Welcome to the

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• Welcome to the
• NQF Safe Practices for Better Healthcare
• 2009 Update
• Webinar
• Medication Safety Complex Issues for All (Safe
  Practices 17-18)
• Hosted by NQF and TMIT

Attendee dial-in instructions Toll-free Call-in
number (US/Canada) 1-866-764-6260 (direct
number, no code needed) To join the online
webinar, go to www.safetyleaders.org Online
Access Password Webinar1 (case-sensitive)
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Welcome and Overview of the Medication Management
Chapter of the 2009 NQF Safe Practices
Charles Denham, MD Chairman, TMIT Co-chairman,
NQF Safe Practices Consensus Committee Chairman,
Leapfrog Safe Practices Program Safe Practices
Webinar June 18, 2009
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Panelists
Charles Denham
Peter Angood
Michael Cohen
Mary Andrawis
Patti ORegan
Jeffrey Schnipper
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Culture SP 1
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Culture

• CHAPTER 2 Creating and Sustaining a Culture of
  Patient Safety (Separated into Practices
• Leadership Structures Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards

Culture Meas, F.B, Interv.
Structures Systems
ID Mitigation Risk Hazards
Team Training Team Interv.
Consent Disclosure

Consent Disclosure

• CHAPTER 3 Informed Consent Disclosure
• Informed Consent
• Life Sustaining Treatment
• Disclosure
• Care of the Caregiver

Informed Consent
Life Sustaining Treatment
Disclosure
Care of Caregiver
Work Force

• CHAPTER 6 Medication Management
• Medication Reconciliation
• Pharmacist Leadership Structures and Systems
• NEW
• Previous practices including Pharmacist Role,
  High-Alert Medications, Standardized Medication
  Labeling Packaging, and Unit-Dose Medications
  are bundled into the Pharmacist Leadership
  Structures and Systems practice.
• Medication Reconciliation updated with expanded
  Additional Specifications and Example
  Implementation Approaches.

• CHAPTER 4 Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care

2009 NQF Report
Nursing Workforce
ICU Care
Direct Caregivers
Legend

• CHAPTER 5 Information Management Continuity of
  Care
• Critical Care Information
• Order Read-back and Abbreviations
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
  including CPOE

Information Management Continuity of Care
No Material Changes
Critical Care Info.
Labeling Studies
Material Changes
CPOE
Read-back Abbrev.
Discharge System
New
Medication Management

• CHAPTER 6 Medication Management
• Medication Reconciliation
• Pharmacist Leadership Role Including High-Alert
  Med. Unit Dose Standardized Medication Labeling
  Packaging

Med Recon.
Pharmacist Systems Leadership High Alert, Std
Labeling/Pkg, Unit Dose

• CHAPTER 7 Hospital Associated Infections
• UTI Prevention
• MDRO Prevention
• Care of the Ventilated Patient VAP,
• Central Venous Catheter Related Blood Stream
  Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention

Healthcare Associated Infections
MDRO Prevention
UTI Prevention
VAP Prevention
Central V. Cath BSI Prevention
Sx Site Inf. Prevention
Hand Hygiene
Influenza Prevention

• CHAPTER 8
• Wrong Site, Wrong Procedure, Wrong Person Surgery
  Prevention
• Falls Prevention
• Organ Donorship
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Gycemic Control
• Contrast Media-Induced Renal Failure Prevention
• Pediatric Imaging

Condition, Site, and Risk Specific Practices
DVT/VTE Prevention
Anticoag Therapy
Falls Prevention
Organ Donation
Pediatric Imaging
Wrong site Sx Prevention
Press. Ulcer Prevention
Contrast Media Use
Glycemic Control
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Challenges of Policy Development for Medication
Management
Peter B. Angood, MD, FRCS(C), FACS, FCCM Senior
Advisor, Patient Safety National Quality
Forum Safe Practices Webinar June 18, 2009
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Medication Safety Overview, Evolution, and
Current Issues
Michael Cohen, RPh, MS, ScD President, Institute
for Safe Medication Practices (ISMP) Safe
Practices Webinar June 18, 2009
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Epidemiological ReviewIOM ? Preventing
Medication Errors

• Medications harm too many Americans
• At least 1.5 million people per year
• Hospitals
• 400,000 preventable ADEs per year
• About 1 medication error per patient per day
• Outpatient setting
• Also frequent, though data less solid
• 530,000 ADEs/year in Medicare patients

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Event types reported to Pa-PSRS
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Hospital Drug Distribution Systems

• Pre-1960s - floor stock system
• Locked narcotic safes/boxes (keys) with manual
  counts
• 1960s individual patient prescriptions
  3-to-5-day supply, nurses poured own meds
• 1970s unit-dose distribution IV admixtures
• Errors much more visible
• More pharmacist oversight of drug distribution
  process
• 1980s-90s Clinical pharmacy practice
• 1990s present - automated dispensing, robotics,
  bar-coding, outsourcing for order review

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Early Studies
Date Hospital Error Rate Observed
1962 University Florida 14.7
1964 University Arkansas 14.4
1967 University Kentucky (UD) 3.5
Kentucky Hosp A 8.3
Kentucky Hosp B 9.9
Kentucky Hosp C 11.5
Kentucky Hosp D 20.6
1975 Johns Hopkins 7.3
Johns Hopkins UD 1.6
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Historic events in medication safety
Year Event
1960s-70s Studies show hospital ME rates up to 20 Community Pharmacy 3-5
1975 ME Feature in Hospital Pharmacy
1990 ISMP and USP form MERP
1992 Dateline NBC premieres with ME story
1995 Events in Florida, Massachusetts, Illinois all make headlines
1995 Leape, Bates, Cullen et al. JAMA
1996-7 IOM chartered study (To Err is Human)
1999 To Err is Human published
1999 TJC SE Alerts NPSGs Med Mgt Stds
2006 NQF Safe Practices Medication Management Chapter
2009 NQF Safe Practices Pharmacist Leadership Structures and Systems
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Clinical consequences of a product-related error
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Communication of Drug Information

• Look-alike/sound-alike drug names combined
  with poor order communication, including during
  digital transmission
• Dangerous abbreviations and dose designations
• Suffixes misunderstood or omitted
• Confusion related to OTC brand name extensions
• Unsafe practices depicted in journal advertising
• Name confusion with medical terminology or
  laboratory nomenclature
• Same established name, different substance
  internationally
• More than one trademark for brand item

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Use of mixed-case (tall-man) characters

• Dobutamine 400 mg
• Dopamine 500 mg
• chlorpropamide 100 mg
• chlorpromazine 100 mg
• hydralazine 50 mg
• hydroxyzine 50 mg

• doBUTamine
• doPAmine
• chlorproPAMIDE
• chlorproMAZINE
• hydrALAzine
• hydrOXYzine

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Example of error due to lackof Patient
Information
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Sound-alike

• Brand names
• FEMARA (letrozole) FemHRT
• SEROPHENE (clomiphene) and SARAFEM (fluoxetine)
• INVANZ (morphine extended release) or AVINZA
  (ertapenem injection)
• Nonproprietary names
• tamoxifen or tomoxetine (now atomoxetine)
• fomepizole or omeprazole
• torsemide or furosemide

Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
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Some changes to brand name as a result of
medication errors

• Losec (confused with Lasix) is now Prilosec
• Levoxine (confused with Lanoxin) is now Levoxyl
• Mazicon (confused with Mivacron) is now Romazicon
• Pediaprofen (confused with Pediapred) is now
  Childrens Motrin
• Altocor (confused with Advocor) is now Altoprev
• Reminyl (confused with Amaryl) is now Razadyne
• Omacor (confused with Amicar) is now Lovaza

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Nonproprietary Name Changes

• amrinone or amiodarone (now inamrinone)
• tamoxifen or tomoxetine (now atomoxetine)
• fomepizole or omeprazole (fomepizole was
  4-methylpyrazole 4-MP and concern was for
  confusion with 6-MP mercaptopurine
• torsemide or furosemide (torsemide was originally
  torosemide)

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Oral orders Read-back vs. Repeat-back

• The receiver of the order should write down the
  complete order or enter it into a computer
• Then the receiver should read it back
• Receive confirmation from the individual who gave
  the order

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Look-alike packaging
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Lilly insulin color differentiation
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United States Before and after both are same
strength
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High-Alert Medications

• Small number of medications that have a high risk
  of causing injury if misused
• Errors may or may not be more common with these
  than with other medications, but the consequences
  of errors may be devastating

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Leading Products in Harmful Medication Errors, CY
2005
Generic Name n
Insulin 386 11.3
Morphine 164 4.8
Heparin 120 3.5
Fentanyl 98 2.9
Hydromorphone 91 2.7
Warfarin 88 2.6
Potassium Chloride 69 2.0
Vancomycin 69 2.0
Enoxaparin 60 1.8
Metoprolol Tartrate 42 1.2
Furosemide 41 1.2
Methylprednisolone 35 1.0
Meperidine 33 1.0
MEDMARX annual report 2007
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Medication Errors Reporting Program (MERP)

• Operated by theUnited States Pharmacopeia
• in Cooperation with theInstitute for Safe
  Medication Practices
• www.ismp.org

Pennsylvania Patient Safety Reporting Program
ISMP is a federally certified Patient Safety
Organization

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Actionable Items

• Be proactive, not reactive. Learn from experience
  of other organizations. Medication safety
  officer/team.
• Focus on unsafe practices/at risk behaviors
  (e.g., unlabelled containers, sharing insulin
  pens, abbreviating drug names, patient weight
  conversions, etc.)
• Implement technologies (smart pumps, bedside
  bar-code scanning, follow automated dispensing
  cabinet guidelines, e-Rx, etc.)
• Standardize drug concentrations, units of
  measure, etc.
• Encourage error reporting internal and external
  (see ISMP Med Safety Alert! Pump up the volume
  tips for increasing reporting. Feb 9, 2006 )
  http//www.ismp.org/Newsletters/acutecare/articles
  /20060209.asp

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Perspectives on the Importance of the Pharmacist
Leadership Safe Practice in the Hospital
Environment
Mary Andrawis, PharmD, MPH Director, Clinical
Guidelines and Quality Improvement American
Society of Health-System Pharmacists (ASHP) Safe
Practices Webinar June 18, 2009
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The Pharmacists Mission

• To help patients make the best use of medicines
• Extensively trained to ensure safe and
  evidence-based use of medications
• Expanded role to meet the need for comprehensive
  medication management

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Literature clearly demonstrates improved patient
outcomes, fewer adverse events, and reduced costs
when pharmacists are involved in care.
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Safe Practice 18 Pharmacist Leadership
Structures and Systems
Pharmacy leaders should have an active role on
the administrative leadership team that reflects
their authority and accountability for medication
management systems performance across the
organization.
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Health-System Administrative Team
Pharmacy Leader
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Items of Impact on Care

• Organizational decision-making.
• Involve pharmacy leaders with
• integral system decisions.
• Direct communication. Engage pharmacy leaders
  with the organizations leadership team and the
  Board.

ASHP Statement on the Roles and Responsibilities
of the Pharmacy Executive PDF
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Items of Impact on Care

• Medication Safety Committee. Create a committee
  led by pharmacy leaders to review errors.
• Walk-rounds. Evaluate
• medication processes and
• get front-line staff input on
• medication safety.

ASHP Guidelines on Preventing Medication Errors
in the Hospital PDF
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Items of Impact on Care

1. Technology Readiness Planning. Call on pharmacy
   to play central role in planning and
   implementation of technologies that affect
   medication use.

ASHP Statement on Bar-Code-Enabled Medication
Administration Technology PDF
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Items of Impact on Care

1. Pharmacists on Clinical Teams. Place clinical
   pharmacists on rounds to optimize safe and
   evidence-based selection and monitoring of
   medications.

ASHPSHM Joint Statement on HospitalistPharmacist
Collaboration PDF
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• Utilize your pharmacy leaders to get
• better patient outcomes
• fewer medication errors, and
• lower costs.
• Examples of Pharmacists Impact

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Where the Rubber Meets the Road Implementation
of Medication Reconciliation at the Practitioner
Level
Jeffrey Schnipper, MD, MPH, FHM Director of
Clinical Research, BWH Hospitalist Service
Associate Physician, Division of General
Medicine, Brigham and Women's Hospital Assistant
Professor of Medicine, Harvard Medical
School Safe Practices Webinar June 18, 2009
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Goals of This Talk

• To review the experience at Partners regarding
  medication reconciliation
• Which patients are at highest risk
• Benefits of Health Information Technology-based
  solutions
• Other lessons learned
• To discuss various ways to approach solutions for
  medication reconciliation

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Classifying and Predicting Errors of Inpatient
Medication Reconciliation
Jennifer R. Pippins, MD, Tejal K. Gandhi, MD,
MPH, Claus Hamann, MD, MS, Chima D. Ndumele, MPH,
Stephanie A. Labonville, Pharm D, BCPS, Ellen K.
Diedrichsen, Pharm D, Marcy G. Carty, MD, MPH,
Andrew S. Karson, MD, MPH, Ishir Bhan, MD,
Christopher M. Coley, MD, Catherine L. Liang,
MPH, Alexander Turchin, MD, MS, Patricia
McCarthy, PA, MHA, and Jeffrey L. Schnipper, MD,
MPH J Gen Intern Med 200823(9)1414-22
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Effect of a Medication Reconciliation Application
and Process Redesign on Potential Adverse Drug
Events A Cluster-Randomized Trial

• Jeffrey L. Schnipper, MD, MPH, Claus Hamann, MD,
  MS, Chima D. Ndumele, MPH, Catherine L. Liang,
  MPH, Marcy G. Carty, MD, MPH, Andrew S. Karson,
  MD, MPH, Ishir Bhan, MD, Christopher M. Coley,
  MD, Eric Poon, MD, MPH, Alexander Turchin, MD,
  MS, Stephanie A. Labonville, Pharm D, BCPS, Ellen
  K. Diedrichsen, Pharm D, Stuart Lipsitz, ScD,
  Carol A. Broverman, PhD, Patricia McCarthy, PA,
  MHA, and Tejal K. Gandhi, MD, MPH
• Arch Intern Med 2009169(8)771-80

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Specific Aims
Determine the effects of a redesigned process for
medication reconciliation, supported by
information technology, on unintentional
medication discrepancies with potential for
patient harm (potential ADEs)
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Intervention I PAML Builder
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PAML Builder Action on Admission
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Reconciliation at Discharge (Site 1)
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Description of Intervention II Process Re-design

• Admission
• Ordering physician takes medication history,
  creates PAML
• Nurse confirms accuracy of PAML
• Physician chooses planned action on admission,
  writes admission orders
• Pharmacist reconciles PAML and admission orders
• During Hospitalization
• PAML updated during hospitalization as needed
• Discharge
• Physician reviews PAML and current medications,
  creates discharge orders, documents
  reconciliation
• Nurse reconciles PAML, current medications, and
  discharge medications, reviews discharge
  medications with patient/caregiver

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Medication Reconciliation Errors in the Control
GroupN180
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PADE Risk Score
Gout medications, muscle relaxants,
hyperlipidemic medications,antidepressants,
respiratory medications
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Distribution of PADE Risk Scores
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Results of RCT
Outcome Events, N (per patient) in Usual Care Events, N (per patient) in Intervention Adjusted and Clustered RR (95 CI)
All PADEs 230 (1.44) 170 (1.05) 0.72 (0.52-0.99)
PADEs due to History Errors 153 (0.96) 125 (0.77) 0.80 (0.55-1.15)
PADEs due to Reconciliation Errors 80 (0.50) 52 (0.32) 0.62 (0.29-1.34)
PADEs at Admission 49 (0.31) 44 (0.27) 0.87 (0.51-1.52)
PADEs at Discharge 181 (1.13) 126 (0.78) 0.67 (0.49-0.98)
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Subgroup Analyses
Subgroup N Adjusted RR (95 CI) P value for interaction
SiteSite 1Site 2 170152 0.60 (0.38-0.97)0.87 (0.57-1.32) 0.32
PADE Risk Score0-3 points4-7 points 155167 1.09 (0.49-2.44)0.62 (0.41-0.93) 0.02
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Discussion

• Intervention successful
• NNT 2.6 to prevent one PADE
• Effective combination of IT and process redesign
• But potentially harmful medication discrepancies
  remained
• Incomplete/inaccurate medication sources
• Lack of patient/caregiver knowledge of
  medications
• Lack of clinician adherence with process
• Software usability issues

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Discussion

• Why more successful at Site 1 than Site 2?
• Differences in timing of roll-out, publicity
• Greater involvement of nurses
• Software integration at discharge
• Chance

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Reconciliation at Discharge (Site 1)
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Reconciliation at Discharge (Site 2)
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Implications

• Unintentional medication discrepancies with
  potential for patient harm are very common
• Most are due to history errors
• Most occur at discharge
• Most are due to omissions
• Patients at high risk can be identified
• Low understanding of preadmission medications
• Number of total and high-risk preadmission
  medications
• Frequent outpatient visits
• Efforts need to focus first on taking accurate
  medication histories, second on correcting
  reconciliation errors at discharge

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Implications (contd)

• Rigorous evidence that medication reconciliation
  can benefit patients
• Particular benefits of IT tools
• Ability to use existing electronic sources of
  ambulatory medication information
• Better workflow integration in sites with CPOE
• Easier sharing of information across providers
• Automatic production of discharge documentation
• Comparisons of medication lists to facilitate
  reconciliation and patient education
• Provision of alerts and reminders to ensure
  compliance
• Ability to track compliance to inform QI

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Discussion

• Steps Taken to Improve Intervention
• Incomplete/inaccurate medication sources
• Working on Link to SureScripts/HubRx Data
• Post-discharge medication reconciliation so EMR
  list is more accurate next time
• Lack of patient/caregiver knowledge of
  medications
• Patient education
• Lack of clinician adherence with process
• Cannot write orders if PAML not complete within
  24 hours of admission continued education
  culture change with time
• Better utilization of pharmacists (help with
  history rather than police of admission order
  discrepancies)
• Software usability issues
• Better integration with admission orders
• Improvements to discharge screens still to come

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Approaches to Medication Reconciliation

• Pharmacists take medication histories, confirm
  reconciliation at admission and discharge in
  all patients
• Likely most effective the most successful
  interventions in the literature have had
  extensive pharmacist involvement
• Also the most resource intensive
• Pharmacist technicians take medication
  histories in the Emergency Department (e.g.,
  Novant Health)
• Physicians take medication histories in most
  patients, pharmacists play supporting role in
  most patients reserve greater pharmacist
  involvement for high-risk patients

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Conclusions

• Medication reconciliation can work
• HIT can be part of the solution
• Interdisciplinary communication is key
• Focus should be on taking good medication
  histories and reconciling medications at
  discharge
• With HIT, little usability issues mean a lot
• Collectively, we need access to better sources of
  preadmission medication information
• Patients and caregivers need to be more a part of
  the solution
• Several approaches to use of personnel are
  possible not clear which is most effective and
  efficient

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Patient Perspective on Medication Management Safe
Practices
Patti ORegan, ARNP, ANP, NP-C, PMHNP-BC Nurse
practitioner, Port Richey, FL founding member,
TMIT Patient Advocate Panel Safe Practices
Webinar June 18, 2009
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Panelists
Charles Denham
Peter Angood
Michael Cohen
Mary Andrawis
Patti ORegan
Jeffrey Schnipper
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Upcoming Safe Practices Webinars

• July 16 Leadership and Leadership Principles
  for Safety (Safe Practices 1-4)
• September 17 Important Condition and Common
  Safety Issues (Safe Practices 26-34)
• October 22 Creating Transparency, Openness, and
  Improved Safety (Safe Practices 5-8)
• November 19 Healthier Communication and Safe
  Information Management (Safe Practices 12-16)
• December 17 Optimizing a Workforce for Optimal
  Safe Care (Safe Practices 9-11)