Title: MEDICATION SAFETY
1MEDICATION SAFETY
- Meeting HFAP Accreditation Standards for Pharmacy
Services and Medication Use
Part One
2- HFAP Chapter 25 keeps you in compliance with the
Medicare Conditions of Participation
3Medication Safety Series
- Prescribing challenges
- Procurement in an era of drug shortages keeping
it safe - Preparation and dispensing includes sterile
preparation - Administration of medications timing, unit
dose, bedside medication verification - Monitoring of therapy, Medication Use Evaluations
4Prescribing Challenges - Objectives
- Describe the optimal environment for safe
prescribing - List the necessary tools for enhancing the
knowledge of medications - Discuss the advantages and disadvantages of
computerized physician order entry (CPOE)
5The Problem
- The Institute of Medicine Report revealed that
errors in medical care are responsible for many
deaths - Many health care providers are not aware of their
responsibilities - Medication errors responsible for numerous
adverse outcomes, including death - This results in high cost (emotional and
financial)
6Who are the participants?
- Physicians
- Nurses
- Pharmacists
- Respiratory Therapists
- Patients
- The casual observers who can alert the care
providers about opportunities for errors
7RESPONSIBILITIES
8Regulatory Standards
- HFAP Chapter 25
- CMS Conditions of Participation 482.25
9The Medication Use Process Components
- Prescribing
- Procurement
- Preparation
- Dispensing
- Administration
- Monitoring
10Where Do Errors Occur?Prescribing 39Transcr
ibing 11Dispensing 12Administering 38
11PRESCRIBING25.01.12, 25.01.13
- Is a collaborative effort
- There is an increasing body of knowledge
- New therapeutic entities
- Drug interactions
- Allergies database
- Food-drug interactions
- Post-marketing data
12PRESCRIBING
- Physician (and other prescribers)
responsibilities - Diagnosis
- Drug and dosing choices
- Medication reconciliation
- Pharmacist responsibilities (25.01.15, 25.01.16)
- Drug information
- Protocol-based management of patient medications
- Review of physician orders
13Training, Memory and Best Efforts As Safety
System Tools
- 1980 medical school graduates needed to really
know 60 drugs well - 2000 this number was estimated at 600 drugs
- 2012 add another 100-200 drugs
- Drug-drug interactions increase exponentially
with these numbers
14Training, Memory and Best Efforts As Safety
System Tools
- DDI drug-drug interaction
- Karas S. Ann Emerg Med 1981 10627-630
Medications Potential DDIs
2 1
4 6
8 28
16 120
15HIGH ALERT MEDICATIONS25.01.01, 25.01.20
- Adrenergic agonists
- Intravenous adrenergic antagonists
- Amiodarone/Amrinone
- Benzodiazepines (especially midazolam)
- Intravenous calcium
- Chemotherapeutic agents
16THE ABBREVIATION PROBLEM
17Medication Prescribing ProcessComponents
Communication
- Written Prescription Orders
- Medication Ordering Systems
- Electronic Order Transmission
- Dosage Calculations
- Verbal Orders
- Medication reconciliation
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
18Written Medication Orders Illegible Handwriting
- 16 of physicians have illegible handwriting.1
- Common cause of prescribing errors.2, 3, 4
- Delays medication administration.5
- Interrupts workflow. 5
- Prevalent and expensive claim in malpractice
cases.3
1. Anonymous. JAMA 1979 242 2429-30 2.
Brodell RT. Arch Fam Med 1997 6 296-8 3.
Cabral JDT. JAMA 1997 278 1116-7 4. ASHP.
Am J Hosp Pharm 1993 50 305-14 5. Cohen MR.
Medication Errors. Causes, Prevention, and Risk
Management 8.1-8.23.
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21Illegible Handwriting Error Prevention
- Prescribers Obligation
- Write/Print More Carefully
- Computers
- Verbal Communications
22Written Medication Orders Complete Information
- Patients Name
- Patient-Specific Data
- Generic and Brand Name
- Drug Strength
- Dosage Form
- Amount
- Directions for Use
- Purpose
- Refills
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
23Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
24Written Medication Orders Patient-Specific
Information
- Age
- Weight
- Renal and Hepatic Function
- Concurrent Disease States
- Laboratory Test Results
- Concurrent Medications
- Allergies
- Medical/Surgical/Family History
- Pregnancy/Lactation Status
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
25Written Medication Orders Do Not Use
Abbreviations
- Drug names
- QD or OD for the word daily
- Letter U for unit
- µg for microgram (use mcg)
- QOD for every other day
- sc or sq for subcutaneous
- a/ or for and
- cc for cubic centimeter
- D/C for discontinue or discharge
Cohen MR. Medication Errors. Causes, Prevention,
and Risk Management 8.1-8.23. Jones EH. Clev
Clin J Med 1997 64 355-9.
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28Written Medication Orders Decimals
- Avoid whenever possible1
- Use 500 mg for 0.5 g
- Use 125 mcg for 0.125 mg
- Never leave a decimal point naked 1, 2, 3
- Haldol .5 mg ? Haldol 0.5 mg
- Never use a terminal zero
- -Colchicine 1 mg not 1.0 mg
- Space between name and dose1,3
- Inderal40 mg ? Inderal 40 mg
- Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23. - Jones EH. Clev Clin J Med 1997 64 355-9.
- Cohen MR. Am Pharm 1992 NS32 32-3.
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30Written Medication Orders Drug Names
- Look-Alike or Sound-Alike Drug Names
- Confirmation Bias
- Addition of Suffixes
- Example Adalat CC 30 mg vs. Adalat 30 mg
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23. Cohen
MR. Am Pharm 1992 NS32 21-2.
31Look-alike And Sound-alike Drug Names
USP Quality Review. www.usp.org/reporting/review/
qr66.pdf accessed on February 6, 2001.
32Medication Prescribing Process Computerized
Prescriber Order Entry (CPOE)
- Computer with 3 Interacting Databases
- Drug History
- Drug Information/Guidelines Database
- Patient-Specific Information
- Avoids
- Illegible Prescriptions or orders
- Improper Terminology
- Ambiguous Orders
- Incomplete Information
Schiff GD. JAMA 1998 279 1024-9.
33Computerized Physician Order Entry (CPOE)
- Provides Decision Support
- Warns of Drug Interactions
- Drug-Drug
- Drug-Allergy
- Drug-Food
- Checks Dosing
- Reduces Transcription Error
- Reduces number of lost orders
- Reduces duplicative diagnostic testing
- Recommends cost effective, therapeutic
alternatives
34CPOE Advantages
- Automate ordering process
- Reduces Order Errors
- Standardized, legible complete orders
- Alerts
- Data collected on variances in practice
35Improved Quality
- CPOE allows for physician reminders of best
practice or evidence-based guidelines - Indiana University study
- Pneumococcal vaccine in eligible patients
- 0.8 36.0
- Heparin prophylaxis
- 18.9 32
36CPOE Disadvantages
- Errors still possible
- Alerts
- Multiple steps
- Access
37Dosage Calculations
- Recognized cause of medication errors
- Use patient-specific information
- height
- weight
- age
- body system function
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
38Dosage Calculations Error Prevention
- Avoid calculations
- Cross-checking
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23. ISMP
Medication Safety Alert 1996 1 (15).
39Verbal Orders Error Prevention
- Avoid when possible
- Enunciate slowly and distinctly
- State numbers like pilots
- (i.e., one-five mg for 15 mg)
- Spell out difficult drug names
- Specify concentrations
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
40Conflict Resolution
- Communication is essential
- No one is right all the time
- Take the time to listen
- Beware of instilling an atmosphere of fear
- Interdisciplinary collaboration
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
41Patient Education
- Educate patients about their medications
- Purpose of each medication
- Name of drug, dose, how to take, etc.
- Provide patients with understandable written
instructions - Lack of involving patients in check systems
- Inform patients about potential for error with
drugs known to be problematic
42PRESCRIBING REVIEW
- Right indication
- Right drug choice
- Correct dosage
- Absence of contraindications
- Allergies
- Drug interactions (food, other drugs)
- Pregnancy and lactation
43HIGH ALERT MEDICATIONS
- Insulin
- Lidocaine
- Intravenous magnesium sulfate
- Opiate narcotics
- Neuromuscular blocking agents
- Intravenous potassium
- Intravenous sodium chloride (high concentration)
44PROBLEMS
- Lack of knowledge of proper dose
- Outdated information
- Illegible handwriting
- Incomplete orders
- Use of the apothecary system
- Order on the wrong chart
- Nameless prescription
45PROBLEMS
- Ordering a total course of therapy instead of
daily doses - Lack of knowledge about proper routes of
administration - Ability to bypass controls in automated systems
- Verbal orders poorly communicated
46SOLUTIONS
- Clear handwriting (Print)
- Avoid abbreviations when errors could occur
- Prescriber order entry
- Avoid verbal orders
- Double check doses
- Review cases of polypharmacy
47SUMMARY
- Prescribing inappropriately can result in serious
medication errors. - Major advances have been made in improving
prescribing safety - Technology is our friend
- Interdisciplinary interactions go a long way
toward preventing errors
48NEXT SESSION
- Medication procurement in an era of medication
shortages - Compounding pharmacies friend or foe?