Transcript Improving Patient Safety with Medication Use System Research

Comparing Pharmacy Practice in VA
Hospitals to General Medical-Surgical
Hospitals: Results from the 2004-2006
ASHP National Hospital Pharmacy Surveys
Craig A. Pedersen, R.Ph., Ph.D., FAPhA
Associate Professor
The Ohio State University College of Pharmacy
614.292.3011
[email protected]
1
Acknowledgements
• William Jones, M.S., R.Ph. (Southwest CMOP)
• ASHP
• Philip J. Schneider, M.S., FASHP (OSU)
• Douglas J. Scheckelhoff, M.S., FASHP (ASHP)
• Elizabeth H. Chang (OSU)
• Virginia S. Torrise, Pharm.D. (Dept of VA)
• Merck & Co, Inc. for funding of the survey
2
History of the ASHP National Survey
• ASHP has a long and distinguished history of
support for examining hospital pharmacy
practice
• First examination by Don Francke and Clifton
Latiolais, “Mirror to Hospital Pharmacy”
published in 1964
− Study took 8 years to complete (1956-1963)
− Objective: “to determine what constitutes good
pharmacy services for patients in hospitals and to
study methods of improving the quality and
expanding the scope of these services in the interest
of better patient care”
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Mirror to Hospital Pharmacy
4
History of the ASHP National Survey
• That vision has remained throughout the years
• ASHP continued to biannually surveyed hospital
practice from mid-1970s through 1996
• Beginning in 1998 survey redesigned to capture
the role pharmacists play in managing and
improving the six steps of the medication-use
process:
− Year 1: Prescribing and Transcribing
− Year 2: Dispensing and Administration
− Year 3: Monitoring and Patient Education
5
The “Swiss Cheese” Model: Weaknesses
in the Medication Use System
Reason, J. BMJ. 2000;320:768-770.
6
What does the VA Inpatient
Medication Use System Look Like?
• VA hospitals are widely thought the lead the way
in pharmacy practice
− Technology (BCMA, CPOE, eMAR)
− Pharmacists’ roles and responsibilities in ambulatory
care (Knapp 2005)
• Last examination was from 1993 (Crawford)
• No broad-based comparison data exist
Knapp KK, Okamoto MP, Black BL. ASHP survey of ambulatory care pharmacy practice in health
systems – 2004. Am J Hosp Pharm. 2005;62: 274-84.
Crawford SY, Santell JP. ASHP national survey of pharmaceutical services in federal hospitals – 1993. Am J
Hosp Pharm. 1994;51:2377-93.
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Objective
• To compare the pharmacy practice between
Veterans Affairs hospitals, and general and
children’s medical-surgical hospitals.
− 6 steps in the medication-use process
− Technology
• 2004-2006 surveys
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Usable Surveys (Response Rates)
Year
VA
Gen Med-Surg
2004
45 (29.4%)
493 (41.7%)
2005
43 (27.9%)
510 (43.5%)
2006
49 (30.8%)
460 (39.0%)
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Caveats
• Results are from pharmacy director responses to
survey questions
• Respondents may be different from nonrespondents (response rates were low for VA
hospitals)
• Your feedback on the results is critical
• Don’t shoot the messenger!
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Prescribing and
Transcribing
2004 ASHP National Survey
11
Formulary System Management Tools
Tools
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Educating prescribers about cost
88.9
65.2
23.7
14.2
Regular review of therapeutic categories
73.3
56.2
17.1
(-3.6)
Regular review of non-formulary
drugs
88.9
54.9
34.0
18.6
Regular evaluation of physician
adherence to medication use policies
57.8
33.5
24.3
(-2.6)
Prior approval required for nonformulary use
95.6
28.0
67.6
49.4
Monitor formulary compliance with
percentage of formulary orders
filled
80.0
29.3
50.7
41.5
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Clinical Practice Guidelines and MUE
Activity
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Use clinical practice guidelines that include
medications
100
83.1
16.9
5.5
Pharmacist involvement in implementing
evidence-based therapeutic protocols
100
89.1
10.9
4.9
Pharmacist involvement in monitoring
evidence-based therapeutic protocols
100
84.0
16.0
4.9
MUE program with pharmacists involved
in compliance with clinical practice
guidelines
94.4
66.5
27.9
17.3
MUE program with pharmacists involved
in review of culture and sensitivity
reports
70.6
81.4
-10.8
(-15.1)
MUE program with pharmacists involved
in tracking and trending treatment
failures
53.3
29.7
23.6
13.5
13
Pharmacist Consultation
Type of Consultation
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Patient teaching
93.3
43.0
50.3
31.5
Anticoagulation (warfarin teaching)
88.9
41.7
47.2
20.4
Compliance / medical history
64.4
14.2
50.2
35.2
Pain management
62.2
37.8
24.4
8.3
Antibiotics
77.8
82.7
-4.9
(-10.9)
Nutrition support
53.3
51.1
2.2
(-19.7)
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Providing Drug Information to
Prescribers
Method of Providing DI
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Pharmacists attending rounds
77.8
35.3
42.5
(-1.3)
Academic detailing
28.9
6.4
22.5
6.9
Formal drug information center
8.9
4.1
4.8
(-18.6)
Newsletters / bulletins
75.6
68.5
7.1
(-14.5)
Disseminating MUE results
77.8
63.9
13.9
14.1
CE programs
62.2
47.7
14.5
(-0.4)
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Use of CPOE with Clinical Decision
Support (2006)
93.9
100
90
80
70
VA Hospitals
Gen Med-Surg Hospitals
400+
60
50
40
30
20
22.6
8.7
10
0
CPOE
2007:
~10% (Gen-Med-Surg)
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Transcribing
• Without CPOE / eMAR (Gen-med-surg hospitals)
− Standard physician order forms
− Any illegible order is clarified before transcription / entry onto
MARs
− Reconcile MARs and pharmacy patient profiles daily
− Special transcribing procedures are used for high-risk
medications
− If computerized prescriber order entry (CPOE) not available,
physicians must print / type all medication orders
− Countersign verbal orders
• Read back all verbal orders (including spelling the drug
name, dose, dosage form, and name of patient)
− VA = 81.6% , GenMedSurg=81.9%, 400+=94.2%
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Dispensing and
Administration
2005 ASHP National Survey
18
Use of Dispensing Technologies
(2005)
100
90
80
70
92.5
81.4
71.8
60.5
VA Hospitals
60
50
40
30
20
40.9
Gen Med-Surg
Hospitals
15
400+
10
0
ROBOT
ADC
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Primary Method of First Dose
Medication Distribution
Method
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Centralized Manual
(Traditional Unit Dose)
79.1
47.9
31.2
54.4
Decentralized Manual (Satellite)
2.3
4.1
-1.8
(-10.6)
Centralized Automated (Robot)
2.3
4.2
-1.9
(-8.5)
Decentralized Automated
(Dispensing Cabinets)
16.3
43.7
-27.4
(-35.3)
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Primary Method of Maintenance Dose
Medication Distribution
Method
VA
(n=43)
All Gen
Med-Surg
Diff (All)
Diff
400+
(n=510)
Centralized Manual (Traditional
Unit Dose)
65.1
52.5
12.6
42.5
Decentralized Manual (Satellite)
0.0
1.9
-1.9
(-6.5)
Centralized Automated (Robot)
32.6
7.8
24.8
4.6
Decentralized Automated
(Dispensing Cabinets)
2.3
37.8
-35.5
(-40.7)
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Philosophy and Direction of Drug
Distribution System
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Centralized
93.0
73.9
19.1
40.3
Decentralized
7.0
26.1
-19.1
Centralized
76.7
50.0
26.7
Decentralized
23.3
50.0
-26.7
Current state
Envisioned future
40.1
22
Primary Method Used to Check Doses
Dispensed by Pharmacy
Method
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Pharmacist fills/ no check
0.0
9.6
-9.6
(-1.1)
Technician fills/ pharmacist checks
32.6
75.4
-42.8
(-37.4)
Technician fills/ technician checks
(e.g. tech-check-tech)
34.9
5.1
29.8
31.7
Automated unit dose dispensing
(ROBOT)/ no check necessary
18.6
6.9
11.7
(-4.0)
Technician fills/ no check
14.0
0.2
13.8
12.9
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Ways to Build Safety Into Drug
Preparation and Dispensing
• Using true “unit dose” (93% orals*, 65%
injectables)
− No manipulations at the bedside
− No “note strength” labels
• Two pharmacist check before dispensing highrisk drug therapies, e.g. chemo (67%)*
• TPN
− Large volume base compounder (37%)
− Additive compounder (19%)
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Formal quality improvement process for
medication preparation and dispensing
Method
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Accuracy of the pharmacy's patient
medication record
62.8
54.5
8.3
1.5
Accuracy of technician cart fill
74.4
50.5
23.9
26.0
Missing dose accounting
65.1
33.2
31.9
33.9
Audit of doses returned in patient
medication drawers
30.2
23.5
6.7
20.5
Sterility of IV admixtures
74.4
48.0
26.4
7.7
Accuracy of IV admixtures
69.8
46.2
23.6
19.3
Pharmacy medication dispensing errors
discovered by nurses
88.4
83.8
4.6
-1.9
Turnaround time in dispensing
55.8
35.6
20.2
6.3
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Pharmacists Review of Orders in the
Traditional “Black Holes” of the Hospital
Method
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Surgery
32.6
9.2
23.4
13.2
Emergency department
25.6
5.0
20.6
11.6
Cath Lab
16.3
5.6
10.7
8.8
Radiology
25.6
8.5
17.1
13.8
Endoscopy
16.3
5.5
10.8
12.0
Better than others, but opportunity exists here
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Medication Administration Record
Method
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Handwritten MAR
0.0
24.1
-24.1
(-21.5)
Computer generated paper MAR
0.0
54.9
-54.9
(-40.9)
Electronic medication
administration record
system (e-MAR)
100.0
20.9
79.1
62.4
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Safe Medication Administration
Practices
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Patient name is always verified by verbal
questioning of patient/patient's arm
band
100.0
96.8
3.2
1.1
Pre-medication administration checks
are performed
100.0
91.0
9.0
8.6
Unit dose packaged medications are
only removed from their package
immediately before administration
95.3
86.4
8.9
2.8
Witness the patient taking the dose
before documenting administration
79.1
85.1
-6.0
-10.2
Method
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Routine MAR Tasks
Method
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Monitoring parameters (e.g. pulse, BP)
entered on MAR
86.0
60.7
25.3
22.6
Patient provided with a copy of his or
her MAR or similar ongoing medication
record
20.9
7.2
13.7
16.6
New medication orders are reviewed by
pharmacy before transcription onto
MAR
97.7
51.2
46.5
40.7
Reason for dose not given recorded on
MAR
97.7
69.3
28.4
20.3
Process for verifying all scheduled doses
administered and charted
86.0
53.4
32.6
31.2
Allergy history noted on MAR
97.7
94.5
3.2
4.1
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System Failures and Interceptions
Prescribing
Transcribing
39%
12%
Dispensing
Administration
11%
38%
System Failures (Where errors occur)
48%
33%
34%
2%
Interceptions of Potential ADE’s
(How often errors are detected)
Source: Leape et al. JAMA. 1995;274:35-43
30
Use of Medication Administration
Technologies (2006)
100
90
95.9
80
70
VA Hospitals
60
50
40
30
20
51.6
42.9
37
Gen Med-Surg
Hospitals
400+
13.2 16.1
10
0
BCMA
2007: ~20%
Smart Infusion Pumps
~41% (Gen-Med-Surg)
31
Smart Infusion Pumps
• IV errors have greatest opportunity for adverse
events
• Nurses value assistance with calculations
• Extensive library (65%*less)
− Library composition
• Used throughout the hospital (88%)
• Drug library automatically on
• Avoid rate-set-go
32
Monitoring and
Patient Education
2006 ASHP National Survey
33
Who Performs Medication Therapy
Monitoring
Type of Pharmacist
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Distributive pharmacists
46.9
44.5
2.4
-4.7
Clinical pharmacists
77.6
38.7
38.9
13.1
Integrated distributive/clinical
pharmacists
57.1
60.4
-3.3
(-19.2)
Pharmacy residents
40.8
11.2
29.6
-4.4
Pharmacy students
42.9
29.0
13.9
-5.5
No pharmacists regularly perform
monitoring services
4.1
6.6
-2.5
3.0
34
Pharmacists Spend More Time Monitoring
and Monitor More Patients in VA’s
• Greater proportion of pharmacist time spent in
medication therapy monitoring activities
− 30% or more of time
• 49% VA : 24% Gen-med-surg : 35% 400+
• Greater proportion of patients monitored by pharmacists
− 75% or more of patients
• 35% VA : 24% Gen-med-surg : 28% 400+
• Mechanisms implemented to improve medication
therapy monitoring (top 2)
− VA: 61% report increased hiring of clinical staff, and 43%
report marketing impact of clinical pharmacy services
− Gen-Med-Surg: 46% report expanding technicians
responsibilities, and 45% increasing access to patient-data
35
Excellent Electronic Access to
Information
100
90
100
100.0
98
87.3
80
70
VA Hospitals
59.2 57.0
60
50
Gen Med-Surg
Hospitals
400+
40
30
20
10
0
To Lab Data
Transfer of Inpt Data to Outpt
36
Pharmacist Authority to Manage
Medication Therapy
• Monitor Medication Levels (88%)
• Order Serum Medication Level (74%)
• Adjust Dosages (67%)
• Notification when Levels are Outside Therapeutic Range
− 63% VA
− ~45% Gen-med-surg and 400+
• Pharmacists document in medical record
− 95% VA
− ~65% Gen-med-surg and 400+
37
Methods used to monitor patients for
adverse drug events
Method
VA
All Gen
Med-Surg
Diff (All)
Diff
400+
Routine review of lab values
59.2
50.7
8.5
-8.5
Therapeutic drug monitoring
61.2
58.2
3
-8.7
Pharmacists round with physicians to
assess ADEs
51.0
16.3
34.7
3.7
Pharmacists round independent of
physicians and notify a physician if
an ADE is identified
16.3
27.6
-11.3
(-22.4)
Medical Record E-Codes
26.5
23.7
2.8
-10.1
Alerting Orders / Trigger
Medications (e.g. nalaxone,
diphenhydramine, flumazenil)
55.1
78.5
-23.4
(-24.5)
Notification from nursing
69.4
91.4
-22
-19.9
Through patient counseling /
interaction
67.3
13.5
53.8
54.4
38
More Patients Receive Medication
Education by Pharmacists
• More than 25% of patients at discharge
− 71% of VA hospitals
− <10% of gen-med-surg and 400+
• More than 25% of patients during inpatient stay
− 40% of VA hospitals
− <10% of gen-med-surg and 400+
39
Summary
• VA has adopted technology at a much higher rate
• Technology appears to be a strategic focus of the
organization
• P&T and formulary process is more active (e.g., CPG’s)
because local/regional/national all take on some aspects
of drug policy and evaluation
• Philosophy of drug distribution is of more centralization,
a robot, patient specific medications, and ADC’s in
procedure areas and not the whole hospital
40
Summary
• VA has more QI activities associated with
medication preparation and dispensing activities
• There is increased control of medication use
• Better use of MAR because of eMAR
• More time on medication therapy monitoring
and more patients monitored
• Monitoring is baked in the cake
41
Summary
• ADE monitoring and reporting occurs much
more frequently through pharmacist contact with
patients and rounding with physicians
• Share more ADE reports externally to learn and
not make mistake again
• Centralized VA control over system has led to
rapid advancements and faster adoption than
highly fragmented systems
42
Summary
• Patient teaching is much more prevalent
• More patients are counseled, more
documentation, more routine education of
patient on high-risk medications
• More physician collaboration through pharmacist
consultations
• Opportunities exist to get even better!
43
Where are the Opportunities for VA
Pharmacy?
• Biggest gaps: Self assessment
• Speed to impact: What can you do by next Tuesday?
• Magnitude of impact: What errors are most common?
• External factors: TJC, USP, National VA initiatives
• Local factors: Politics, need, resources
• Change requires: Leadership, infrastructure,
competence, and will
44
The “Swiss Cheese” Model: Weaknesses
in the Medication Use System
Reason, J. BMJ. 2000;320:768-770.
45
2004-2006 Surveys
• Pedersen CA, Schneider PJ, Scheckelhoff DJ. “ASHP
National Survey of Pharmacy Practice in Hospital Settings:
Prescribing and Ttranscribing—2004.” American Journal
of Health-System Pharmacy 2005; 62:378-90.
• Pedersen CA, Schneider PJ, Scheckelhoff DJ. "ASHP
National Survey of Pharmacy Practice in Hospital Settings:
Dispensing and Administration—2005." American Journal
of Health-System Pharmacy 2006; 63:327-45.
• Pedersen CA, Schneider PJ, Scheckelhoff DJ. "ASHP
National Survey of Pharmacy Practice in Hospital Settings:
Monitoring and Patient Education—2006." American
Journal of Health-System Pharmacy 2007; 64:507-20.
46
Comparing Pharmacy Practice in VA
Hospitals to General Medical-Surgical
Hospitals: Results from the 2004-2006
ASHP National Hospital Pharmacy Surveys
Craig A. Pedersen, R.Ph., Ph.D., FAPhA
Associate Professor
The Ohio State University College of Pharmacy
614.292.3011
[email protected]
47