Preventing Medication Errors in Long-Term Care

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Transcript Preventing Medication Errors in Long-Term Care

Preventing Medication
Errors in Long-Term Care
Facilities
Ilene Warner-Maron
PhD RN-BC CWCN CALA NHA FCPP
Institute for Continuing Education and Research
(ICER) at the Philadelphia College of
Osteopathic Medicine (PCOM)
[email protected]
Goals of This Program
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Using data collected from Pennsylvania
Department of Health surveys 20092012:
◦ Identify 3 factors that increase the risk of
medication errors in long-term care
◦ Identify 5 issues most commonly cited with
regard to medication errors
◦ Identify 5 interventions to decrease the
incidence of these errors
How Long Does it Take for a
Nurse to Administer 9:00 a.m.
medications in your facility?
Defining Medication Errors
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An error occurs when the preparation or
administration of a drug is not done in
accordance with:
◦ Physician’s orders
◦ Manufacturer’s specifications
◦ Accepted professional standards and
principles (by the author of the prescription,
the dispensing pharmacist or the
administrating nurse)
Physician/NP/PA-C Related-Errors
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Handwriting leading to transcription errors
Lack of specificity regarding diagnosis, duration of
treatment, frequency of administration
EMR related errors: wrong chart, wrong dose
Failure to review other medications and allergies
before prescribing additional medications
Failing to identify the symptoms the new medication
is treating are due to adverse drug reactions from
medications already prescribed
Lack of physician-physician handoff communication
during transitions of care
Covering physicians order medications for residents
whom they know very little
“Do No Harm” has changed to
“Do Something”
Pharmacy-Related Errors
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Delivery issues
Expired medications in E-box, refrigerator
Dispensing errors
◦ Medication
◦ Dose
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Failure to identify issues:
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Laboratory monitoring
Drug-drug interactions
Allergies
Duplicate categories of medications
Nursing-Related Issues
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Failure to follow
◦ Right medication, dosage, resident, route, time
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Failure to assess vital signs
Failure to monitor laboratory markers for
medications with narrow therapeutic index
(NTI)
Failure to assess the resident’s condition
before administering the medication
Dose omissions, “holds,” recaps, crushing
Friday at 5:00 admissions
24-hour chart checks “done”
Administrative-Related Issues
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Frequent Distractions/Care Changes
Communication between disciplines
Failure to identify medication diversion, re-ordering
issues, multiple STAT orders, restocking E-box,
borrowing from resident to resident
Inadequate attention to the role of the nurse
administering medications
Lack of support/resources/supervision
Contract with pharmacy provider does not include
requirement for medication pass observations, inservice education or consultations for residents
with frequent falls
Federal Regulations
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42 C.F.R. section 483.25(m):
◦ The facility must ensure that
 1. It is free of medication error rates of 5 percent or
greater and
 2. Residents are free of any SIGNIFICANT medication
errors
The error rate is determined by N/D where the
numerator is the total number of errors the survey
team observes (significant and insignificant) over the
denominator which is the total number of opportunities
for error including all the doses of all the medications
the survey team observed PLUS the doses that were
ordered but not administered
Additional CMS Clarifications:
Enteral Feeding Tubes
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May also involve F322 if:
◦ Placement of tube is not verified before administration of
medications
◦ If residents on fluid restriction receive too many fluids
with medications as well as flushes
◦ If each medication is not administered separately and
flushed before and after administration (unless a physician
specifies flushes should be limited due to fluid balance
issues)
◦ F425 pharmacy services may also be cited if there are
inadequate policies as well as F520 for QAA for quality
assurance oversight of policies
Failure to flush before and in between medications
is considered a single medication error
Additional CMS Clarifications: MDI
If more that one puff is required, whether it
is from the same or different medications,
there is a 1 minute wait between puffs
except for Albuterol and other short-acting
agents where 15-30 seconds is acceptable
 Surveyors are citing facilities for the failure
to have the resident rinse after steroid
inhalers
 Surveyors have been citing facilities regarding
the ORDER that MDIs are given:
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◦ Bronchodilators first
Additional CMS Clarifications: PPIs
Proton Pump Inhibitors (PPIs) such as Prevacid,
Protonix, Nexium, Aciphex and Prilosec are more
beneficial if given on an empty stomach, 30-60
minutes before meals
 Many older adults are prescribed this category of
medications in the hospital but may not need to
continue the medication in a nursing home or
indefinitely
 The duration and indication for use is required
 May also involve F281 Professional Standards of
Quality, F329 Unnecessary Medications and F425
Pharmacy Services
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Additional CMS Clarifications:
Controlled Substances
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Fentanyl (Duragesic) patches should be folded
upon itself (sticky sides together) then placed in
the sharps container with surveillance to prevent
diversion or accidental exposure
Timely identification and removal of medications
from the current supply
Identification of storage method for medications
awaiting final disposition
Documentation by 2 nurses of actual destruction
consistent with state and federal
Additional F309 QofCare; F425 Pharmacy; F431
Controlled substances; F514 Clinical records;
F520 QAA
Significant versus Insignificant Error
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Significant errors cause discomfort or
pain and jeopardize health and safety and
are dependent upon:
◦ The resident’s underlying condition such
as giving one dose of Lasix to a resident who
is dehydrated
◦ The drug category, particularly medications
with NTI
◦ The frequency of the error including
repeated omissions, failure to observe “holds”
General Medication Errors Seen in
the US Long-Term Care Facilities
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Failure to shake
medications as
required by the label
Mixing, rolling, creating
air bubbles in insulin
Crushing medications
on the no crush list
Incorrect amount or
type of fluids given
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Giving meds before
meals instead of with
meals
Giving meds with
meals instead of before
Failing to wait 3-5
minutes between eye
drops
Failing to administered
MDI in the correct
order and with
sufficient time
between puffs
Part D-Related Errors
Part D providers may require a
substitution of a prescribed medication
using a different formulary, adding further
steps to the process of administration
 Part D providers may substitute
extended-release medications, requiring
the use of shorting acting medications to
be administered more frequently
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Tracking and Reporting Errors
A Pennsylvania cautionary tale of Coumadin
 Define categories of errors (prescribing,
dispensing, administration, monitoring,
compliance)
 Develop a simple medication error reporting
form and process for investigation
 Increase education and knowledge of all
types of errors
 Conduct root cause analysis (RCA) as many
issues are multi-factorial
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Medication Errors PA DOH
Citations 2009-2012
Methodology: surveys of all types
reviewed for four years, noting citations
for any type of medication error F332
 Total number of surveys reviewed: 16, 125
 Total number of citations for all counties
in PA: 738
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Citations by County 2009-2012
County
Number of Citations
Allegheny
78
Lycoming
38
Montgomery
32
Washington
30
Northampton
29
Lancaster
28
Luzerne
25
Mifflin
24
Westmoreland
24
Northumberland
23
Mercer
22
Lebanon
21
Schuylkill
21
Types of Medication Errors 20092012
Type of Error
Number of
Citations
Percent of
Citations
Wrong dose, calculation issues,
spilled full dose, wrong strength
94
12.74%
Crushed inappropriately
82
11.11%
Not administered due to
unavailability, missing
71
9.62%
Wrong time
60
8.13%
Should have been given with food
or milk
59
7.99%
Should have been given in a fasting
state
47
6.37%
MDI administered without rinsing
mouth
35
4.74%
Pharmacy delivery issues
27
3.66%
MDI administered too closely
24
3.25%
Other Common PA DOH Citations
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No/expired order
Infection control
violations
Insufficient diluent
SSI timing issues
Eye drop
technique/time
between drops
Transcription errors
Recap errors
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MAR does not match
Controlled Drug log
E-box issues
Therapeutic
Interchange error
Allergies
Acetaminophen dose
exceeded
Cardiac medications
not held despite vital
signs outside of
parameters
Other Common PA DOH Citations
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Failure to report significant
medication errors to DOH
Anticoagulant doses not
altered in accordance with
PT/INR
LOA medications given
without directions for family
Policy failures
Anemia medications given
without monitoring
laboratory results or
obtaining parameters
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Failure to remove one patch
before placing another
No order for selfadministration
Pre-signing medications
Medication schedule not
changed when dialysis
schedule changed
Inadequate resident
instruction
No gradual dose reductions
for psychotropics
Incorrect medications from
pharmacy
Medication Caveats
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SSI
MDI
Thyroid preparations
Multiple forms of
acetaminophen
Policies to cover NTG
in case of angina
Medications that are
every other day,
weekly or monthly
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Cathartics/stimulants
requiring 8 ounces of
water
Inhalers followed by
pills
Labeling of OTC and
supplements
Pre-authorized
medication delays
Measurement of
liquids
Medication Caveats
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OD, OS, OU artificial
tears
Lidoderm over area of
pain
Reading x 3 not done
Physician not informed
when medications are
unavailable
Delays in obtaining
narcotics for new
admissions
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Nurse unaware of the
reason a medication
was administered
Nurse unaware of the
differences in onset,
peak and duration of
insulins administered
Hospitalization for
residents administered
wrong drugs, allergies
Interventions
Split halls for 8 and 9 a.m. medications to
allow for 3 hours of medication
administration
 Separate pharmacy provider from pharmacy
consultant
 Ensure monthly medication pass by
pharmacy to desensitize nurses to
observations
 Reviews to decrease the number of
medications in total and those administered
at 9 a.m.
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Interventions
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Replace SSI with standard dosing for the individual
resident
Anticoagulant flow sheets
Checking the 24-hour chart check
Resources for Do Not Crush (ER, XL, LA, SR and
other suffixes
In-services for the use of MDIs
Observations of nurses during med passes
Decreasing interruptions for nurses
Increased use of pharmacy consulting services for
residents with falls and other potential issues
related to medications
Interventions
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Particular attention to “hold” medications
and when to resume them
LOA instructions for medication use
BP in 2 positions at least weekly for
residents on one or more antihypertensive
agents
Understanding and disseminating information
about policies, medication errors while
maintaining an atmosphere where selfreporting errors is supported/expected
48 hour oversight and multiple reviews of all
new admissions
RCA
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http://www.jointcommission.org/Framework
_for_Conducting_a_Root_Cause_Analysis_
and_Action_Plan/default.aspx
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Issue: A resident was admitted for
rehabilitation following a hospitalization for
newly diagnosed Stage IV breast cancer. The
oral chemotherapy agent was not
administered during the entire 3 week
admission
RCA for Missed Chemotherapy
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Intended Process Flow
Missteps in Process
Human Factors
Equipment Failure
Environmental Factors
Organizational Factors
Staff Competence
Staffing
Information Readily Available
Communication Issues
Education
Technology
Resources
American Society of Consultant Pharmacists (ASCP) Guidelines on Preventing
Medication Errors in Pharmacies and Long-Term Care Facilities Through
Reporting and Evaluation, 1997.
Aronow, Wilbert S. Multiple Blood Pressure Medications and Mortality Among
Elderly Individuals. Journal of the American Medical Association (JAMA) 2015;
313;(13): 13642-4.
Brady, Eric L. Medication Errors in the Nursing Home. Nursinghomefamilies.com
Mixon, Amanda S et al. Characteristics Associated with Postdischarge Medication
Errors. Mayo Clinic Proceedings 2014;89(8):1042-1051
Munley, Evvie. CMS Memo Clarifies Nursing Home Survey Guidance for
Medication Errors and Pharmacy Services. LeadingAge November 7, 2012.
Stefanacci, RG and Spivack, BS. Preventing Medication Errors. Annals of LongTerm Care 2006; 14(10).
Many thanks to my former colleague at St. Joseph’s University, Reecha Sharma,
MD, for her assistance with the analysis of DOH data.