Transcript Is RCA Really Voluntary? - Massachusetts Medical Society

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Patient Safety Curriculum
Practical Approaches to Patient Safety
Module II
Medication Safety, Systems &
Communication
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Patient Safety Curriculum
Module II
Practical Approaches to Patient Safety
• Prescription and medication safety
• Communication issues
– tracking and follow-up
– communication skills
• Transcultural issues
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Types of Medication Errors
(>40 steps from doctor to patient)
• Prescribing errors
– wrong drug
– wrong dose
• Transcription errors (miscommunication)
• Dispensing errors
• Administration errors
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wrong drug
wrong route
wrong time
improper syringe or IV prep
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Common Causes of
Medication Errors
 Incomplete patient information
 Unavailable drug information
 Miscommunication of drug orders
 Environmental factors and distractions
 Labeling problems
Source: AHA Quality Advisory 1999
http://www.hospitalconnect.com/DesktopServlet
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Common Causes of
Medication Errors
Incomplete Patient Information
• Diagnoses
• Lab values
• Allergies
Unavailable Drug Information
• Drug contraindications
• Other medications
– Duplicate prescriptions
– Drug interactions
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Common Causes of
Medication Errors
Miscommunication of Drug Orders
• Written prescriptions
• Look-alike names
• Sound-alike names
• Misuse of decimal points and zeroes
• Inappropriate abbreviations
• Misuse of metric and apothecary measures
• Ambiguous or incomplete orders
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Common Causes of
Medication Errors
Environmental Factors and Distractions
• Noise, interruptions
– transcription errors
– multitasking
• Fatigue
• Work overload
• Poor lighting
• Stocking and storage problems
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Common Causes of
Medication Errors
Packaging and Labeling Problems
Look-alike packaging
Hard-to-read labels
Source: Institute for Safe Medication Practices 2000. (Photos used with permission)
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Common Causes of
Medication Errors
When the Patient Leaves the Office
• Dispensing error at pharmacy
• Failure to read or understand labeling and
product information
• Drug (e.g., OTCs) or food interactions
• Non-adherence
– Prescription not filled or refilled
– wrong dose, wrong time
– improper administration (e.g., asthma inhalers)
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Solutions for Look-alike or
Sound-alike Names
• Don’t rely solely on memory
• Tips for error prevention
– tell the patient/caregiver what it is and
why you are prescribing it
– provide both generic and brand names on
handwritten prescriptions
– consider ePocrates, MDPad, iScribe for Palm Pilot
– Computerized Physician Order Entry (CPOE) systems
Source: Cohen M. Medication Errors 1999. Joint Commission on Accreditation of
Healthcare Organizations 2001; National Coordinating Council for Medication Errors
Reporting and Prevention 2001.
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Solutions for Look-alike or
Sound-alike Names
For Verbal or Telephone Orders
• Spell out the name of the drug
– E.g., “X” and “Z” are common sound-alikes
• Ask listener to repeat the drug name,
dosage, and frequency —“Hear Back”
Source: National Coordinating Council for Medication Error Reporting and Prevention 2001.
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Danger of Handwritten
Prescriptions
• Virtually all prescriptions are handwritten
• >30% of pharmacies investigated (n = 245)
filled prescriptions for potentially lethal
drug combinations
• Computerized pharmacy orders increase
safety
– allergy alerts
– interaction alerts
– tracking and record-keeping functions
Source: Schiff GD, Rucker TD. Computerized Prescribing, JAMA, 1998.
Cavuto NJ, et al. Pharmacies and prevention of potentially fatal drug interactions, JAMA, 1996.
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Solutions for Measures and
Administration Orders
• Symbols and abbreviations can be dangerous
– Q.D.
Q.I.D.
Q.O.D.
– Never use “U” for “unit,” easily confused with “0” and “4”
– Write the indication with “prn” meds
• Triple check dose, form (e.g.,XL, CR, SR), and
frequency
• Use leading zeroes, but not trailing zeroes
– 0.5 NOT .5
– 5 NOT 5.0
• If you must write, do so legibly!
Source: Cohen M. Medication Errors 1999.
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Group Discussion
• What do you see in your practice?
• How do you deal with it?
– What or who helps? (maximize)
– What or who hinders? (remedy or removal)
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Medication Errors at Home
• Patients or caregivers are in control
• Pharmacists are your partners
• Information and education are critical
– is labeling/information easy to read?
– is labeling/information easy to
understand?
– how do you know?
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Systems & Communication
Tracking and Follow-Up
What happens when…
• you hand off to another physician?
• the patient goes home?
• the patient switches health plans?
• the patient moves to a different state?
How do you know?
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Systems & Communication
Dealing with Handoffs
Handoff = Opportunity for Error
• Miscommunication
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especially with verbal communications
listening skills are critical: “Hear Back”!
due to distractions (e.g., noise, interruptions)
due to fatigue and stress
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Systems & Communication
Tracking and Follow-Up
Reducing the Risk of Error
• information must follow the patient
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Systems & Communication
Continuity of Care and Safety
High Risk
• Chronic conditions
– complex care
– many providers
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Changing health plans/employers
Vulnerable populations
Cultural/language issues
Post-screening
– for cancer, cardiovascular disease, etc.
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Systems & Communication
Electronic Medical Records
• Tremendous potential
– rapid, seamless communication; easy retrieval
– automatic interaction and allergy checking
• Barriers to adoption
– patient privacy
– money
– reimbursement
– training
– proprietary systems that can’t communicate with
each other
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Systems & Communication
Communication Skills
• Sometimes we see or hear what we
expect, not what’s really there
– slips and lapses due to conditioning biases
• Every link in a chain of communications
harbors a latent failure
– put it in writing
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Systems & Communication
Communication Skills
Many Ways to Communicate
• Speaking
– face-to-face
– via telephone
• Writing
– on a chart, sign-out, or prescription pad
– in a letter or fax
– via computer (e-mail)
• Sign language
• Body language
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Systems & Communication
Transcultural Issues
Cultural Diversity Adds Complexity
• Language barriers: “once” vs. once
• Health belief models
• Social styles and moral values
• Religious beliefs and practices
• Economic considerations
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Systems & Communication
Language Barriers
• Access to translators
– “language banks”: AT&T, etc.
– multicultural staff
– judicious use of family members as translators
• Qualifications
– ability to translate medical terminology
– competence with dialects
• Expense/reimbursement
– another unfunded mandate
– an issue that will not go away
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Systems & Communication
Health Belief Models
• Diverse views on health and wellness
– perceptions of distinguishing physical attributes
– how the human body works and stays well
• Attitudes toward physical intervention
– drawing or receiving blood; surgery
– laying on of hands
• “Alternative” therapies
– home remedies
– physical therapies (e.g., acupuncture)
– diet
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Systems & Communication
Social Styles and Moral Values
• Trust
• Eye contact
– propriety
• Touch
– modesty
• Social interactions
– within family systems
– between males and females
– between different age groups
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Systems & Communication
Religious Belief and Practices
• Fasting
• Prayer
• Reverence for elders, family, and
ancestors
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Systems & Communication
Transcultural Issues
Group Discussion
• What do you see and hear in your practice?
• How do you deal with it?
– What or who helps? (maximize)
– What or who hinders? (remedy or removal)
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Module II - Conclusion
• Prescription and medication safety
– look-alike and sound-alike drug names
– decimals, zeroes, and abbreviations
– CPOE and pharmacist consults can reduce errors
• Tracking and follow-up
– chronic conditions present problems
– complete, accurate charting and confirmation
– electronic medical record systems can help
• Transcultural issues
– more than language