NAPLEX: Pharmacy Foundations - Medication Safety & Quality Improvement

medication error

any preventable event that may cause or lead to inappropriate medication use or patient harm

adverse drug reactions vs medication error

ADR are not usually preventable

severity of ADR can be reduced w changes in care

close call (near miss)

an error or situation occurs but was corrected before reaching the patient

sentinel event

patient safety event that results in death, severe harm, or permanent harm of a patient

errors of omission

when something was left out that is needed for safety (ex: failing to use the pharmacist double check system for chemotherapy orders)

errors of commission

when something was done incorrectly

ex: prescribing bupropion to a pt w a hx of seizures)

5 rights

5 things to double check every time a medication is administered

- right patient

- right time and frequency

- right dose

- right route

- right drug

at risk behaviors

behavioral choice when an individual has lost the perception of risk or mistakenly believes the risk to be insignificant or justified

ex: workarounds for time consuming or tedious processes like not scanning a barcode prior to administration

reckless behaviors

conscious disregard of substantial and unjustifiable risk

ex: working under the influence or alcohol and drug diversion

causes of compromised patient safety

- low patient health literacy

- insufficient training, lack of experience or unfamiliarity with tasks

- breakdowns in communication (rushed, or hesitancy to speak up)

- competing priorities in the face of stress, fatigue, or burnout

- fast paced, high volume environment w time constraints

- complex technology and processes

institution for safe medication practices (ISMP)

non profit organization dedicated to prevention of medication errors in healthcare settings

share information across healthcare organizations to proactively implement process improvement

medication errors reporting program (MERP)

confidential, voluntary reporting program that analyzes causes of medication errors + provides recommendations for prevention

where to report medication errors + close calls

ISMP website

www.ismp.org

joint commission on accreditation of healthcare organizations (TJC)

independent, not for profit organization that accredits and certifies more than 20,000 healthcare organizations and programs in the US

focused on highest quality and safety of care and sets standards that institutions must meet to be accredited

national patient safety goals (NPSG)

set annually by TJC for types of healthcare settings

examples of NPSG

identify patients correctly: use 2 patient identifiers when providing care

improve staff communication: repeat critical results of tests in a timely basis

use medications safely:

- label all meds/containers/solutions in perioperative / procedure settings

- reducing likelihood of patient harm associated w anticoagulants

- maintain and communicate accurate patient information (med rec, discharge counseling)

use clinical alarms safely

prevent infections: hand hygiene guidelines

center for medicaid and medicare services (CMS)

surveys hospitals seeking reimbursement fo rmedicare and medicaid patients

national association of boards of pharmacy (NABP)

accredits many pharmacy settings (community, compounding)

culture of safety

- acknowledge high risk nature of healthcare

- implement blame free environment (just culture)

- encourage collaboration across disciplines

- dedicate resources to track, monitor, and address safety concerns

system based approach

identify situations or factors that are likely to give rise to human error + recommend changes

human factors engineering strategies

high reliability

- forcing functions

- computerized automation

- human machinery redundancy

human factors engineering strategies

medium reliability

- standardization and simplification

- environment and physical layout

- reminders and alerts

- double checks

human factors engineering strategies

low reliability

- education and training

- policy changes

human factors engineering strategies

forcing functions

high reliability strategy

creating hard stop in a design or process to eliminate risk of incorrect use

ex: require specific fields to be completed during order entry

human factors engineering strategies

computerized automation

high reliability strategy

utilize automated processes to remove human effort and variations that cause error

ex: use computerized order entry system to prevent transcription errors

human factors engineering strategies

human machine redundancy

high reliability strategy

create a repetitive step to confirm a correct action in an error prone process

ex: electronically scan barcode of med in addition to visual inspection

human factors engineering strategies

standardization and simplification

medium reliability strategy

align processes to minimize variation, complexity, and learning curve

ex: every pharmacy follows same approved renal dosing protocol

human factors engineering strategies

environment and physical layout

medium reliability strategy

design workspaces that facilitate correct action and minimize error and/or distractions

ex: stock meds prone to error should be separated from each other

human factors engineering strategies

reminders and alerts

medium reliability strategy

develop processes and prompts to notify clinicians to check actions to reduce errors

ex: alerts for pt allergies and DDIs

human factors engineering strategies

double checks

medium reliability strategy

engage a second person to independently review a high risk process

ex: require 2 pharmacists to individually review chemo

human factors engineering strategies

education and training

low reliability strategy

provide regular instruction on medication errors

ex: monthly review of recent med errors with staff

human factors engineering strategies

policy changes

low reliability strategy

develop a policy to address general workflows, error prone processes, and best practices

ex: policy outlining multidisciplinary review of med errors that occur in facility

medication reconciliation process

- develop list of current meds (including OTC) and dietary supplements

- develop list of meds to be prescribed

- compare meds on 2 lists

- note discrepancies and make decisions to continue, stop, or hold medications based on comparison and clinical status of pt

- communicate new list to pt, caregivers, and other health professionals involved in pt care

medication therapy management (MTM)

preparing personal medication record (PMR) + medication related action plan (MAP)

then conducting interventions or referrals, documentation, and plans for follow up

target pt taking multiple drugs and are likely to incur annual costs for coverign drugs that exceed a predetermined level

reviews may include identifying missing therapy, de-prescribing, improving non adherence, switching to generics or more affordable brands

stewardship

interdisciplinary process that involves reviewing pt medications to optimize safety and efficacy + ensure appropriate se

collaborate practice agreement (CPA)

allow pharmacist to perform advanced care activities (order and monitor therapeutic drug levels, modify medication dose)

medication error policy should include what

- internal notification: who to notify within institution + when

- external reporting: who to notify outside of institution

- disclosure: what info should be shared w pt / family + who is present when this happens

- investigation: what is process for immediate and long term internal investigation of an error

- improvement: what process will ensure immediate and long term preventable actions are taken

who should report medication errors

staff member who discovers the error using established reporting structure

how quickly do error investigations need to take place

within 48 hrs of the incident

who should be notified of medication errors in a hospital

P&T committee

med safety committee

failure mode and effect analysis (FMEA)

proactive method to reduce frequency and consequences of errors

analyze design of system to evaluate potential for failures and determine what potential effects can occur when med delivery system changes in any way or if potentially new dangerous drugs are added to formulary

root cause analysis (RCA)

retrospective investigation of an event that has already occurred

includes reviewing sequence of events that led to error

continuous quality improvement (CQI)

improving efficiency, quality, and patient satisfaction while reducing costs

ex: lean six sigma

unsafe abbreviations

U, u (unit)

- potential problem

- use instead

problem: mistaken for 0 (zero), the number 4, or cc

instead: write "unit"

unsafe abbreviations

IU (international unit)

- potential problem

- use instead

problem: mistaken for IV or the # 10

instead: write "international unit"

unsafe abbreviations

Q.D. QD qd (daily), Q.O.D. QOD qod (every other day)

- potential problem

- use instead

problem: mistaken for each other, period after Q mistaken for "l" and "O" mistaken for "l"

instead: write daily or every other day

unsafe abbreviations

trailing zeros (X.0 mg) or lack of leading zeros (.X mg)

- potential problem

- use instead

problem: decimal point is missing resulting in a 10 fold dosing error

instead; write X mg, 0.X mg

unsafe abbreviations

MS, MSO4, MgSO4

- potential problem

- use instead

problem: can mean morphine sulfate or magnesium sulfate - confused with one another

instead: write "morphine sulfate" or "magnesium sulfate"

how should look alike sound alike medications be labeled

with tallman lettering

ex: celeXA, celeBREX, predniSONE, prednisoLONE

how to use high alert medications safely

- developing policies, protocols, or order sets to use

- using premixed products whenever possible

- limiting concentrations available in the institution

- stocking high alert products only in the pharmacy

examples of high alert medications

- anesthetics; inhaled or IV (propofol)

- antiarrhythmics IV (amiodarone)

- anticoag/antithrombotics (heparin, warfarin)

- chemotherapeutics (methotrexate)

- epidural/intrathecal drugs

- hypertonic saline (greater than 0.9% NaCl)

- immunosuppressants (cyclosporine)

- inotropics (digoxin)

- insulins (insulin aspart, insulin U-500)

- magnesium sulfate injection

- neuromuscular blocking agents (vecuronium )

- opioids

- oral hypoglycemics (SU)

- parenteral nutrition

- potassium chloride and phosphates for injection

- sterile water for injection

drug recall protocol

pharmacies should be prepared to remove recalled medications from stock and prevent dispensing of recalled products to patient

should have policy in place to identify recall + remove drug from distribution

how should measurements be recorded

in metric system only

crash carts

- should contained unit dose packaging

- age specific

- standardized drug reference sheet should be available during emergencies

code blue

patient requiring emergency medical care typically for cardiac or respiratory arrest

use closed loop communication (repeating back for verification) + careful documentation

pharmacy informatics

integration of medication related knowledge w technology + automation

computerized physician/provider order entry (CPOE)

process that allows direct entry of medical orders by prescribers into computer system

helps reduce errors + minimize ambiguity resulting from handwritten orders

can include standard order sets, clinical decision pathways + protocols

alert fatigue

desensitization to alerts d/t frequency or low importance alerts leading to excessive overrides

barcoding advanges

- helps ensure meds are properly stocked in the right place

- helps prevent drug diversion

- ensure right drug is scanned + going to the right patient

- prevent wrong IV meds being given through pumps

automated dispensing cabinets (ADC)

pyxis, omnicell, scriptpro, accudose

helps provide enhanced security of controlled drugs

methods to improve ADC safety

- pharmacists must review order before meds can be removed for a pt (except in override - limited to select list of meds)

- barcode scanning to prevent wrong drug / dose going to pt

- look alike sound alikes being stored in different locations

- avoid putting certain meds in ADC (U-500 insulin, warfarin, high dose narcotics)

- nurses cannot put meds back into med compartments; have separate drawer for all returned meds

PCA devices

pt can self administer doses of meds with the push of a button + doesn't allow pt to take more than ordered

pca safety considerations

- device can be complex + require setup and programming; only use by well coordinated health teams

- pt may not be appropriate candidates for PCA

- friends + family cannot administer PCA doses

- consider age/obesity/concurrent use of CNS meds to avoid respiratory depression

pca safety steps

- limit opioids available outside of ADC + use standard order set s

- educate staff about hydromorphone + morphine mixups

- implement PCA protocols like independent double checking of drug, pump setting and dosage

- use barcoding

- assess pt pain, sedation, and respiratory rate on a scheduled basis

safety checks - inpatient med use process

drug ordered from supplier

- limit available drugs to those on formulary (P&T)

- limit concentrations stocked

safety checks - inpatient med use process

drug arrives in pharmacy and is checked into inventory

barcode scanning to make sure right drug was received + tracked for inventory

safety checks - inpatient med use process

drug added to pharmacy stock

- separate look alike sound alike drugs

- use tallman lettering

- clearly label high alert medications

safety checks - inpatient med use process

medication order placed for patient

- CPOE and CDS decrease errors; verbal or handwritten orders can be misinterpreted

- avoid abbreviations

safety checks - inpatient/outpt med use process

pharmacist reviews drug order

- assess pt specific dose, frequency, route, and risk for drug interactions

- CDS provides safety double check

safety checks - inpatient med use process

drug delivered to patient care unit

routes for drug delivery

- drug prepared + labeled in pharmacy, checked by pharmacist, then delivered to unit

- drug stocked by pharmacy in ADC on unit; nurse removes drug from ADC once order is approved/verified

barcode scanning to make sure right drug/dose was selected for the right patient

safety checks - inpatient/outpt med use process

drug administered to pt

5 rights w/ barcode scanning

- patient (2 identifiers)

- drug

- route

- dose

- time

proper counseling to reduce error risk

safety checks - outpatient medication use process

prescription filled

- barcode scanning to make sure the correct drug was pulled from pharmacy stock

- drugs may be stored in ADS in pharmacy; drug counted + vial filled using automated technology to reduce errors

common types of hospital acquired infections + how to treat

UTI from indwelling catheters

remove catheter ASAP

which IV lines have highest risk of bloodstream infections (hospital acquired infections)

central lines + catheters

what is most common cause of pneumonia in hospital acquired infections

ventilators

contact precaution

prevent transmission of infectious agents spread by direct / indirect contact w pt + environment

- recommended for pt w MRSA, VRE, cdiff

single pt rooms preferred, if not available keep >3 ft spatial separation between beds to prevent sharing of items between pt

healthcare personnel need to wear gown + gloves for all interactions w infected pt

droplet precaution

prevent transmission of pathogens spread through contact w respiratory secretions

- recommend for pt w active B pertussis, influenza virus, RSV, adenovirus, rhinovirus, N meningitidis, group A strep (for first 24 hrs of antimicrobial therapy)

single pt rooms preferred, if not available keep >3 ft spatial separation + draw curtain between beds

healthcare personnel should wear masks for close contact w pt

airborne precautions

prevent transmission of infectious agents that remain infectious over long distances when suspended in air

- recommend for pt w active pulmonary TB, measles, varicella virus

place pt in airborne in airborne infection isolation room (AIIR) - has air exhausted directly to outside / recirculated through HEPA filtration before being returned

healthcare personnel should wear mask or respiratory (n95 level or higher) when interacting w pt

how to avoid catheter related bloodstream infections

- use aseptic technique during catheter insertion (proper handwashing, standard protocols of catheter insertion)

- minimize use of IV catheters through IV to oral route conversion protocols

- set appropriate time limits for catheter use (peripheral catheters should be removed/replaced every 2-3 days)

- use skin antiseptics, antibiotic impregnated central venous catheters, and abx/ethanol lock therapy

what do antimicrobial hand soaps contain

chlorhexidine (hibiclens)

when to perform hand hygiene

- before entering and after leaving pt room and between pt contacts if there is more than 1 pt per room

- before donning and after removing gloves

- before handling invasive devices including injections

- after coughing / sneezing

- before handling food and oral medicatons

- whenever hands are visible soiled

use soap and water in these situations

- before eating

- after using restroom

- anytime there is visible soil

- after caring for pt w diarrhea or known cdiff or spore forming organisms (alc based hand rubs have poor activity against spores)

- before caring for pt w food allergies

soap and water technique

- wet both sides of hands, apply soap, rub together for at least 15 seconds

- rinse thoroughly

- dry w paper towel + use towel to turn off water

alcohol based hand rub technique

- use enough gel (2-5 mL or about the size of a quarter)

- rub hands together until gel dries (15-25 seconds)

- hands should be completely dry before putting on gloves

safe injection practices for healthcare facilities

- never administer an oral solution / suspension IV; label oral syringes "for oral use only"

- never reinsert used needles into a multidose vial or solution container

- needles for withdrawing blood or any body fluid should have engineered sharps protection

- never touch the tip or plunger to avoid contamination

- lancing devices should never be used for more than 1 pt

- disposable needles taht are contamined should never be removed from original syringes

- immediately discard used disposable needles / sharps without recapping

- do not overfill sharps container + routinely replace

when should a sharps container be discarded

when about 3/4 full

if a FDA cleared sharps container is not available what is a suitable alternative

heavy duty plastic household container (ex: plastic laundry detergent container) - must be leak and puncture resistant w tight fitting lid

where can sharps containers be dropped off

- drop boxes at hospitals, pharmacies, police or fire stations

- household hazardous waste collection sites

- mail back programs

- residential special waste pickup services

risks of opioid induced respiratory depression

- advanced age

- obesity

- concurrent use of CNS depression ( in addition to higher opioid doses)