Transcript Medication Error Prevalence

Medication Error
Prevalence
IOM Reports
1999
 Healthcare is not as
safe as it can be and
should be.
 Strategies for
improvement
2001
 Reinventing the
delivery of healthcare
Consequences
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Costly to hospitals – $17- $29 billion per year
Patients loose trust in the healthcare system
Patients pay in psychological and physical
discomfort and healthcare professionals pay
in frustration for the inability to deliver the
best care.
The Findings
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Errors are not the result of one person’s reckless actions but
of system failures.
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Systems analysis is essential to discover the failures.
Front line staff’s participation in the analysis is necessary to
understand what is truly happening.
Healthcare has become increasingly complex.
Rapid changes in practice and technology has left healthcare
unable to transfer the knowledge into practice.
To align knowledge with practice, all stakeholders must work
together to identify a limited number of priority conditions
and develop strategies to improve the delivery of care for
these conditions.
Recommendations
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Establish a national focus
Identify and learn from errors through
mandatory and voluntary reporting systems
Raise performance standards and expectations
Establish a culture of safety
Goal to reduce preventable errors by 50%
over 5 years
The Vision
Recommendations include adopting six aims for improvement
and ten rules for system design.
Aims
Care must be
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Safe
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Patient Centered
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Effective
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Equitable
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Timely
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Efficient
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Aims must be emphasized
and imbedded in all health
delivery systems
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Rules
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Based on continuous
healing
Organized based on
patient needs and values
Controlled by patient
Knowledge is shared
Decision making is
evidence based
Safety is a system property
Transparency is necessary
Needs are anticipated
Waste is continuously ↓
Cooperation among
clinicians is a priority
ADEs and Medication errors
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7000 deaths annually related to prescription
error
Drug related morbidity and mortality may
cost up to 77 billion annually
Patients who experience an ADE have an
average LOS 8-12 longer.
Errors rates involving children are three times
that of errors involving adults.
Medication Safety Alerts
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11/00:
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an infant dies after receiving 5mg of morphine instead of
the ordered .5mg.
5/01
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A 9-month-old died after receiving 5 mg of morphine
instead of the ordered .5 mg of morphine.
No leading zero
Misread and transcribed as 5 mg
A 9 Year Study
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1987-1995
All medication errors with potential for adverse outcome detected
were recorded and analyzed
Errors increased from 522 to 2115 and correlated to admissions.
Most common dosing; errors and inappropriate forms, and
prescribing a medication for which the patient was allergic.
Hospitalized patients are at a greater risk for an ADE
Limited changes occurred as similar errors repeated with increasing
frequency.
Healthcare organizations and providers must incorporate reduction,
prevention and detection mechanisms into daily provision of care.
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Arch of Internal Med. 1997 Jul 28;157(14):1569-76
Study – Cost of ADEs in Hospitalized
Patients
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Cohort study including 4108 admissions
190 ADEs; 60 preventable
Additional LOS 2.2
Additional LOS for preventable 4.6
Increased cost of $2595 for all ADES and $4685 for
preventable ADEs
Equates to $2.8 million (700 bed hospital) and $5.6
million (bed hospital)
This does not include the cost of patient harm and
malpractice payments
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JAMA Vol 277 No 4, Jan 1997
Malpractice
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1990-2003
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7,472 medication related malpractice acts or
omissions
26% of malpractice acts or omissions
$920,577,368 in payments
2003
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49 reports made against RNs
61 payments made by RNs
Mean payment $181,162
Where do errors occur and what is
being done to reduce incidence?
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Medication
management system.
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Marketing
Ordering/prescribing
Transcribing
Dispensing
Administration
Monitoring
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Interventions to reduce
likelihood for ADEs
and ADRs
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AERS
CPOE
Automated dispensing
cabinets
Bar coding
NPSG
Common causes
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Poor communication
Ambiguities in product names, directions for
use and strength designation on labels
Poor procedures or technique
“Variation is the enemy of quality.”
Marketing
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FDA – Gate keeper for medication safety.
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Estimated that half of the side effects from
pharmaceuticals are avoidable.*
Premarket risk assessments and postmarket
surveillance
Complex system – unclear roles and
responsibility postmarket
Global market
*Bates, D.W., L.L. Leape and S. Petrycki, “Incidence and
Preventability of Adverse Drug Events in Hospitalized Adults,” J Gen Intern Med., 8:289294, 1993. Managing the risks and benefits from medical product use
It is simply not possible to identify all the
side effects of drugs before they are
marketed.*
* Wood, Stein and Woosley, New England journal of Medicine, 339,pp.
1851-1854 (1998)
Improvements in Post Market
Surveillance
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Move from mandatory reporting of all user
facilities to annual reports by a representative
sample – sentinel sites
Establishment of an office to oversee postmarket risk assessments (OPDRA – Office of
Post Marketing Risk Assessment)
Expand AERS to integrate reporting of post
marketing safety information worldwide
Current Model
New Model
Model for Improvement
Ordering/Prescribing
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Illegibility – 6%*
Abbreviations
Improper Dosing – 7%*
Dosing Errors
Ordering medications to
which patient was allergic
Duplicate therapy – 5%*
Unclear/incomplete
medication history
*JAMA 1995;274(1):29-43
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Standardized pre-printed
orders
Standard abbreviations
including abb. Not to use.
Calculators
Pharmacy involvement
Read back policies
Medication reconciliation
CPOE – computerized physician order
entry
Although published studies report that CPOE
reduces medication errors up to 81%* a recent
survey of hospitals responding to the Leap Frog
Group’s hospital Quality and Safety survey, only 64
out of 1,143 have CPOE fully implemented.
*Koppel, Metlay, Cohen, Abaluck, Localio,
Kimmel, Strom, JAMA.2005;293:1197-1203
Benefits of CPOE
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Decrease LOS
Reduce costs
Decrease medical errors
Improve compliance with guidelines
Decrease overuse, underuse and misuse.
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Study:
2 year implementation; within first 30 days, 4,500
medication orders with 40 drug-drug interactions noted
requiring intervention; within first 4 months at approx.
5000 med orders/month, 72 drug-drug interactions.
Issues Associated with CPOE
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Substantial cost
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Technology
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Organizational analysis and process design
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Redesign
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Support
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Training
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Study:
261 house staff surveyed, five focus groups and 32 1 to 1 intensive
interviews with house staff, IT, pharmacy, physician and nurses identified
that the CPOE system facilitated 22 types of medication errors including
inflexible ordering formats that generated wrong orders and inventory
displays mistaken as dosage guidelines. These types of errors were
experienced weekly or more often. (Jama, 2005;293:1197-1203)
Unexpected increase in mortality
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Study included children transferred to tertiary care
children’s hospital during an 18 month period
CPOE system was rapidly implemented over 6 days
during this period
Retrospective analysis 13 month before and 5
months after implementation
Mortality rate increased from 2.8% (39/1394) prior
to implementation to 6.57% after (36/548)
Pediatrics. 2005 Jan;117(1):216-7
Examples
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Lower case l misidentified by the software as
I and instead of Lodine, pulled up Iodine
Most commonly misidentified were I/l, O/0
and Z/2
Many computer systems display drug doses
using naked decimal points and unsafe
abbreviation (QD and U)
ISMP Recommendations
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List products by generic name using “tall-man”
letters to distinguish look-alike, sound-alike
medications. Ex. hydrOXYzine and hydrALAZINE.
Express weights and measures in standard fashion
List brand names in upper case to differentiate from
generic; standard in pharmaceutical industry
Provide ways to communicate patient or medication
related warnings related to prescribed medication;
i.e. colored font, italics
26 total recommendations as of 2003
MOE – One Study
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500 bed hospital
7.9 one time operating and capital expense
with 1.35 annually
Opted for MOE over CPOE
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Less costly
Provides decision support
Addresses legibility issues
Cost return in short time
Transcription
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Intervene to clarify unclear orders.
Contact prescriber to clarify unapproved
abbreviations even if they appear clear
Use triggers to prompt.
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If two medical professionals can not read the order or to
continue to have questions, contact the prescriber.
Dispensing
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Labeling errors during
repackaging
Lack of access to the
right medication at the
right time
Less control over
inventory
Poor/no audit trail
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Single dose units
Mandatory bar coding
Automated medication
dispensing cabinets.
Benefits of ADC
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Control over inventory
Creates audit trail
Links patient to medication
Provides timely access to a greater number of
medication
Improved security for medications
Issues with ADC
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Not enough cabinets to service the patient
care area
Override functions can facilitate orders
carried out prior to review by pharmacy
Reminders and alerts may not provide
adequate information
No forcing function to control and record
narcotic wasting
Administration
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Wrong patient
Wrong medication
Wrong time
Wrong dose
Wrong route
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Bar coded patient
identification system
Clear policies and
procedures for
medication
administration
including patient
identification.
Red rules to impress
importance
Red Rule
PATIENT SAFETY ALERT
ALL CLINICAL STAFF
RED LETTER RULE #3
MEDICATIONS
When administering medications, the Medication Administration Record (MAR) and the
medication in the original packet or unit dose must be brought to the patient’s bedside.
The following steps must occur:
Verify patient identification using two identifiers (neither to be the patient’s room)– resolve
discrepancies before administering medication.
Ensure compliance with the 5 Rights of Medication Administration:
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Right Patient
Right Drug
Right Dose
Right Route
Right Time
Validate with another RN a documented double-check for all insulin, heparin, warfarin and
narcotic medications prior to the administration of the medication.
THERE ARE NO EXCEPTIONS TO THIS RULE
Monitoring
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Failure to recognize
adverse reactions
Failure to report adverse
reactions
Failure to educate patients
about potential side effects.
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Prompt added to MAR to
identify new medication
and document patient
response.
Get patients involved in
their healthcare decisions
Computerized monitoring
utilizing signals.
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Lab values
Rash
Fever
Diarrhea
ADEs and ADRs can occur along the entire
medication management system.
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Approval for public use
Ordering
Transcribing
Administering
Monitoring
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Good systems – “Each system is designed to
get exactly the results it gets.”
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Constantly evaluate your systems and find
opportunities for improvement.
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Quality is not perfection.
Computerized Monitoring
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Computer assisted antibiotic dosing monitor tracks
renal function daily and identifies patients who may
receiving excessive doses of antibiotics.
Integrated with lab, pharmacy and other patient
specific information identifies allergies, drug-drug
and food-drug contraindications
Detects possible ADES through combinations of
orders and lab results: an order for a drug along with
an abnormal lab value that would indicate a possible
ADE
Review Study
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617 ADEs were discovered
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Chart review – 398
Computer monitoring – 275
Voluntary reporting – 23
Although chart review discovered the most, computer monitoring was
considered more efficient because it discovered more than voluntary
reporting and was less time consuming than chart review.
J Am Med Inform Assoc 1998;5(3):305-14
Reason’s Model