Transcript Kirke C. AnalyzErr Pilot Study 2006

Experience with
Medication Error Reporting
Systems
in an Irish Hospital
Tim Delaney, FPSI
Head of Pharmacy
AMNCH Tallaght, Dublin 24, Ireland
First OECD Health Care Quality Indicators Seminar
on Improving Patient Safety Data Systems.
Farmleigh House, Dublin, June 29-30, 2006
Indicators
- starting point for change
Medication Error Reports
as Indicators
OECD Health Technical Papers No. 19 (2004), p.29
Drugs involved in harmful incidents
Percentage of Reports
9
8
Enoxaparin
7
Paclitaxel
6
Amiodarone
Insulin
5
Moxifloxacin
4
Zoledronic acid
3
Aspirin
2
Clopidogrel
1
Tetracaine
0
Top Drugs involved in Reports
(Kirke C. AnalyzErr Pilot Study 2006)
Irish Experience:
Errors by stage of the
Medication Use Process (all reports)
50
40
30
20
10
N/
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0
Pr
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Percentage of Reports
60
(Kirke C. AnalyzErr Pilot Study 2006)
Stage involved in harmful incidents
(Kirke C. AnalyzErr Pilot 2006)
50
40
30
20
10
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Percentage of Reports
60
5 Principles for Creating an
Environment for Safety
1. Culture: There should be a non-punitive culture for
reporting healthcare errors that focuses on preventing
and correcting systems failures and not on individual or
organisation culpability.
2. Data Analysis: Information submitted to reporting
systems must be comprehensively analysed to identify
actions that would minimise the risk that reported events
recur.
General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)
5 Principles for Creating an
Environment for Safety
3. Confidentiality. Confidentiality protections for patients,
healthcare professionals, and healthcare organizations
are essential to the ability of any reporting system to
learn about errors and effect their reduction.
4. Information Sharing. Reporting systems should
facilitate the sharing of patient safety information among
healthcare organizations and foster confidential
collaboration with other healthcare reporting systems
General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)
5 Principles for Creating an
Environment for Safety
5. Legal Status of Reporting System Information.
• The absence of legal protection for information submitted
to patient safety reporting systems discourages the use
of such systems, which reduces the opportunity to
identify trends and implement corrective measures.
• Information developed in connection with reporting
systems should be privileged for purposes of state
judicial proceedings in civil matters, and for purposes of
state administrative proceedings, including with respect
to discovery, subpoenas, testimony, or any other form of
disclosure
General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)
Legal protection and reporting
• In Ireland, incident report and analysis may
be protected under the Freedom of
Information Act but are still discoverable in
the event of civil litigation
• This is a significant deterrent to the
production of RCA reports.
Factors to Consider when
Comparing Reporting Rates
• Reporting Culture
• Differences in the types of reporting and
detection system
• Differences in the patient populations
served
• Definition of error
1. Culture
• Differences in culture among health
care organisations can lead to
significant differences in the level of
reporting of medication errors.
Culture - sense-making in a
community of practice
Fellenz. M. (Trinity College Dublin / Irish Management Institute, 2006)
Drive out fear!
Great loss is associated with fear,
when workers are afraid to ask a
question of to take a position.
A secure worker will report faults
and point to conditions that impair
quality
W. Edwards Deming : “Out of the Crisis” (1986)
AMNCH – A culture of safety?
Staff Values (1998)
Respect
Caring
Openness
Partnership &
teamwork
Fairness & equity
Reporting
Culture (2000)






Blame
Punishment
Secrecy
Adversity
Cynicism
Unfairness &
inequity
160
100%
140
97%
99%
100%
80%
83%
120
100
80
60%
49%
40%
60
40
20%
20
0
0%
Pharmacists Nurses
Pharmacy Doctors
technicians
Frequency
Cumul %
Dieticians
Cumulative % Reports
No. Reports (Oct-Dec 2004)
Reporting culture varies between
professions at AMNCH
2. Populations Served
• Differences in the patient
populations served by various
health care organisations can
lead to significant differences in
the number and severity of
medication errors occurring
among organisations.
3. Definition of error
• Differences in the definition of a
medication error among health care
organisations can lead to significant
differences in the reporting and
classification of medication errors.
Definition – what’s in a name?
Hierarchy of Medication Safety Incidents
Medication
Safety
Incident
Potential
Adverse Drug Event
(PADE)
Near Miss
Hazardous Condition
Adverse Drug Event
(ADE)
Adverse Drug Reaction
(ADR)
Medication Error
Source: AMNCH Tallaght: Medication Safety Incident Reporting Policy DTC4/2002
OECD uses JCAHO operational definition
OECD Health Technical Papers No. 19 (2004), p.29
NCC MERP Definition
“Any preventable event that may cause or lead to
inappropriate medication use or patient harm
while the medication is in the control of the
health care professional, patient, or consumer.
Such events may be related to professional
practice, health care products, procedures, and
systems, including prescribing; order
communication; product labelling, packaging,
and nomenclature; compounding; dispensing;
distribution; administration; education;
monitoring; and use."
NCCMERP (1998)
4% of reported incidents involved
patient harm
Number of Reports
(AMNCH data 2004)
150
100
119
67
69
31
50
8
4
0
0
1
E
F
G
H
I
0
A
B
C
D
NCCMERP Category
(Kirke C. AMNCH Data Oct-Dec 2004)
7% of reported incidents involved
patient harm
(5 Irish Hospitals Pooled Data, 2006)
100
Cumulative Percentage
Percentage of Reports
90
80
70
60
50
40
30
20
Percentage of
Reports
Cumulative
Percentage
10
0
A
B
C
D
E
F
G
H
I
NCC-MERP Category
(Kirke C. AnalyzErr Pilot Study 2006)
Issues with definitions
• OECD definition is equivalent to NCC
MERP Categories G and I
• Covers only 2 of 5 NCC MERP subcategories of errors causing harm
• Excludes a major harm category -errors
where emergency intervention was
needed to sustain life
4. Reporting Systems
• Differences in the types of reporting
and detection systems for medication
errors among health care organizations
can lead to significant differences in the
number of medication errors recorded
Monthly Medication Safety Incident
Reporting at AMNCH 2001-2005
Medication Safety
Incident Reports Received Monthly
Jan 2001 - December 2005
160
140
120
100
80
60
40
Target
Total Medication Safety Incidents Reported in Adult and Paediatric Services
Nov-05
Sep-05
Jul-05
May-05
Mar-05
Jan-05
Nov-04
Sep-04
Jul-04
May-04
Mar-04
Jan-04
Nov-03
Sep-03
Jul-03
May-03
Mar-03
Jan-03
Nov-02
Sep-02
Jul-02
May-02
Mar-02
Jan-02
Nov-01
Sep-01
Jul-01
May-01
Mar-01
0
Jan-01
20
Six-Monthly Mean
AMNCH Tallaght
Dispensary Errors 2004/2005
Errors detected in Pharmacy 2004
Errors detected on Ward
Errors reaching patient
Detection in Pharmacy per 100,000 items
Detection in Ward per 100,000 items
Not detected (given to patient) per 100,000 items
2,125
81
41
709
27
14
Errors detected in Pharmacy 2005
Errors detected on Ward
Errors reaching patient
2,795
77
21
Detection in Pharmacy per 100,000 items
Detection in Ward per 100,000 items
Not detected (given to patient) per 100,000 items
1067
29
8
Limitations of passive reporting
OECD Health Technical Papers No. 19 (2004), p.30
Number of Reports
What is counted?
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Medication Error reporting at AMNCH Tallaght
2002-5
2002
2003
2004
Dispensary errors
Medication Safety Incident Reports
Aseptic Unit Errors
Clinical pharmacist QA Interventions
2005
Number of Reports
What CIS sees
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Medication Error reporting at AMNCH Tallaght
2002-5
2002
2003
2004
Dispensary errors
Medication Safety Incident Reports
Aseptic Unit Errors
Clinical pharmacist QA Interventions
2005
“ Mistakes are
the portals
of discovery.”
James Joyce