Critical Access Hospital Medication Safety Project: A Review of the Florida Experience

Kyle Campbell, PharmD Thomas Johns, PharmD, BCPS

Objectives

• List the components of and barriers to an effective medication safety program as discovered in the Florida experience.

• Describe resources that define medication safety components relevant to critical access hospitals (CAHs) and select effective assessment techniques.

• List commonly encountered medication-related quality deficits found in CAHs.

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Presentation Overview

• Project Background • Methods • Commonly Encountered Safety Deficits • Key Recommendations • Lessons Learned

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Project Background

• Joint effort – Florida Department of Health (DOH) – FMQAI – University of Florida College of Pharmacy • Funding source – Florida DOH Office of Rural Health • Project goal – Improve the safety of medication use in Florida’s 11 CAHs • Currently completing project year 8

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✖ ✖ ✖ ✖ Florida CAH Locations: Graceville Bonifay Chipley Blountstown Apalachicola Madison Live Oak Lake Butler Starke Wauchula Clewiston ✖ ✖ ✖ ✖ ✖ ✖

Pharmacy Services in CAHs

• Consultant pharmacist with minimal involvement (3-10 hours/wk) • Onsite pharmacist (40 hours/wk) • Remote pharmacist coverage (24/7) – Cardinal – ePharmPro – Healthsystem (Shands, Florida Hospital) • Combination of onsite and remote

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Methods

• Annual site visits / medical staff meetings – Standardized assessment tool – Facility-specific reports • Annual summit – Site visit summary report – Clinical and administrative topic discussions – CAH networking

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Methods

• Ongoing technical support – Website – E-mail discussion group • Push important patient safety information to hospitals • Encourage discussion between groups – Teleconferences

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Methods

• Site visit components – Visual inspection of medication storage areas – Patient chart review – Nurse shadowing during medication administration – Conference with DON, RM, Pharmacy, CFO, CEO – QI-related documentation review – Policy review

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Methods

• Medication Safety Assessment Tool (MSAT) – ISMP Medication Safety Self-Assessment • Antithrombotic therapy • Automated dispensing cabinets – 2009 The Joint Commission • National Patient Safety Goals (CAH) • Medication management standards – Institute for Healthcare Improvement (IHI) high-alert medications – Other sources • Clinical guidelines • Various medication safety initiatives – Adapted for CAH setting – Best practice tool

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Methods

• Demographics • 24 clinical domains – A = There has been no activity or it has been formally discussed and considered, but it has not been implemented.

– B = This item has been partially implemented in some or all areas of the organization.

– C = This item is fully implemented throughout the organization.

– N/A = Not applicable or not able to assess during site visit.

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Methods

Method

Visual Inspection Visual Inspection Visual Inspection

MEDICATION DISPENSING

Commercially prepared parenteral medications are dispensed whenever available. Includes heparin, antibiotics, maintenance IV infusions, TPN, potassium boluses, saline and heparin flushes, LMWH.

Specially designed oral syringes, which cannot be connected to IV tubing, are used for oral liquid solutions not available in unit of use dosing cups.

Medications are dispensed in the most ready to-administer forms available, and, if feasible, in unit dose. This includes less or more than a full tablet & warfarin doses.

A B C N/A 12

Methods

• Site Visit Report to Facility – Detailed Assessment – Top 10 Recommendations • Track Quality Improvement – Set Relative Improvement Goals by Facility – Track Composite Scores over time

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Average Scores Across Facilities

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Common Medication Safety Deficits

• Pharmacy security (locks, nursing access) • Implementation of automated dispensing cabinets • Pharmacist review of medication orders • Removal of concentrated electrolytes • Removal of heparin 10,000 unit/mL vials • Storage and labeling of neuromuscular blockers • Increased use of unit dose packaging • Increased use of pre-mixed IV solutions • Standardization of emergency drug supplies and references • Availability of drug references • Increased use of pre-printed, standardized medication orders • Increased medication error reporting and investigation • Enhanced medication reconciliation process

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Recommendation Categories

• Standardization of physician orders • Quality improvement teams • Pharmacist review of medication orders • Investment in infrastructure • Use of high-risk medications • Prescribing best practices • Process improvements

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Standardization Of Physician Orders

Develop, implement, and monitor use of standardized pre-printed physician order forms for unfractionated heparin, warfarin reversal, venous thromboembolism (VTE) prophylaxis, and subcutaneous insulin therapy with sliding scale component

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VTE Prophylaxis Initiative – Ideas for Evaluation and Follow-Up

• Percent admissions with VTE risk screening • Percent admissions with VTE risk re screening • Percent admissions with risk-appropriate prophylaxis selection • Percent discharges on appropriate prophylaxis (agent and duration)

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Quality Improvement Teams

• Multidisciplinary team, including medical staff, to formally evaluate blood glucose control and pain management in the inpatient setting • Goals – Establish a standard organizational care process – Implement necessary policies and procedures – Develop and implement process tools (e.g., pre printed physician order forms) – Monitor outcomes of the program

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Quality Improvement Teams

“To do” list 1. Assign team leader (part of annual performance appraisal) 2. Assign team participants (include medical staff and administrator) 3. Set goals and timetable for process implementation 4. Obtain medical staff buy-in/approval 5. Implement program 6. Require monitoring to determine effectiveness (provide incentives) 7. Provide individualized feedback for area/individual non compliance

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Quality Strategic Plan

• Identify quality indicators important to the organization (external and internal) • Develop scorecard for measuring performance • Acquire Board of Directors’ approval • Establish quality agenda item at each BOD meeting • Develop performance improvement teams to address each quality indicator (leadership, MD and administrator participation)

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Pharmacist Review of Medication Orders

• Formally evaluate the ability of the organization to provide 24/7 pharmacist review of all medication orders prior to medication administration – Review current resources – Review services provided by commercial vendors

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Pharmacist Review of Medication Orders

• Revaluate override medication policy – If medication orders are not reviewed by a pharmacist, ensure nursing staff are only retrieving and administering medications if harm would come to the patient due to the delay or provider is physically located at the patient bedside. • Document a reason for each overridden medication and review by management as part of an ongoing QI program

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Investment in Infrastructure

1. Replace current crash carts with a commercially manufactured emergency cart. 2. As a component of the new emergency cart, purchase and implement a standardized medication tray that effectively separates drugs and allows for effective labeling to prevent errors.

3. Ensure drug references are not outdated.

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Investment in Infrastructure

4. Develop a process to require all medications in oral solid dosage forms to be dispensed from pharmacy in unit dose packaging.

5. Review procedures for sterile product compounding. Ensure IV preparation compounding outside of a class 5 environment are administered within one hour of preparation.

6. Ensure IV compounding takes place in a functionally separate area that is free of clutter.

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Investment in Infrastructure

7. Purchase and install an automated dispensing cabinet for use in the inpatient nursing unit.

8. Require nursing staff to retrieve medications for patient administration directly from automated dispensing cabinet.

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Investment in Infrastructure

9. Eliminate the use of medication carts as a component of the medication distribution system. 10.Only allow a licensed pharmacist to enter the pharmacy unescorted.

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Access to the Pharmacy – Florida Law

• 465.019(2)(b), F.S.

– ……However, a single dose of a medicinal drug may be obtained and administered to a patient on a valid physician's drug order under the supervision of a physician or charge nurse, consistent with good institutional practice procedures. The obtaining and administering of such single dose of a medicinal drug shall be pursuant to drug-handling procedures established by a consultant pharmacist…… • 64B16-28.602, F.A.C. – …..A single dose of medicinal drugs based upon a valid physician’s drug order may also be obtained and administered under the supervision of the nurse in charge consistent with good institutional practice procedures as established by the consultant pharmacist and written in the policy and procedure manual which shall be available within the pharmacy. • 64B16-28.604, F.A.C.

– ….When the pharmacy department is closed, no person other than a Florida licensed pharmacist shall enter, except as authorized by subsection 465.019(2)(b), F.S., and Rule 64B16-28.602, F.A.C.

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Access to the Pharmacy – Joint Commission & ISMP

• • • Joint Commission Standard MM.05.01.13 The critical access hospital safely obtains medications when the pharmacy is closed.

– When non-pharmacist health care professionals are allowed by law or regulation to obtain medications after the pharmacy is closed, the following occurs: • Medications available are limited to those approved by the critical access hospital.

• The critical access hospital stores and secures the medications approved for use outside of the pharmacy. • Only trained, designated prescribers and nurses are permitted access to approved medications.

• Quality control procedures (such as an independent second check by another individual or a secondary verification built into the system such as bar coding) are in place to prevent medication retrieval errors. • The critical access hospital arranges for a qualified pharmacist to be available either on call or at another location (for example, at another organization that has 24-hour pharmacy service) to answer questions or provide medications beyond those accessible to non-pharmacy staff.

Darryl Rich Dec 2009: No one is allowed access to pharmacy but a “pharmacist” after the pharmacy is closed. ISMP – Only a licensed pharmacist is allowed to enter the pharmacy unescorted.

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Investment in Infrastructure

11.Complete refrigerator temperature logs (daily / twice daily for vaccines). Record actions to temperature deviations. 12.Organize medication refrigerators to prevent product selection errors. 13.Organize the pharmacy to reduce the potential for retrieval errors (separate bins; high-alert drugs flagged; appropriate labels).

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Use of High-Risk Medications

• Continue to develop and implement high-risk medication policy – Consistency of labeling practices in all medication storage areas – Inclusion of warning information at order entry into ADC – Double-checks by nursing personnel during order entry and removal of medications from ADC – Administration procedures (including IV pump programming)

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Use of High-Risk Medications

• Remove promethazine 50 mg/mL injectable vials from the pharmacy and delete from the formulary – Create comment that appears on pre-printed medication orders, labels and MAR...“dilute in 10 mL and infuse over 10 minutes” – Prohibit IV route of administration

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Use of High-Risk Medications

• Utilize oral unit dose syringes for all oral liquid medications drawn up in nursing unit – Oral unit dose syringes should be stocked and readily available in the nursing unit.

– Nurses should not utilize injectable (luer lock) syringes for oral liquid preparation.

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Use of High-Risk Medications

• Evaluate policies and procedures for neuromuscular blockers storage and labeling – Should be stored to segregate them from all others – Use small, red box to store in refrigerators • Should have a lid • Should contain a warning sticker: “Warning: Paralyzing Agent – Causes Respiratory Arrest” – Place each vial in a shrink-wrap sleeve that also contains the above warning language

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Use of High-Risk Medications

• Use diverse insulin vials / pens to prevent look alike/sound-alike errors • Do NOT place insulin vials back in original boxes for storage after opening

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Prescribing Best Practices

• Remove Darvocet ® from the hospital formulary and prohibit use of the patient’s own supply during the inpatient admission

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Prescribing Best Practices

• Develop and implement a policy to prohibit the use of fentanyl transdermal patches for the treatment of acute pain or in those patients who are not opioid tolerant – Develop a drug-specific pre-printed physician order form for prescribing fentanyl transdermal patches – Require use of this form

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Process Improvements

• Medication administration – Evaluate current medication administration policy and procedure to ensure it contains a reliable system • Nursing personnel to take the MAR to the bedside during the administration process • Enforce two patient identifiers • Require medications to remain in the unit-dose packaging until the point of administration • Verify expiration dating

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Lessons Learned

• A standardized assessment tool improves ability to quantitatively assess improvements • Site visit success centers on adapting style to match CAH needs and personnel • Recommendations must be customized to account for differences in CAHs

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Acknowledgements

Special Thanks

Bob Pannell, MSP and Joel Libby, MHA Florida DOH – Sponsorship Almut Winterstein, PhD University of Florida – Co-PI

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For More Information

Kyle Campbell, PharmD Project Director, FMQAI [email protected]

Thomas Johns, PharmD, BCPS Coordinator, Drug Use Policy and Medication Safety Department of Pharmacy Shands at the University of Florida [email protected]

Project Website http://www.fmqai.com/PatientSafety-CAH.aspx

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