Skills IV Second Half Review

Medication Error

any preventable event that may cause/lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer 

difference between Adverse Drug Event and Adverse Drug Response?

• An Adverse Drug Event (ADE) is any harm caused by a medication, whether from proper use, overdosing, or mistakes

  • ANY medication related harm

• an Adverse Drug Reaction (ADR) is a specific type of ADE—harm that occurs despite taking the medication correctly at a normal dose

  • unexpected harm occured at normal dose

• All ADRs are ADEs, but not all ADEs are ADRs.

Medication Use System:

1. Planning: plan for safe use of medication - FMEA, GAP risk assessment 

2. Selection and Procurement (formulary)

3. Storage (how meds are stored, LOOK ALIKE SOUND ALIKE, ADC safety)

4. Patient Admission 

   1. Medication history

   2. Medication reconciliation on each transition of care

5. Ordering/Transcribing/Reviewing 

6. Preparing; repackaging, barcoding, compounding, USP 795, 797, 800

7. Dipsensing; Pharmacist review, ADC safety

8. Administration: 5 rights (patient/drug/dose/route/time)

9. Monitoring

10. Patient Discharge: patient education, prescriptions ordered, lab tests/follow-up

11. Evaluation: root cause analysis

Categories of Errors: NO ERROR

• Cat A: No error, no harm

Categories of Errors: Error, NO Harm

• Cat B: error did not reach patient 

• Cat C: error reached patient but caused no harm

• Cat D: error reached patient and required additional monitoring/intervention

Categories of Errors: Error, HARM Occured

• Cat E: error occurred and may have contributed to temporary harm to patient

• Cat F: error occurred and required initial prolonged hospitalization

• Cat G: error may have contributed to permanent harm

• Cat H: error requiring life-sustaining intervention 

Categories of Errors: Error, DEATH

• Cat I: error may have contributed to patient death…

Future Error Prevention Depends on…

1. Reporting of errors and potential for errors 

2. Proper identification of the primary (root) cause of all contributing factors

3. Prevention Strategy directed at the cause and contributing factors

Medication Reconciliation

formal process aimed to collect patient’s current medication list

• Process of developing an accurate list of current medications a patient is taking

• Develop and review a list of medications to be ordered/prescribed on admission, transfer, or discharge

• Always occurs at transition points = care-hand off

Med Rec Process…

3 Step Process

1. Verification - collection of patient’s medication hx from at least 2 sources

2. Clarification - ensure that meds and doses are appropriate 

3. Reconiclliation 

Pharmacy Benefit Report…

• What is it? A list of current patient prescription medications run through insurance companies

• RX: date, medication, quantity/DAY supply, pharmacy, and prescriber

Define Side Effect

expected, well known reaction…

• both negative and beneficial

• little to no change in HOW we treat the patient

falls within ADE’s but is NOT an ADR

Planning Stage…

FEMA, GAP analysis

• PROACTIVE Risk assessments

thinking about what COULD go wrong before they do

Pharmacy Benefit Report…

• What is it? A list of current patient prescription medications run through insurance companies

• RX date, medication, quantity/DAY supply, pharmacy, and prescriber

Information you can determine from a pharmacy benefit report:

• Adherence information; timing of refills 

• Medications and Medication doses/strengths 

• Formulations of Medications 

• Provider and Pharmacy information

Information you can determine from interviewing the patient/family member not on the report:

• Herbals/supplements/OTC products 

• Medication paid for using cash, compounds, FREE MD Samples

  • Any med not run through insurance 

• Date and time of last dose

what predicts harm with future administration ?

Adverse Drug Reactions (ADRs) predicts harm with future admin…

Alcohol Use Disorder Identification Test (AUDIT) Prescreen

Alcohol Use Disorder Identification Test (AUDIT) Prescreen

US screening for substance use disorder alcohol

Score: 

• I - low risk = brief education

  • 0-6: women and all ages > 65 (men)

  • 0-7: men < 65

• II - risky = brief intervention

  • 7-15: women and all ages > 65 (men)

  • 8-15: men < 65

• III - harmful = brief intervention or referral to specialized treatment 

  • 16-24 for both women/men

• IV - severe = referral to specialized treatment 

  • 25+ for both women/men

NIAA Low Risk Recommendations…

For Women: 

• No more than 3 drinks/day or 7 drinks/week

For Pregnant: no drinks ever

For men: 

• No more than 4 drinks/day or 14 drinks/week

For ADULTS over age 65 years age (both men and women)

• No more than 3 drinks/day or 7 drinks/week

Drug-Abuse Screen Test (DAST-10)

OTHER substances

Score: 

• I - healthy 

  • Score of 0 and no injection 

• II - risky = brief intervention 

  • Score of 1-2 

• III - harmful = brief intervention or referral to specialized treatment

  • Score of 3-5 OR yes to injection (automatically puts them in harmful)

• IV - severe = referral to specialized treatment 

  • 6+ score

Brief Intervention Steps: 

1. Raise the subject 

2. Provide Feedback 

3. Enhance Motivation 

4. Negotiate a plan

Standard Drinks

1. Regular beer = 12 ounces

2. Malt liquor = 8 ounces 

3. Wine = 5 ounces 

4. Hard liquor = 1.5 ounces

Motivation Interviewing

4 Steps of Motivational Interviewing:

1) raise the subject (ask for consent if they are ok talking about it)

- develop discrepancy: highlight gap between current state and future states of health

- roll with resistance (avoid direct opposition)

- support self efficacy

2) Discuss screening finds and other relevant medical issues, LINK substance use to known consequences of patient

3) Enhance Motivation (pros and cons of substance abuse)

• use readiness ruler

4) Negotiate a plan/referral to treatment

Skills OARS
1) open ended questions 

2) affirmations 

3) reflective listening 

4) summarizing 

HIPAA: 

• Privacy Rule 

  • National standards for when personal health information may be used and disclosed 

• Security Rule

  • Safeguards entities and business associates must implement to protect electronicPHI

• Breach Notification Rule

  • Required entities must notify affected individuals, Department of Health and Human Services, and media sources 

HIPAA Enforcement: Office of Civil Rights

Privacy Rule:

establishes standards to protect personal health information

• PHI cannot be released except as permitted or required by: 

  • The individual 

  • With consent to carry out treamtnet and payment

  • Without consent:

    • Indirect treament relationship 

    • Inmate 

    • Emergency situation

    • Required by law 

    • Unable to obtain consent

RISKS of Readmission?

1. Hospital acquired infections

2. Medication errors

3. Overall de-conditioning 

Hospital Redamissions Reduction Program

penalizes hospitals with ABOVE-average 30 day readmission rates 

→ financial incentive for hospitals to decrease readmission 

Factors that determine appropriate site of care for discharge?

1. Medical

   1. Medical needs are met 

   2. Insurance coverage 

   3. Decision making capacity 

2. Functional 

   1. Ability to complete normal activities of daily living 

   2. Stairs, first floor bathroom 

3. Social

   1. Family or companion support 

   2. Transportation and financial capacity to obtain medication and medical services

Counseling Requirements

MUST PROVIDE COUNSELING WHEN

1. New patient 

2. New prescription 

3. ANY changes in dose, strength, route of administration, or direction

Offer: Who can make the offer: interns, clerks, techs, pharmacy staff 

Who must perform counseling: pharmacists or pharmacy interns

Benchmarking

process of comparing a medical organization’s clinical, operational, or financial performance against peers or industry best practices to improve quality and efficiency

Drug Recall

Action taken by company to remove product from market 

• Who can initiate?

  • Company or FDA

Recall Class

1. Class I: use or exposure will cause serious harm or death 

2. Class II: use cause temporary adverse reaction

3. Class III: use not likely to cause adverse health consequences

Drug Shortages:

Causes: 

• Manufacturing 

• supply/demand 

• Natural disasters 

• Unknown 

Consequences?

• Lack of treatment

• Suboptmial treatment (use of lesser alternative therapies)

• Medication safety 

• Financial 

Drug Shortage Solutions…

1. Generic equivalent 

2. Select another manufacturer 

3. Use similar drug/therapeutic equivalent 

4. IV to PO conversion