strategies to prevent medication errors in your facility

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GINA GAMBARODirector, Marketing &

Business Development

2020 MONTHLY WEBINAR SERIES

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Housekeeping notes

INTRODUCTION

ModeratorPAMELA BRYAN KRAMERExecutive Vice President

2020 MONTHLY WEBINAR SERIES

Strategies to Prevent Medication Errors in Your FacilityDana Saffel, PharmDCPh, BCGP, FASCPPresident, CEO

▶Review strategies for conducting an efficient medication reconciliation on transitions of care to reduce medication errors.

▶Give examples of common errors discovered during a medication reconciliation.▶Describe root cause analysis and failure modes and effects analysis (FMEA) and their roles

in preventing medication errors.

▶ Identify error-prone situations and processes to improve patient outcomes.

Objectives

6

A Glimpse at the Magnitude of the Problem

1. Slone Epidemiology Center at Boston University. Patterns of medication use in the United States, 2006.2. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US emergency department visits for outpatient adverse drug events, 2013-2014. JAMA 2016;316:2115-253. Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006.

ADE – Adverse Drug Event

82% of American adults take at least one medication and 29 percent take five or more1

ADEs cause approximately 1.3 million emergency department visits and 350,000 hospitalizations each year2

1.5 million Americans are harmed by medication errors costing in excess of $3.5 billion and 7000 deaths annually3

More than 40% of costs related to ambulatory (non-hospital) ADEs might be preventable3

You are 100 times more likely to die from a healthcare error than from

railroad or airline accidents

▶Preventable event that may cause or lead to: Inappropriate medication use Patient harm

▶Occurs while the medication is in the control of the healthcare professional, patient, or consumer

▶Related to: Professional practice, health care products, procedures & systems including:

Medication Error

• Prescribing• Order communication• Labeling • Packaging• Nomenclature• Compounding

• Dispensing • Distribution• Administration• Education• Monitoring• Use

Types of Errors

▶Latent Error Hidden problems within health care

systems that contribute to adverse event

▶Active Error Errors occurring at the point of

interface between humans and a complex system

The Swiss Cheese Model

• Patient education

/COMMUNICATING

- labeling/packaging- storage

Medication Reconciliation

Where Medicare Errors Happen

▶Can occur anywhere in the medication use process but are most frequent during: Prescribing (39% - 49%) Administering (26% - 38%)

▶Errors include: Omission errors – failure to administer an ordered medication dose Improper dose/quantity errors – any medication dose, strength, or quantity that

differs from that prescribed Unauthorized drug errors – medication dispensed or administered was not authorized

by the prescriber (includes wrong-drug errors)

Medication Errors Occur Throughout the Medication Use Process

Institute of Medicine Report. 2006

16.2%

4.6%3.1% 2.7% 2.3% 2.2% 2.0% 1.7% 1.7% 1.4%

0.0%2.0%4.0%6.0%8.0%

10.0%12.0%14.0%16.0%18.0%

Medications Commonly Implicated in Medication Errors

© USP MedMarx Annual Report 2008 p. 393

“The movement of patient between healthcare locations, providers, or different levels of

care within the same location as their needs change…”

Transitions in Care

National Transitions in Care Coalition. www.ntocc.org. Accessed June 8, 2015

Errors in the Transition Process

▶On average, 3.9 medication discrepancies identified per outpatient discharge

▶ADRs implicated as the reason for readmission in 4.5% of patients.

Armor, Wight, and Carter. J Pharm Pract 2014; October epub.

Anderegg et al. Am J Health-Syst Pharm 2014; 71: 1469-79

At least one medication discrepancy was identified in over 70% of SNF admissions.

- PharMerica report

▶A process for obtaining and documenting a complete and accurate list of a patient’s current medicines upon admission and comparing this list to the prescriber’s admission, transfer and/or discharge orders to identify and resolve discrepancies. This is done to avoid medication errors such as omissions, duplications,

dosing errors, or drug interactions.

▶Should be conducted at every transition of care in which new medications are ordered or existing orders rewritten.

Medication Reconciliation

Joint Commission Sentinel Event Alert Issue 35, January 25, 2006

Medication Orders

Admission

Discharge

Transfer Within System

Medication ReconciliationVerify Medications Taken at

Home (Best Possible Medication History

[BPMH])

Reconcile Home Medications with Those Ordered on Admission

Reconcile Home Medications with Those Ordered on Discharge

Reconcile Home Medications with Those

Ordered on Transfer

51%

22%

21%4%

2%

Incorrect / Missing Dose

Drug Commission

Errors Commonly Found During Medication Reconciliation

Incorrect / MissingFrequency

Incorrect Drug Drug Omission

Hart C, et al. A program using pharmacy technicians to collect medication histories in the emergency department. P T. 2015;40(1):56-61

• Incorrect or Missing Doses -record lists a different dose than what the patient is being given, or does not list the dose

• Incorrect or Missing Frequency – records lists an incorrect administration time

• Drug Commission - the record lists a drug that the patient is not actually taking

• Drug Omission - error is related to an action not taken

Society of Hospital Medicine. https://www.hospitalmedicine.org/clinical-topics/medication-reconciliation/. Accessed April 2, 2019.

21Society of Hospital Medicine. https://www.hospitalmedicine.org/clinical-topics/medication-reconciliation/. Accessed April 2, 2019.

▶Medication reconciliation is often inconsistent – Even with mandates, medication reconciliation processes can vary widely by

hospital, post-acute care setting, and out-patient setting..▶Time constraints sometimes trump safety –

While patient safety is often a top priority in principle, this does not always carry through in reality. Clinicians sometimes spend less than 15 minutes with a patient during an appointment and can lack the time necessary to perform proper medication reconciliation.

▶Medication reconciliation creates an opportunity to discuss adherence – Patients fail to take their medications about 50% of the time. While reasons why

vary, clinicians should stress the risk factors associated with non-adherence with patients and help improve compliance with instructions.

Best Practices for Medication Reconciliation

Medication Reconciliation: The Key Patient Safety Issue for Healthcare Providershttps://www.cureatr.com/medication-reconciliation-the-key-patient-safety-issue-for-healthcare-providers. Accessed March 31, 2019.

"It probably takes about 25 minutes to take a good medication history, and the average provider probably gives it about 4 minutes. You get what you pay for."

Jeffrey Schnipper, MD Brigham and Women’s Hospital, Boston

▶EHRs aren’t solving the problem – The use electronic health records (EHRs) can make medication reconciliation

worse in some cases, such as when clinicians complete documentation requirements without giving a patient proper attention during a visit.

▶Data gaps are a major issue – If your EHR is not connected to other providers and facilities, your

documentation may be missing critical information on medication history. This increases the risk associated with making treatment decisions because providers are working off of an incomplete picture of a patient’s health.

▶Medication reconciliation is vital to preventing readmissions – When a new medication is prescribed but other medications that the

patient might be taking are unknown, there is an increased chance of a complication, potentially resulting in harm and a readmission.

Best Practices for Medication Reconciliation (Con’t)

Medication Reconciliation: The Key Patient Safety Issue for Healthcare Providershttps://www.cureatr.com/medication-reconciliation-the-key-patient-safety-issue-for-healthcare-providers. Accessed March 31, 2019.

Error-Reduction Strategy Power (leverage)

Fail-safes and constraints High

Low

Forcing functionsAutomation and computerizationsStandardizationRedundanciesReminders and checklistsRules and policiesEducation and informationSuggestions to be more careful or vigilant

Error Reduction Strategies

Institute for Safe Medication Practices. Selecting the Best Error-Prevention Tools for the Job. https://www.ismp.org. Accessed August 26, 2016.

▶Actively engage in reporting safety events If you have ideas for solutions share those

▶Encourage others to report▶Proactively identify potentially unsafe situations – don’t

wait for an error to occur to report▶Ask to attend committee meetings, involvement in process

improvement groups.▶Foster the culture of safety by supporting those around you

Celebrate great catches Encourage others to report

▶Regularly consult and use the resources mentioned today

How To Engage In Your Organization’s Safety Program

Root Cause Analysis vs Failure Mode and Effects Analysis

▶RCA – Root Cause Analysis Reactive – process initiated after

an error has already occurred Asks key questions:

What process failed? Human vs Technology? How can we change moving forward?

▶FMEA - Failure Mode and Effects Analysis Proactive – process initiated to

evaluate potential pitfalls and vulnerabilities of processes

Asks key questions: IF this process fails, what is the outcome? Is this outcome acceptable?

▶ Senders JW. Qual Saf Health Care 2004; 13: 248-9.

▶ The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp

▶Structured method used to analyze serious adverse events Focused on process, not individual human error Multidisciplinary Analysis of timeline and events Identifies latent errors that allowed occurrence of active error

▶Outcome of RCA is to identify and eliminate the latent errors that allow the active error to occur

Root Cause Analysis

https://www.psnet.ahrq.gov/primers/primer/10. Accessed April 3, 2019.

▶Criticisms of Traditional Root Cause Analyses Term implies “one” root cause Focuses on analysis, but action is as important as the analysis

NPSF proposes RCA2 – Root Cause Analysis + Action Effectiveness of RCA variable

▶Consensus recommendations from national patient safety leaders and organizations

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.

▶Recommended team size: 4 to 6 members Larger teams use more resources and may make scheduling

more difficult.▶Recommended to interview but not include those most

closely involved with the event in the RCA Guilt / trauma Insist on corrective measures beyond what is prudent May steer team away from their role in the event and

activities that contributed to event Makes it harder for other team members to ask difficult

questions and have frank discussions

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.

▶Analysis Steps and Tools Provides all steps that should be completed

Example: triggering questions “was communication between frontline team members adequate?”

▶Actions Teams should identify at least one stronger or intermediate strength

action for each RCA review Each action requires at least one measure / metric

▶Feedback RCA actions should be shared with the organization and those closely

involved including patients and families.

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

3National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.

Step 1 Step 2 Step 3 Step 4 Step 5

Failure Mode Effects Analysis (FEMA) Process

The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp

Determine how medication will be procured, packaged, dispensed,

delivered and used (from purchase to administration)

Step 1 Step 2 Step 3 Step 4 Step 5

Failure Mode Effects Analysis (FEMA) Process

Identify potential failure points throughout the entirety of the

defined process

The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp

Determine how medication will be procured,

packaged, dispensed, delivered and used (from

purchase to administration)

Step 1 Step 2 Step 3 Step 4 Step 5

Failure Mode Effects Analysis (FEMA) Process

The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp

Identify potential failure points throughout the entirety of the

defined process

Determine the likelihood of failure at any of the pre-

specified points

Determine how medication will be procured,

packaged, dispensed, delivered and used (from

purchase to administration)

Step 1 Step 2 Step 3 Step 4 Step 5

Failure Mode Effects Analysis (FEMA) Process

Examine preexisting processes to detect error prior to reaching the

patient

Identify potential failure points throughout the entirety of the

defined process

Determine the likelihood of failure at any of the pre-

specified points

The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp

Determine how medication will be procured,

packaged, dispensed, delivered and used (from

purchase to administration)

Step 1 Step 2 Step 3 Step 4 Step 5

Failure Mode Effects Analysis (FEMA) Process

Outline the severity of failure and whether current or

developed processes would minimize potential for failure

and/or harm

Determine the likelihood of failure at any of the pre-

specified points

Determine how medication will be procured,

packaged, dispensed, delivered and used (from

purchase to administration)

Identify potential failure points throughout the entirety of the

defined process

Examine preexisting processes to detect error prior to reaching the

patient

The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp

About CE creditAdministrator credit

This program has been approved for Continuing Education for one total participant hour by NAB/NCERS.

Approval #20210820-1-A68432-DL

Q & A

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▶Certificates should be emailed in about 30 days

Want more CE after this?

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February: Rebuilding Census After COVID

March: Survey Support

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