol Narcotic Who Receive Subsequent Treatment with Naloxone Narcotic with Treatment Appropriately Managed According to Protocol Sedative Who Receive Subsequent Treatment with Flumazenil Sedative with Treatment Appropriately Managed According to Protocol Warfarin with INR Outside Protocol Limits IHI Measure Examples The number of adverse drug events (ADEs) associated with an anticoagulant per 100 admissions in which the patient was administered at least one dose of an anticoagulant, as detected using the IHI Global Trigger Tool (using only the Medication Module and Care Module triggers). The percentage of patients receiving insulin with blood glucose levels outside the safety limits set by the hospital’s insulin protocol during insulin administration Duke University Hospital Approach Identify High Alert Medications Understand what causes harm at DUH Data analysis Decrease variation and standardize Develop long lasting solutions Involvement with front line staff up to senior leadership Demonstrate improvement with data Duke High Alert Medications Direct Thrombin Inhibitors Neuromuscular Blocking Agents IT administered medications Total Parenteral Nutrition (TPN) Antiarrhythmics (amiodarone IV, lidocaine IV, dofetilide) Vasopressors (dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine) Potassium IV Heparin IV Opiates Chemotherapy IV and IT Benzodiazepines Warfarin Insulin IV Selection of High Alert Medications Based on: Previous medication errors Sentinel Events ISMP, USP and other national data Increased risk of causing significant patient harm when they are involved in medication errors. Although mistakes may or may not be more common with these drugs, the consequences of an error are potentially more devastating to patients. Data Collection ISMP Quarterly Action Agenda IHI Trigger Tool Electronic Surveillance Tool Voluntary Reports Root Cause Analysis Failure Mode and Effect Analysis On-Line Reporting Single Portal for all events: Blood Transfusion related, Falls, Patient Visitor issues, Surgical/invasive, Treatment/testing, and Equipment On-Line Reporting Areas of Focus Prescribing Preparation Dispensing Administration Monitoring Identification and Mitigation of Risk Analyze medication related events specific to institution Utilize scientific methodology to identify root causes and opportunities for improvement Multi-disciplinary teams to develop action items to address the root causes Culture and buy-in to adopt these improvements Mistake proof where possible to ensure long lasting solutions Identification and Mitigation of Risk Analyze RCA, FMEA Scientific Methodology Six Sigma, PDSA, FADE Culture AHRQ Culture of Safety Survey Mistake Proofing Elimination, Replacement, Facilitation, Detection, Mitigation Six Sigma Deployed January 2004 ~32 Black Belts ~62 Green Belts DMAIC, DMADV, GE Workout™, Lean, Change Management Six Sigma Oversight Committee with RAIL (rolling action item list) Multidisciplinary Participation Official Physician champions for each effort Report out at several physician, nursing and pharmacy forums Clinical Peer Review Committee Clinical Practice Council Performance Improvement Oversight Committee Medication Safety Council Knowledge experts included Address Issues that have been identified Share your institution’s data Example: Mistake Proofing Insulin Examples Standardization to one IV insulin nomogram CPOE Insulin order sets (Subcutaneous and IV) and can only order insulin from order set Standardization of hypoglycemia treatment protocol- placed in all patient charts Nutrition and insulin Example: Insulin administered at MN and tube feed held at 3am due to residuals. What do you do? Insulin Advisor Opiate Examples Standardized the PCA concentrations available for the adult population CPOE Standardized ordering using a PCA orderset Added critical risk factor assessment Additional monitoring recommendations Lean body weight for dosing Hard stop for morphine PCA and ESRD RT consult for patients with sleep apnea Developed a pre-op screening electronic assessment tool with the critical risk factors related to potential oversedation highlighted in red at the top of the electronic form Developed pre-op screening education for patients to help set realistic expectations for post-op pain management PCA Advisor Pre-op screening alert Anticoagulation Examples Standardized ordering in CPOE (10/1/07) Direct Thrombin Inhibitors Heparin Warfarin Nursing protocol to alert physicians to returned lab results and prompts for change in orders Revised the pharmacist managed warfarin monitoring form Warfarin Monitoring Form Look-Alike High Alert Drugs Look-Alike Drugs Look-Alike Drugs Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Look-Alike/Sound-Alike Drugs hydralazine hydroxyzine cerebyx celebrex vinblastine vincristine chlorpropamide chlorpromazine glipizide glyburide daunorubicin doxorubicin Look-Alike/Sound-Alike Drugs TALL MAN LETTERING hydrALAZINE hydrOXYzine ceREBYX ceLEBRex vinBLASTine vinCRIStine chlorproPAMIDE chlorproMAZINE glipiZIDE glyBURIDE DAUNOrubicin DOXOrubicin DUH Look Alike/Sound Alike Efforts TallMan Lettering: Smart Pumps, Automated Dispensing Cabinets, Medication Administration Record, bin in the central pharmacy, storeroom, IV room and satellites Future: CPOE, Pharmacy computer system Posters highlighting similar products Example: Ephedrine and Promethazine Communication and Education Key to Success Often an after thought, but needs to be part of the efforts Staff and Faulty Medication Safety Minutes Flyers Grand Rounds Patients Brochures Pamphlets Videos Medication Safety Flyer Medication Safety Flyer Demonstration of Improvement Current Balanced Scorecard (BSC) Reduction in ADEs resulting in harm Reduction in ADEs resulting in harm specific to opiates and insulin Increase in overall reporting Future Incorporation of ADE-Surveillance (Triggers) on BSC IHI Global Trigger tool Balanced Scorecard Critical Success Factors DUHS establishes priorities within each quadrant of the Balanced Scorecard. Clinical Quality, Customer, Finance, Work Culture Critical Success Factors (CSFs) help to communicate and measure these priorities. The CSFs cascade down throughout lower level scorecards within the organization and support the DUHS vision and strategy. Demonstration of Improvement Individual projects Process measures Outcome measures Unique to projects Oversight by Core Safety Team for Clinical Service Line or by Six Sigma Oversight Committee What We Know About Making Errors All of us make errors Errors are not made on purpose No one wants to admit errors if they know punishment is the result Error ≠ Bad Behavior Errors happen for a reason Lucian Leape, MD Medication Safety Bottom Line: If the system is not fixed the same error will happen again