Transcript SCI2003 Template - American Pharmacists Association

Preventing Errors Related to
Drug Delivery Devices and
Using Technology to Prevent
Medication Errors
Learning Objectives
• Describe types of technology available for
reducing the potential for medication
errors
• Explain the potential errors in drug
administration created by implementing
technology
• Discuss the role of multidisciplinary teams
in choosing and implementing
technologies to prevent medication errors
Preventing Medication Errors Related to
Drug Delivery Devices
• Misuse of infusion pumps and other parenteral device
systems is the second most frequent cause of medication
errors during drug administration
• When using failure mode and effects analysis (FMEA) to
assess these devices, both safety features and intuitive use
should be as important as price and service in the evaluation
Purchasing Infusion Pumps
• An interdisciplinary team should use FMEA to predict
possible errors and identify other failures and their potential
harmful effects before purchasing new pumps
• See page 276 in the textbook for FMEA questions for
evaluating potential new purchases or the safety of the
current pumps in use
Infusion Pumps
Preventing Programming Errors
• Administration errors involving the IV route are the most
likely to cause patient harm
• IV pumps deliver a more accurate flow rate than a gravityflow drip, however they are prone to programming errors
• IV pumps can be difficult to use: multiple functions, small
screens, confusing or disorderly menus
• 2006 Institute of Medicine (IOM) report calls for the Agency
for Healthcare Research and Quality and the medical device
industry to promote and apply user interface designs based
on the cognitive and human factors principles
– Errors will continue if programming functions are illogically placed or
the keys do not function
– A nurse set an infant’s total parenteral nutrition (TPN) solution at 130
mL/hour when she meant to set it at 13.0 mL/hour, but the decimal
point key failed
Infusion Pumps
Preventing Programming Errors (continued)
• Some pumps automatically calculate an infusion rate, which
should reduce potential errors
– However, the process of programming is error-prone
• Calculations are only as accurate as the information entered
– Nurse may need to enter patient weight, concentration of drug, rate
desired
• All data entry must be accurate to be effective
• Independent checking should accompany the infusion of
high-alert medications
– One nurse should prepare the solution and program the pump
– Another nurse should verify the drug, dose concentration, line
connection, patient identification, and pump setting
– Both practitioners should observe the pump’s final infusion rate when
using pumps that automatically calculate the rate
Infusion Pumps
Preventing Programming Errors (continued)
• Use a single standard concentration for drug solutions
– Particularly important for high-alert medications
• Affix auxiliary labels that list the data to be entered into the
pump
– Pharmacists can affix labels with dose/infusion rate tables for
commonly used drug infusions
– Nurses can verify final infusion rate calculated by the pump is correct
Infusion Pumps
Protection From Free-Flow
• Free-flow is accidental, uncontrolled gravity flow of IV fluids
and drugs after an IV administration set is removed from the
pump
• Free-flow happens when an IV without a mechanism to
prevent the flow is not clamped by the operator
• Newer pumps have a fail-safe mechanism
• Free-flow errors can result in patient death
• The Joint Committee (TJC) requires hospitals to guarantee
that free-flow protection is in place for all patient-controlled
analgesia (PCA) pumps and general-use infusion pumps
used in their organization
Infusion Pumps
Preventing Line Mix-Ups
• Multiple-channel pumps allow several solutions to be infused
into a patient, thus having space around the patient for
providing care
• Lines can be confused when more than one line or more than
one pump is used
• Nurses should handle only one line at a time, tracing the line
from the solution, through the pump, and to the insertion site
• An independent check system should be used with high-alert
medications
– One nurse should hang the solution and ready it for infusion
– Another nurse should validate the original order, the patient’s
identification, the dose and concentration, the route, and the pump
setting
• Drug names may be affixed to each IV line at the end closest
to the patient and at the point where the line enters the pump
Infusion Pumps
Preventing Line Mix-Ups (continued)
• The label must be removed when the drug is discontinued;
the nurse should not depend upon the label alone to select
the correct channel
• All IV solutions should be checked by the nurse more than
once each shift, tracing the individual lines from solution to
channel and verifying the correct channel is selected
• Never use one multiple-channel pump to infuse two patients
• Evaluate the risk of line mix-up when purchasing multiplechannel pumps
– Be aware that two single-channel pumps on the same pole could
potentially cause errors
• Bar coding could verify the solution being hung, but will not
find an error if the tubing is switched during set up
Infusion Pumps
Protecting Epidural Lines
• Special tubing with a yellow line running along the lumen
and containing no side ports is available for epidural infusion
– May prevent epidural administration of drugs or solutions not
intended to be administered by this route
– A distinctive infusion pump is used in some organizations to prevent
IV solutions from being given epidurally
Removing Lines
• Remove tubes and catheters that are no longer needed as
soon as possible
– A patient suffered intense pain because a nurse administered an IV
dose of pain medication into an intra-arterial line that was not in use
Smart Infusion Pumps
• Smart infusion pumps that warn nurses about programming
errors before the infusion has started have been available
since 2002
• A traditional IV infusion pump becomes smarter with the
addition of medication safety software (a drug library to
cross-check for programming that is not within high or low
preset limits)
– The computerized pump can be programmed with standard
concentrations
– Dose limits for adults and children can be set
– Pumps can be set for each treatment area (e.g., oncology, critical
care)
– Pumps are loaded with the dose information and terminology by each
individual hospital
Smart Infusion Pumps
• An alert will appear in a smart pump if the rates do not fall
within the dose limits
– Pump programmed for 7 units/kg/hour; ordered dose was 7 units/hour
– Patient was 70 kg; dose was set for 490 units/hour
– Programmed dose was outside the normal limits and alerted nurse
• To reach their full potential, smart pumps should be used as
part of an integrated system
• Developing and applying a standard terminology to ensure
better communication among smart pumps and other clinical
information systems is recommended in the 2006 IOM report
• Smart pumps do not detect line mix-ups
Smart Infusion Pumps
• Transaction data are retrievable from the pumps
– Data may be stored on the pumps (1 to 2 days’ worth or
months’ worth on a server)
• Multidisciplinary teams are crucial
– Must determine who is responsible for updates and
maintenance of drug libraries
– Team must determine maximum and minimum limits and
approve them through Pharmacy and Therapeutics (P&T)
Committee
• Smart pump technology is available for standard IVs
and PCAs, and may integrate with electronic medication
administration records (eMAR), computerized prescriber
order entry (CPOE), and bar code medication
administration (BCMA) technologies
PCA Devices
• PCAs allow the patient, rather than the nurse, to administer
analgesics, thus reducing the risk of oversedation when
used correctly
• PCAs used incorrectly can cause errors that are sometimes
serious
• Table 12-1 lists safety strategies to reduce these errors,
such as:
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–
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Improving access to information
Limiting access
Using reminders
Carefully monitoring
Standardizing and simplifying
Differentiating
Requiring redundancies
Including forcing functions and fail-safes
Employing FMEA
PCA Devices
PCA by Proxy
• Only patients should administer the alagesics
• “PCA by proxy” is when health care personnel or family
members push the pump to try to keep the patient comfortable
– PCA by proxy can lead to death due to respiratory depression
Improper Patient Selection
• Candidates for PCA should be physically and psychologically
able to manage their own pain
– PCAs have been given to children and those in confused mental
states thus leading to PCA by proxy or undertreatment because of
inability to communicate pain
– Oversedation may result when PCAs are given to patients with
conditions such as asthma or obesity, and patients at risk for
respiratory depression receiving drugs that potentiate the action
of opioids
PCA Devices
Appropriate Monitoring
• Frequent patient monitoring, especially during the first 24
hours and at night
– Even a patient with opioid toxicity can be aroused and assessed
• Patients can be easily stimulated to a higher level of consciousness and an
increased respiratory rate
• Patient may return to the oversedated state once the
stimulus is removed
• Pulse oximetry readings can offer a false sense of security
because oxygen saturation is usually maintained, especially
if oxygen is being administered
PCA Devices
Improper Patient Use
• Inadequate patient education contributes to improper PCA
use
• Most patients can be educated about PCA use
– Not immediately after the postoperative period when they are groggy
• Directions can be misunderstood even by patients who are
fully alert; e.g., thought the pump had to be pushed every 6
minutes even though their pain was under control
• PCA button resembles a call button
• Some pumps have no feedback mechanism (visual or
auditory) so the patient does not know whether the button
was successfully pressed
PCA Devices
• Misprogramming
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Complex programming sequences
Pump design flaws
Requirement of multiple steps
Device design is not intuitive
• Common pump design flaws
– Users may not know the manufacturer default settings
– Verification of some program settings is difficult
• Some do not require users to review all settings before the start of infusion
– Some programs require dosing in milliliters, not milligrams
– Defaults may be hidden and thus unknown to the user
PCA Devices
Misprogramming (continued)
• A nurse programmed a PCA at 50 mcg/mL as prescribed for
fentanyl
– Model defaulted to 1 mcg/mL when the enter key was not pressed
within a specified amount of time, causing the delivery to be 50 mL
• Persons programming the PCAs can have mix-ups or
mental slips
Mechanical Problems
• Examples of mechanical problems leading to PCA failures
– Siphoning of air from broken syringes or cassettes
– Short circuits
– Insufficient batteries
• View of the label on the syringe or cassette can be
obstructed once they are in the pump
PCA Devices
Staff Education
• Train nurses adequately
– PCA programming, potential adverse events, and monitoring
• Nurses may not be proficient if multiple types of PCAs are
used or if PCAs are used infrequently
• Prescribers have made errors because:
– There is no requirement to demonstrate proficiency in areas such as
conversion of dosages of oral drugs to IVs dosages
– Incorrectly prescribing for morbidly obese, elderly, or opioid-naïve
patients
– Concurrent orders can result in therapy duplication and overdose
Drug Mix-Ups
• Name similarities (e.g., morphine and hydromorphone)
• Packaging is similar for multiple concentrations
• Opioids are typically unit stock
• PCA orders have been misheard and misread
Oral Syringes
• Failure to identify the correct tubing has led liquid medications
meant for gastric or nasogastric tubes to be given intravenously
– Small-bore polyurethane nasogastric feeding tubes or percutaneously
inserted gastric tubing connections fit IV line connection tubing
– Cardiac arrest was caused when nimodipine in a parenteral syringe
was given through an IV rather than through the nasogastric tube
• Oral syringes should be clearly labeled “oral only” in red attached
to the plunger
• Making the connections between IV lines and nasogastric tubes
incompatible would help eliminate some errors
Enteral Feedings
• Some containers can be spiked at the main entry point with
an IV administration set
– Container looks like a three-in-one parenteral nutrition admixture
• Many ready-to-hang containers allow formula to flow
through a standard IV infusion set despite the use of an
inline filter, which can quickly become occluded
– A patient given 200 mL of an enteral feeding by IV infusion over 1 to
2 hours instead of receiving TPN later died
• Warnings on enteral feeding containers are not sufficient to
stop errors
• The proper enteral administration set should be attached to
the enteral product container before stocking or dispensing
Enteral Feedings
• Discontinued products should immediately be removed from
patient care areas and returned to their source
• Some nurses purposely use IV pumps to administer enteral
feedings or solutions when enteral administration sets are
not available
– A child was started on GoLytely (PEG-3350 and electrolytes) at 400
mL/hour via IV tubing attached to a nasogastric tube, but 1 hour later
the nurse found it was actually being administered through an IV
access line
– A safer solution: use an adapter to connect two enteral feeding
pumps, with each delivering half the desired volume of the product
simultaneously
• Some nasogastric tubes have a dual port for this type of
connection
• Some enteral pumps can administer a higher dose than
usual volumes
Other Tubing Misconnections
• Tubing used on a blood pressure (BP) device connected to
an IV port
– Patient went to radiology; BP device was disconnected before the
MRI and presumably reconnected afterward
– Family member discovered that the BP monitor tubing was really
attached to a needleless Y injection port on the patient’s IV line
• Oxygen tubing was mistakenly attached to a total joint
drainage system instead of the suction tubing
– Patient died from a gas embolism
• Oxygen tubing connected to a nebulizer became
disconnected and mistakenly reconnected to IV line, killing a
child
• Figures 12-1, 12-2, and 12-3 in the textbook show potential
for misconnections
Using Technology to Prevent
Medication Errors
Getting Started
• Technology for error prevention—organizations
call for widespread use
• IOM recommendations
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Enhanced point-of-care electronic references
Full electronic prescribing by 2010
Widespread computerized patient monitoring
Improved consumer drug information via Internet
• Institute for Safe Medication Practices
recommendations
– Elimination of handwritten prescriptions
– Call for manufacturers to include bar codes on all
medications
– Advocate for point-of-care BCMA
History-Taking
Obtain
Medication-related
History
Document
Medication History
Medication Management Process
•Wireless
devices for
medication
history
capture, etc.
With Specific Technologies
Medication Inventory Management
Ordering
Diagnostic/
Therapeutic
Decisions Made
Inventory
management
Order verified and
submitted
•Physician
order entry
Surveillance
Incident/adverse
event surveillance
and reporting
Medication
Ordered
Formulary, purchasing
decisions
Pharmacy Management
Evaluate order
•Automated
surveillance
Select
medication
Prepare
medication
•Robotic
dispensing
systems
Dispense/
distribute
medication
•Pharmacy
information
systems
Administration Management
Monitor/Evaluate Response
Intervene as
indicated for
adverse
reaction/error
Assess and
document
patient response
to medication
according to
defined
parameters
Document
Document
administration
and associated
information
•Bar coding
administration
Administer Medication
Administer
according to
order and
standards for
drug
Select the
correct drug for
the correct
patient
Education
Educate patient
regarding
medication
Educate staff
regarding
medications
27
Pharmacy Computer Systems
• Maximize system capabilities
– Incorporate alerts and clinical decision support
– Alerts and upgrades should be easily added
• See Chapter 15 Appendix of textbook for Draft
Guidelines for the Electronic Presentation of
Information About Prescribed Medications
– Drug information database should include:
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Allergy alerts
Drug-drug, drug-disease, drug-food interactions
Duplication warnings
Minimum and maximum doses
Contraindications
Pharmacy Computer Systems
• Maximize system capabilities (continued)
– Interface with laboratory information systems
• Table 15-4 discusses Ways Lab and Pharmacy Can Be
Linked to Improve Care
– Require allergies, patient weight, and height to be
entered prior to medication orders
– Font should be easily changed for TALL-Man format
– Require pharmacist verification for all orders
– Implement hard stops (forcing functions) for unsafe
orders
– Default to review of current orders before new orders
are entered
– Generate customized MARs
Alerts and Warnings
• Alerts and warnings work only if the
information is entered into the system
– A patient allergy must be coded correctly for
the computer to recognize it
– Heights and weights must be updated each
time a patient is admitted
• Systems should include a verification step
when data are from a prior admission
Presentation of Information
• MARs and labels must be clear to nurses
– Allow for prospective review of labels prior to
implementation
• Allow for the use of commas in the strength field
– Ensure proper spacing between the drug dose and
strength
• Mnemonics for drug selection has led to order
entry errors
– ACTO could be ACTOS (pioglitazone) or ACTONEL
(risedronate)
– Use of both brand and generic names may decrease
potential for errors
System Maintenance
and Support
• Systems must be continually maintained
and upgraded
• Budgets must include continued support
– Hardware and software upgrades
– Internal personnel responsible for testing and
maintaining the system
– Orientation for new employees
– Customized enhancements as needed
Automated Dispensing Cabinets (ADCs)
ADCs
• Designed to control storage and documentation
of medications in patient care areas
– Replacing cart exchange systems
– Expanded software capabilities
– May be used for floor stock, narcotics, or complete
drug storage on patient care units
– Benefits of ADCs
•
•
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Improved productivity within the pharmacy
Improved nursing and pharmacy productivity
Cost reduction
Improved charge capture
Decreased errors
ADC-Related Errors
• Errors may be related to:
– Stocking errors
– Overrides or “work-arounds”
– Available safety functions being turned off
– Look-alike, sound-alike medications stored
near each other
– Removing medications for multiple patients at
one time
– Nurses returning medications to the ADC with
no double check
ADC Safety Steps
• Purchase:
– Adequate number of cabinets per patient area
– Systems that allow for patient profiling (pharmacist review)
– Systems that are BCMA compatible
• Carefully select drugs and quantities to be stocked
• Separate look-alike, sound-alike medications and different
strengths of the same medication
• Use separate cabinets for pediatric and adult medications, if
possible
• Periodically reassess drugs stocked in each cabinet
• Remove only a single dose of the medication ordered
– Nurses should not return unused doses to the ADC
ADC Safety Steps
• Require a double check after cabinet restocking
• Incorporate screen alerts for certain medications
• Do not make up doses of medications when the ordered
strength is available
– Do not ask nurses to split doses in half; the device cannot
account for half doses
• Incorporate a system of documenting the reason for
overrides
– Routinely run and analyze override reports
• Develop and test downtime procedures
CPOE
• CPOE is an electronic system for entry of
medication orders by prescribers
– Prescriber system is linked to:
• Patient history
• Alerts of allergies and interactions, duplicate therapy,
contraindications based on diagnosis, and unsafe or
subtherapeutic doses
• CPOE systems significantly impact prescribers
– Identify physician champions in early stages
CPOE
• Integrate or Interface?
– CPOE and pharmacy systems must be integrated or
seamlessly interfaced
• If not, electronically entered orders will print in the pharmacy
and need to be reentered into the pharmacy computer
system (PCS)
• Creates potential for transcription errors
– Interfacing systems from multiple vendors requires
maintenance of multiple drug databases
– Interfacing versus one vendor = “best of breed”
• CPOE and PCS must support the MAR
• MAR information should closely match labels
• Administration instructions should flow from
pharmacy to nursing
CPOE
• Staff Involvement
– In addition to physician champions:
• Identify a multidisciplinary team to investigate, analyze, “sell”
benefits to others, and implement
– Prospectively identify team leaders and departments
responsible for maintenance and education
– P&T Committee should be actively involved
• Drug Versus Lab Orders
– Lab and drug orders must be distinctive to identify
drug order versus lab studies
• Drug levels should not just be the drug name
– Digoxin versus digoxin level or digoxin assay
Clinical Decision Support (CDS)
• CDS is a set of rules, alerts, and information that
orders are checked against for safety
– These rules are often written by each facility
– CDS should be checked carefully prior to
implementation
– CDS databases must be updated regularly
– Caution should be used to avoid excessive trigger
alerts
• Effects of excessive “noise” leads to bypassing of alerts
Point-of-Care BCMA
•
•
•
•
•
•
•
•
Jane Doe, RN
Ensures 5 “rights” of
administration using bar codes
3-way match at bedside
Wireless real-time medication
tracking
Discrepancy alerts
Online profile/MAR
Administration planning
Data for patient monitoring
activities
Charting and charge capture at
the time of administration, not
dispensing
BCMA
• 38% of medication errors occur at the
bedside, with only 2% being caught
• BCMA focuses on the administration
phase of drug delivery
• Rapidly evolving area of technology
• Newer models can interface with CPOE,
eMAR, and smart infusion pumps
BCMA
• Workflow Changes
– Implementation of BCMA must be done with
input from nursing
• Many of the pitfalls of implementation can be
overcome by modifications to the system
– Difficult to document deviations from
scheduled administration times
• Leads to work-arounds
– Nurses would scan medications and then put them in
their pocket so they would show as “on time” in the
computer
BCMA
• Alerts and Overrides
– Overrides should be used only for urgently
needed medications
– Number of alerts must not be overwhelming
• Bar Codes on All Doses
– FDA requires bar codes on all medications
• Does not require all medications be available in unit
dose package
• Bar code format has not been standardized
– Organizations will likely need to repackage many
doses
• May be done in-house or outsourced
BCMA
• Considerations for preparing medications for
repackaging
– Orientation of bar code on the product
• Bar codes on curved areas (vials and bags) are difficult to scan
– Verify that manufacturer bar code matches pharmacy
database
– Pharmacy computer system should print readable bar
codes for multiproduct IVs
• Must match the components in the IV
– Dispense patient-specific doses with bar codes
– Label equipment (printers) must be checked often for
accuracy
Conclusion
• Technology can reduce the potential for
adverse drug events
• Stakeholders must commit both budget
and manpower for planning,
implementation, continuous education,
and monitoring
• Technology implementation has the
potential to introduce new errors
References
Grissinger M, Cohen H, Vaida AJ. Using
technology to prevent medication errors. In:
Cohn MR, ed. Medication Errors. 2nd ed.
Washington, DC: American Pharmacists
Association; 2007.
Smetzer JL, Cohen MR. Preventing medication
errors related to drug delivery devices. In:
Cohen MR, ed. Medication Errors. 2nd ed.
Washington, DC: American Pharmacists
Association; 2007.