Transcript N101Y Health Information Technology Module

N101Y Health
Information
Technology
Module
Medication Safety
Patient Safety
Error Prevention
Patient Safety
What is a culture of safety?
A Culture of Safety
• IOM:
• To Err is Human: Building a • Medication Errors
Safer Health System
• Adverse Drug Events
(19919)
• Adverse Drug
• Crossing the Quality
Reactions
Chasm – A New Health
System for the 21st Century
(2001)
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Assessing the Culture
Teamwork
Patient Involvement
Systems
Openness/Transparency
Accountability
Medication Errors
Types and when they occur
Types of Med Errors
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Prescribing error
Omission error
Wrong time error
Unauthorized drug error
Improper dose error
Wrong dosage-form error
American Society of Hospital Pharmacists. ASHP guidelines
on preventing medication errors in hospitals. Am J Hosp
Pharm. 1993; 50:305–14.
When Med Errors Occur
• Ordering: wrong dose, wrong choice of drug,
• Transcribing: wrong frequency of drug administration,
missed dose because medication is not transcribed,
• Dispensing: drug not sent in time to be administered at
the time ordered, wrong drug, wrong dose,
• Administering: wrong dose of drug administered,
wrong technique used to administer the drug, and
• Monitoring: not noting the effects of the given
medication
Med Error Discussion
Think about medication administration
As a student have you experienced
• A near miss?
• A medication error
• Witnessing a near miss
• Witness a medication error
From http://www.psqh.com/sepoct05/barcodingrfid1.html
Preventing Medication
Errors:
Technology and Equipment
Beyond the 5 Rights.
Medication Administration
Technology
ORDERING/TRANSCRIBING:
• eMARs
• ePrescriptions
• CPOE (Computerized Provider Order Entry)
• CDSS (Clinical Decision Support Systems)
Medication Administration
Technology
DISPENSING:
• Automated medication
dispensing devices (“Pyxis®”)
ADMINISTERING:
• BCMA (Bar Code Medication
Administration)
• RFID
• Smart Pumps
MONITORING:
• Smart Rooms
• EMR
EMR and Human Error
Elements in the EMR that reduce human error:
• CPOE
• Bar Code systems
• CDSS
• High Alert Medication Documentation
• Point of Care Documentation
• Mandatory Fields
• Communication Tool
• Med. Recon.
Potential for errors
with technology
Errors with BMCA:
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Medication does not come packaged as •
bar-coded unit-dose product
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Pharmacy does not scan products arriving
in pharmacy for readability
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Pharmacy applies correct label with bar
code to wrong product
Drugs not available in ready-to-use unit- •
doses for nurse (e.g., tablets not broken in
half)
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Nurse fails to scan patient
Nurse fails to scan medication
Bar code on patient and/or medication is
unreadable
Patient wristbands are not on patients but
other locations (e.g., clipboards, med
rooms)
Nurse overlooks alert displayed on
computer screen
Nurse overrides alert without investigating
its cause
Potential for errors with technology
ERRORS WITH CPOE/EMR/eMAR/ePrescribing:
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Mostly user interface issues:
o Wrong patient chosen
o Drop down menu issues (too many choices!)
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Software issues
In 2010 computers at a major Midwest hospital chain :
o EMR would switch to another patient record without the user directing it
to do so
o electronic pharmacy orders weren't being delivered to nurses for
dispensing to patients
http://www.huffingtonpost.com/2010/08/04/fda-obama-digital-medical_n_670036.html
Emerging Patient Safety
Technologies
The present and the future
Other patient safety
technologies
What is patient safety technology?
1. Used in direct hands-on care of the patient
2. Documentation tools
3. Meeting the needs of patients and families
4. Supporting the staff caring for the patient and the
family
SOME EXAMPLES:
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Bedside monitoring
CDSS
Communication Tools
Educational
Smart rooms
Smart Rooms
• http://youtu.be/09PSFU7loV0
Educational Technology
Potential for errors
OTHER TECHNOLOGIES:
DISCUSS
What are some other areas that might have potential for error
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CDSS
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Automated medication dispensing devices
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Smart Pumps
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Smart Rooms
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Others?
The Nurse’s Role
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Culture of safety
Technology
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The future
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Participate or organize equipment fairs to evaluate technology and equipment
before it is purchased at your facility
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Practice and learn to use new technology on challenging scenarios in a simulated
setting
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Mentor and oversee temporary (agency) nurses and other personnel as they use your
facility’s technology
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Become critical users of technology by identifying problems early and
communicating them to vendors and in-house biomedical engineering staff
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Ensure that adverse events associated with medical devices are reported to the Food
and Drug Administration MAUDE reporting system and/or ECRI’s Problem Reporting
System
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Serve as a resource person on your unit for new technologies by being a SuperUser!
From: http://www.ncbi.nlm.nih.gov/books/NBK2686/