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MEDICATION SAFETY

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Title: MEDICATION SAFETY


1
MEDICATION 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

3
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

4
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)

5
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)

6
Who are the participants?
  • Physicians
  • Nurses
  • Pharmacists
  • Respiratory Therapists
  • Patients
  • The casual observers who can alert the care
    providers about opportunities for errors

7
RESPONSIBILITIES
8
Regulatory Standards
  • HFAP Chapter 25
  • CMS Conditions of Participation 482.25

9
The Medication Use Process Components
  • Prescribing
  • Procurement
  • Preparation
  • Dispensing
  • Administration
  • Monitoring

10
Where Do Errors Occur?Prescribing 39Transcr
ibing 11Dispensing 12Administering 38
11
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

12
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

13
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

14
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
15
HIGH ALERT MEDICATIONS25.01.01, 25.01.20
  • Adrenergic agonists
  • Intravenous adrenergic antagonists
  • Amiodarone/Amrinone
  • Benzodiazepines (especially midazolam)
  • Intravenous calcium
  • Chemotherapeutic agents

16
THE ABBREVIATION PROBLEM
  • U
  • ug
  • q.d.
  • qod
  • SC
  • TIW

17
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.
18
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.
19
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20
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21
Illegible Handwriting Error Prevention
  • Prescribers Obligation
  • Write/Print More Carefully
  • Computers
  • Verbal Communications

22
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.
23
Cohen MR. Medication Errors. Causes,
Prevention, and Risk Management 8.1-8.23.
24
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.
25
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.
26
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27
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28
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.

29
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30
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.
31
Look-alike And Sound-alike Drug Names
USP Quality Review. www.usp.org/reporting/review/
qr66.pdf accessed on February 6, 2001.
32
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.
33
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

34
CPOE Advantages
  • Automate ordering process
  • Reduces Order Errors
  • Standardized, legible complete orders
  • Alerts
  • Data collected on variances in practice

35
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

36
CPOE Disadvantages
  • Errors still possible
  • Alerts
  • Multiple steps
  • Access

37
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.
38
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).
39
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.
40
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.
41
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

42
PRESCRIBING REVIEW
  • Right indication
  • Right drug choice
  • Correct dosage
  • Absence of contraindications
  • Allergies
  • Drug interactions (food, other drugs)
  • Pregnancy and lactation

43
HIGH ALERT MEDICATIONS
  • Insulin
  • Lidocaine
  • Intravenous magnesium sulfate
  • Opiate narcotics
  • Neuromuscular blocking agents
  • Intravenous potassium
  • Intravenous sodium chloride (high concentration)

44
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

45
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

46
SOLUTIONS
  • Clear handwriting (Print)
  • Avoid abbreviations when errors could occur
  • Prescriber order entry
  • Avoid verbal orders
  • Double check doses
  • Review cases of polypharmacy

47
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

48
NEXT SESSION
  • Medication procurement in an era of medication
    shortages
  • Compounding pharmacies friend or foe?
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