Download - Rats in the Swiss Cheese Model
Rats in the Swiss Cheese Model
Challenges with Integrated Medication Management
Rhonda McManus, Pharm DDirector, Clinical OperationsCardinal Health
The Swiss Cheese Model of Systems Accidents
Objectives for Pharmacists
Know the prevalence of technologies used in medication management process
Describe synergies of integrated technologies Explain challenges identified with integrated
technologies Understand work-arounds end users have
established Discuss opportunities for pharmacists created by
integrated automated systems
Objectives for Pharmacy Technicians List three technologies used in the medication
management process Describe techniques end users employ to
bypass safeguards in the medication use process
Explain the role of the pharmacy technician in monitoring the medication distribution process
Newest Thing in Integrated Technologies
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No machine will ever take the place of good clinical judgment.
The Perfect Integrated Solution
CPOE* PIS* ADM* BPOC* Billing
* With step-specific and service specific embedded decision support and common formulary table
ADT Billing
Supply Chain management
CPOE
PIS
ADC
BPOC
Charting
Clinical DecisionSupport
Lab, radiology, otherancillary departments
Pharmacy storageand packaging
Bedside Verification
1 2 3 4 5
Provider Education and Baseline Assessment
CPOEOrder
Management
Patient Monitoring and Outcome Review
ADE Review
Prescribing Transcribing Dispensing Administering
Drug Interaction Review EUM Replenishment
Point-of-CareAutomation
PatientMonitoring
InformationIntegration
Information Integration Information Integration Information Integration Information Integration
Medication Use Safety: Foundational Functionalities
Process
Physician Orders
Order Management
Pharmacy Control and
Distribution
Patient-Specific Medication
Preparation and Dispensing
Medication Administration
at the Point of Care
* Leape, L.L., D.W. Bates, D.J. Cullen, et al. for the ADE Prevention Study Group, 1995.
“Systems Analysis of Adverse Drug Events.” Journal of the American Medication Association. 274: 35-43.
Phases of the medication management process where errors occur
So How Many Health Systems have Implemented?
Adoption Rates: BCMA
Schneider, Philip. “Opportunities for Pharmacists” American Journal ofHealth-system pharmacists, 64:s12-s16.
Adoption Rate: CPOE
Schneider, Philip. “Opportunities for Pharmacists” American Journal ofHealth-system pharmacists, 64:s12-s16.
Decentralized Distribution Trends
Schneider, Philip. “Opportunities for Pharmacists” American Journal ofHealth-system pharmacists, 64:s12-s16.
Benefits of CPOE
Reduced errors related to handwriting Decreased order turn around time Decreased look-alike, sound-alike errors Integration with medical records and decision
support systems Decreased errors related to decimal point,
trailing zeros and use of apothecary measures Easily linked to drug-drug interaction programs
Benefits of CPOE
Link to ADE reporting systems Links to lab for alerts Standardization of therapy Formulary control Support for cost effective drug therapy choices Decreased duplicate orders Identification of prescriber Access to data for analysis Force inclusion of reason for therapy
Nine Unintended Consequences of Computerized Order Entry More/new work for clinicians Unfavorable work-flow issues Endless demands by the system Unwillingness to give up paper Changes in communication patterns and practices Negative feelings toward the system and those responsible
for it Introduction of new errors Unexpected changes in the power structure such as the
committee designing the computerized protocols making judgments about best practices
Over-reliance on the technology
Source: “Types of Unintended Consequences Related to Computerized Provider Order
Entry,” Journal of the American Medical Informatics Association, June 23, 2006.
More Unintended Consequences
Order sets created without nursing and pharmacy; broad orders with clinical decisions put nurses in jeopardy of practicing medicine
Order sets increase the number of orders pharmacists review and dispense
Weak interfaces between CPOE and PIS make pharmacy corrections necessary
Physicians use notes section to enter orders if they cannot find the medication listed, so pharmacists have to check the notes section
Examples of Errors Facilitated by CPOE User errors
Wrong patient selection Wrong medication selection Unclear log-on and log-off Failure to renew medication post surgery Loss of data and time when CPOE system is down Late day orders lost for 24 hours Uncertainty regarding changing orders, discontinuing
orders and resuming orders
Examples of Errors Facilitated by CPOE Systems errors
Assumed dose informationMedication discontinuation failuresProcedure-linked medication discontinuationDiluent options and errorsAllergy information delayConflicting or duplicate medications
CPOE Work-arounds
Increased verbal orders Enter orders in physicians’ notes section Override alerts and warnings Over-use of order sets Refuse to use CPOE and continue to use
paper orders Make less frequent adjustments to therapy
Benefits of ADM
Medication is available on nursing unit as soon as pharmacist verifies CPOE order
Decreased missing doses Decreased chance for error due to
“borrowing” medications Warnings and alerts at medication
preparation phase- not at patient bedside
ADM Challenges
Adequate equipment Profile-enabled Single drug access Refill accuracy Management of inventory levels Integrating with BCMA Perception of nursing of decentralized
distribution model
ADM Work-arounds
Matrix drawers Pocket and belt bag stock “The Pumpkin” stock Cancel transactions Inventory feature Return to pocket feature
ISMP ADM Focus Group
Met in March 2007 Sponsored by Cardinal Health, McKesson and
Omnicell Meeting of pharmacists users, nurse users and
vendors as well as ISMP Purpose: to define best practice around the use
of automated dispensing devices Report of findings posted on ISMP Website and
presented at ASHP in December 2007
ISMP, 2008
ADC Core Processes
Provide ideal environmental conditions for the use of ADCs
Ensure ADC system security Use pharmacy-profiled ADCs Identify information that should appear on the
ADC screen Select and maintain proper ADC inventory Select appropriate ADC configuration
ISMP, 2008
ADC Core Processes
Define safe ADC restocking processes Develop procedures to ensure the accurate
withdrawal of medications from the ADC Establish criteria for ADC system overrides Standardize processes for transporting
medications from the ADC to the patient’s bedside
Eliminate the process for returning medications directly to their original ADC location
Provide staff education and competency validation
BPOC Benefits
5 Rights Billing accuracy
BPOC Challenges
Bar codes Purchase Preparation Unexpected changes in bar codes Readable
Patient ID Pharmacy Order Entry changes Medication Management in BPOC world
BPOC Work-arounds
List of patients with bar codes Patient “stickers”
List of medications with bar codes Pick from patient list Pick from medication list Remove from ADM, no documentation of
medication administration: Bad documentation or diversion?
Opportunities for Pharmacists
Take an active, leadership role in any and all technology implementations and upgrades
Clinical Decision support Database management Process redesign Ongoing maintenance Data to knowledge to action Monitor process changes for new errors
Opportunities for Pharmacy Technicians System maintenance Data management Process redesign Increasing role in distribution
responsibilities Monitor for new errors, process work-
arounds
Questions and Comments