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Prevalence of Safe Medication Practices in Small Rural Hospitals 7th Annual Safety Healthcare Confer

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We Can't Hide From the Problem of Medical Error 'Fatal Drug mix-up Exposes Hospital Flaws' ... Do not store concentrated solutions on care units. Ensure ... – PowerPoint PPT presentation

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Title: Prevalence of Safe Medication Practices in Small Rural Hospitals 7th Annual Safety Healthcare Confer


1
Prevalence of Safe Medication Practices in Small
Rural Hospitals 7th Annual Safety Healthcare
ConferenceNorth Platte, NEOctober 6, 2006
  • Katherine Jones, PhD, PT

Supported by the Office of Rural Health
Policy HRSA Grant No. 1U1CRH03718-01-00
2
Prologue...Patient Safety Principles
  • Medical error is NOT rare
  • Why errors happen...healthcare is not a high
    reliability organization
  • What do we need to do...consider human
    limitations, be just in discipline, prevent
    errors with reliable processes, make errors
    visible, and mitigate harm when errors reach
    patients

3
We Cant Hide From the Problem of Medical Error
  • Fatal Drug mix-up Exposes Hospital Flaws

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7
Frequency of Harm Related to Prescribing Errors
Lucian Leape, Harvard School of Public Health
8
Will we ever really know the full extent of the
problem?
  • Do patients always know when theyve been harmed
    or have received less than optimal care?
  • If we punish providers for making mistakes, will
    they tell us about mistakes?

9
Why Do Errors Happen?
  • Limits to human performance
  • Sensory
  • Cognitive
  • Overestimate abilities and underestimate
    limitations
  • Tendency for behavior to migrate
  • Poor reliability of health care processes
  • Lack strategies to deal with unreliable processes
    and unsafe individual acts

10
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11
Demonstration
12
Systemic Migration to Boundaries
Illegal normal Real life standards
Safety Regulations Certification/ Accreditation
standards Evidence-based practice
BTCUs Border-Line tolerated Conditions of
Use Usual space of action
Individual Benefits
VERY UNSAFE SPACE
Expected safe space of action as defined by
professional standards
ACCIDENT
Adapted from R. Amalberti
Performance
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16
  • Implement Evidence-based practices/guidelines
  • Voluntary reporting, FMEA, RCA make risks visible
  • Teamwork/communication strategies intercept errors
  • Communicate and disclose unanticipated events to
  • patients and peers

17
Evidence-Based Practices/Guidelines
18
  • Every system is perfectly designed to achieve
    the results it gets.
  • Donald Berwick, MD
  • President and CEO Institute for Healthcare
    Improvement

19
The Patient Safety Agenda
  • Dont kill me
  • Dont hurt me
  • Dont leave me in pain
  • Dont make me wait
  • Dont leave me powerless
  • Dont lie to me

20
Objectives
  • Identify safe medication practices in each phase
    of the medication use process
  • Explain how prevalence of safe medication
    practices varies with hospital size
  • Explain the advantage of the all or none
    approach to quality measurement
  • Identify potential policy options to improve
    prevalence of safe medication practices in small
    rural hospitals

21
Background
  • Despite evidence-based safe medication practices
  • Adverse drug events most common adverse event
  • Medication errors widespread
  • Field work in 25 Critical Access Hospitals (CAHs)
    revealed variation from best practices in
    medication use and medication error reporting
  • Previous research positive relationship between
    pharmacy support and reporting near misses
  • ASHP national survey of pharmacy practicefloor
    effect of small hospitals lt 50 beds

22
Proven Medication Safety Practices
  • Use systems-oriented approach to reduce
    medication errors
  • Implement standard processes for medication doses
    and dose timing
  • Standardize prescription writing, prescribing
    rules
  • Read Back Policy, Medication Reconciliation,
    Approved abbreviations
  • Limit different kinds of common equipment
  • Use pharmaceutical software
  • Micromedex to check for drug-drug interactions
  • Implement unit dosing

23
Proven Medication Safety Practices
  • Use written protocols for high-risk medications
  • Double check for Oh My God meds
  • Central pharmacy supplies high-risk IV solutions
  • Do not store concentrated solutions on care units
  • Ensure availability of pharmaceutical support
  • Make patient information available at point of
    care
  • Unit dose and MAR at the bedside
  • Improve patients knowledge of their treatment
  • JCAHO Speak Up Campaign

24
Sample Map of Medication Use
25
Research Questions
  • To what extent have hospitals with fewer than 50
    beds implemented evidence-based safe medication
    practices and systematic voluntary medication
    error reporting?
  • Hypotheses Average daily census related to
    implementation of safe medication practices,
    extent of voluntary medication error reporting,
    pharmacy support, and accreditation by JCAHO

26
Instrument Development
  • Review of literature
  • Collaboration with ASHP
  • Pilot tested among sample of 5 DONS
  • Domains
  • Medication use
  • Medication error reporting
  • Practices reflecting culture of safety
  • Pharmacy support

27
Methodology
  • Combined
  • List of CAHs from Flex Monitoring Team
  • List of hospitals on ORHP web site eligible for
    small rural hospital (SRH) improvement grants
  • AHA database to obtain hospital characteristics
  • Generated random sample of 474 CAHs and 312 SRHs
    with 26 49 beds
  • Mail survey using Dillman method Aug Oct 05
  • Target respondentDirector of Nursing
  • Compare results to ASHP national sample (all or
    large gt 400 beds)

28
Methodology
  • Overall response rate 53
  • (408/775)
  • CAH response rate 55
  • (261/472)
  • SRH response rate 49
  • (147/303)
  • Compare to ASHP response rate of 43.5

Katrina Effect 9 SRHs and 2 CAHs across MS and
AL removed from sample
29
Nonresponse Bias?
Statistically significant difference at p lt 0.05
30
Sample Characteristics
  • Size
  • 24 reported avg daily census 0-5
  • 26 reported avg daily census 6 10
  • 50 reported avg daily census gt 11
  • Type64 Critical Access Hospital
  • Ownership95 not for profit
  • JCAHO accreditation28

31
Medication Use/PrescribingStatistically
significant difference between smaller hospitals
32
Medication Use/Documenting Statistically
significant difference between smaller hospitals
33
Medication Use/Dispensing Statistically
significant difference between smaller hospitals
34
Tall Man Lettering
  • Zyprexa
  • Zebeta
  • zYPReXa
  • zEBeTa

35
Unit Dose or Bulk Stock
36
Medication Use/Dispensing Statistically
significant difference between smaller hospitals
37
Medication Use/Administering Statistically
significant difference between smaller hospitals
38
Medication Error Reporting Statistically
significant difference between smaller hospitals
39
Safe Culture Practices Statistically
significant difference between smaller hospitals
40
Pharmacy Support Statistically significant
difference between smaller hospitals
41
All or None MeasurementNolan Berwick. JAMA,
295 (10) 1168-1170)
  • Multiple discrete measures define quality
  • Determine the indisputable basics that
    determine the standard of care
  • Numerator
  • 0 if any one element of care missing
  • 1if all of care provided
  • Denominator
  • Patients eligible for care
  • Organizations providing care

42
All or None Measurement
  • The indisputable basics
  • Advantages
  • Patient-centered
  • System perspective
  • Sensitive scale for assessment of improvements

Donald Berwick, M.D. President and CEO, Institute
for Healthcare Improvement
43
The Indisputable Basics
  • Ordering
  • Pharmacist review within 24 hours
  • Documenting
  • Transcription to MAR double-checked before drug
    obtained
  • Dispensing
  • Selection of medication independently
    double-checked within pharmacy or med room
  • Administering
  • Nurse verifies unopened unit dose at bedside with
    MAR

44
Overall All or None 18
45
Multivariate Logistic Regression
Dependent Variable Achievement of all or none
measure
46
Conclusions
  • The majority of the nations smallest hospitals
    can make significant improvements
  • Use of knowledge-based safe medication practices
    across all phases
  • Development of a systematic approach to reporting
    and learning from medication errors
  • Measuring and achieving a culture of safety
  • The greatest room for improvement is in those
    hospitals with avg daily census of 5 or fewer

47
Conclusions
  • 18 of the nations smallest hospitals have
    knowledge-based processes in place that can
    consistently achieve the indisputable basics of
    medication use across all phases
  • Consistency of knowledge-based practices should
    be determined prior to implementation of
    technology-based interventions
  • Accreditation by JCAHO and the professional
    driver of a minimal amount of pharmacy support
    are predictors of consistency in small rural
    hospital medication use

48
Conclusions
  • Further adoption of safe medication practices,
    systematic medication error reporting, and
    building a culture of safety in the nations
    smallest hospitals may require a combination of
    regulatory, professional, and market drivers

49
Conclusions
  • Regulatorychanges in Medicare COP to require
    review of orders, use of unit dose?
  • Professional
  • achievement of true multidisciplinary approach to
    medication use with access to pharmacist judgment
    in all hospitals
  • IOM Quality through Collaboration QIOs,
    universities, state associations, network
    hospitals to obtain tools improve knowledge of
    systems approach to error prevention
  • Markettransparency in event reporting

50
Contact Information
Katherine Jones, PhD, PT kjonesj_at_unmc.edu Gary
Cochran, PharmD, SM glcochran_at_unmc.edu Keith
Mueller, PhD kmueller_at_unmc.edu
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