MEDICATION SAFETY

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MEDICATION SAFETY

• Meeting HFAP Accreditation Standards for Pharmacy
  Services and Medication Use

Part One
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• HFAP Chapter 25 keeps you in compliance with the
  Medicare Conditions of Participation

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Medication Safety Series

1. Prescribing challenges
2. Procurement in an era of drug shortages keeping
   it safe
3. Preparation and dispensing includes sterile
   preparation
4. Administration of medications timing, unit
   dose, bedside medication verification
5. Monitoring of therapy, Medication Use Evaluations

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Prescribing 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)

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The 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)

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Who are the participants?

• Physicians
• Nurses
• Pharmacists
• Respiratory Therapists
• Patients
• The casual observers who can alert the care
  providers about opportunities for errors

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RESPONSIBILITIES
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Regulatory Standards

• HFAP Chapter 25
• CMS Conditions of Participation 482.25

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The Medication Use Process Components

• Prescribing
• Procurement
• Preparation
• Dispensing
• Administration
• Monitoring

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Where Do Errors Occur?Prescribing 39Transcr
ibing 11Dispensing 12Administering 38
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PRESCRIBING25.01.12, 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

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PRESCRIBING

• 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

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Training, 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

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Training, 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
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HIGH ALERT MEDICATIONS25.01.01, 25.01.20

• Adrenergic agonists
• Intravenous adrenergic antagonists
• Amiodarone/Amrinone
• Benzodiazepines (especially midazolam)
• Intravenous calcium
• Chemotherapeutic agents

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THE ABBREVIATION PROBLEM

• U
• ug
• q.d.
• qod
• SC
• TIW

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Medication 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.
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Written 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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Illegible Handwriting Error Prevention

• Prescribers Obligation
• Write/Print More Carefully
• Computers
• Verbal Communications

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Written 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.
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Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
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Written 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.
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Written 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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Written 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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Written 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.
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Look-alike And Sound-alike Drug Names
USP Quality Review. www.usp.org/reporting/review/
qr66.pdf accessed on February 6, 2001.
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Medication 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.
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Computerized 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

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CPOE Advantages

• Automate ordering process
• Reduces Order Errors
• Standardized, legible complete orders
• Alerts
• Data collected on variances in practice

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Improved 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

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CPOE Disadvantages

• Errors still possible
• Alerts
• Multiple steps
• Access

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Dosage 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.
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Dosage 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).
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Verbal 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.
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Conflict 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.
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Patient 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

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PRESCRIBING REVIEW

• Right indication
• Right drug choice
• Correct dosage
• Absence of contraindications
• Allergies
• Drug interactions (food, other drugs)
• Pregnancy and lactation

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HIGH ALERT MEDICATIONS

• Insulin
• Lidocaine
• Intravenous magnesium sulfate
• Opiate narcotics
• Neuromuscular blocking agents
• Intravenous potassium
• Intravenous sodium chloride (high concentration)

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PROBLEMS

• Lack of knowledge of proper dose
• Outdated information
• Illegible handwriting
• Incomplete orders
• Use of the apothecary system
• Order on the wrong chart
• Nameless prescription

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PROBLEMS

• 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

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SOLUTIONS

• Clear handwriting (Print)
• Avoid abbreviations when errors could occur
• Prescriber order entry
• Avoid verbal orders
• Double check doses
• Review cases of polypharmacy

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SUMMARY

• 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

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NEXT SESSION

• Medication procurement in an era of medication
  shortages
• Compounding pharmacies friend or foe?