Transcript File

Independent Double Checks for
High Alert Medications
in the Perioperative period
Presented by:
Kenny-Joe Wallen
Introduction
• Medication errors are all too common in the United
States and are extremely costly to all parties involved.
• Certain medications are known to carry a higher risk
of harm than other medications, these are known as
High Alert Medications (HAM)
• Implement a manual Independent Double Check
(IDC) in the perioperative period when administering
all HAM will help ensure that patients receive
medications in the safest manner possible.
Key points
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Definition.
Medication Errors
Effects of Medication Errors
Why Medication Errors Happen
Conformational Bias in the perioperative period
High Alert Medications (HAM)
Ways to Minimize Medication Errors
Putting it all Together
I. Definition
• Medication Errors
A medication error is "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” (U.S. Food
and Drug Administration, 2013).
• High Alert Medications :
Drugs that bear a heightened risk of causing significant patient harm when
they are used in error. Although mistakes may or may not be more common
with these drugs, the consequences of an error are clearly more devastating
to patients (The Institute for Safe Medication Practices, 2009).
Medication Errors
• Remain one of the leading threats to patient safety.
• On average, a U.S. hospital patient is subjected to at least one medication
error per day; making them the most common cause of preventable adverse
patient events
• Medication error are more likely to occur in intensive care units, operating
rooms, and emergency departments
• Occur at any step in the medication process but most frequently in the
perioperative period during the administration phase.
• The Institute of Medicine (IOM) states that not only are patients effected,
but also their families, their employers, and the hospitals, health-care
providers, and insurance companies.
• Are most likely to occur in intensive care units, operating rooms, and
emergency departments
Effects of Medication Errors
• Physical Harm
– 1.5 million preventable adverse drug events (ADE) occur each year in the United States
with roughly 100,000 of those resulting in death due to medical mistakes
• Financial Cost
– Medication errors adds roughly $8,750 per patient to the cost of the hospital stay, with an
annual cost of drug related morbidity and mortality between 1.56 billion and 5.6 billion
– Patients injured by ADEs have their hospital stays extended by an average of two days,
at an additional cost of $2,000 to $2,500 per patient.
– Medication errors are said to cost between $17 billion and $29 billion per year in
hospitals nationwide, including the expense of additional care necessitated by the errors,
lost income and household productivity, and disability.
Effects of Medication Errors
• Lost Trust
– Medication Errors diminish satisfaction by both patients and healthcare professionals.
• Patients
– experience longer hospital stays and experiences additional physical and psychological
discomfort.
– They lose trust in the provider and the healthcare system.
• The Healthcare System
– Lose morale and frustration not being able to provide the best care possible.
• Society
– Bears the cost of errors in terms of lost worker productivity, reduced school attendance by
children, and lower levels of population health status
Why Medication Errors Happen
• Humans are fallible and errors inevitable. They are a part of Human Nature
• Providers are overworked, minimal resources, staffing shortages, poor
communication
• However, the majority of medication errors do not occur due to individual
recklessness or the actions of a particular group yet they are due to faulty
systems, processes, and conditions that lead people to make mistakes or fail
to prevent those.
Conformational Bias
• Conformational Bias is one condition that causes people to make mistakes
• Grissinger defines it by saying that, “Most mental processing occurs
outside of conscious awareness. The amount of information that can be
taken in by our senses is limitless, but the brain has limited resources when
it comes to attentiveness. Our senses receive much more information than
what can possibly be processed at one time. To combat information
overload, the brain allows large amounts of information to enter, almost
entirely unassimilated, and peels off just a few pieces of selected
information for a closer look” ( 2012).
Conformational Bias in the
perioperative period
• When anesthesia providers prepare drugs in the
operating room (OR), they retrieve the needed
medication from a cart, read the vial or ampule
label, draw up the medication, and apply a
color-coded adhesive label to the syringe
• Often times though there are multiple drugs
within a class. Most of the time they are in the
same size vial or container and have the same
color sticker, but have very different properties.
Conformational Bias in the
perioperative period
• Providers become so amerced in providing care for their
patient that people do not always read labels as carefully
as they should. Instead they depend on a single variable,
such as the color, shape, or size of the container, when
selecting a drug. The problem is the more colors that are
used, the greater the risk of confusing a color and its
meaning.
• In fact, many errors in fact are made by intelligent,
vigilant, and attentive people; and that the cause is
usually rooted in “inattentional blindness,” a condition
all people exhibit periodically
High Alert Medications (HAM)
Classes/Categories of Medications
Adrenergic agonists I.V (e.g, epinephrine, phenylephrine, norepinephrine ).
Adrenergic antagonists I.V ( e.g, propranolol, metoprolol, labetalol )
Anasthetic agents: inhaled and IV ( e.g, propofol, ketamine )
Antiarrhythmics, I.V ( e.g, lidocaine, amiodarone ).
Anticoagulant : (e.g, heparin, warfarin ).
Chemotherapeutic agents : parentral and oral.
Oral hypogylcemics.
Inotropic medications I.V ( e.g, digoxin , milrinone ).
Moderate sedation agents I.V (e.g, midazolam), Oral (e.g, chloral hydrate)
Narcotics/Opiates I.V, transdermal and oral.
Neuromuscular blocking agents ( e.g, succinylcholine).
High Alert Medications (HAM)
Specific medications
Colchicine injection .
Insulin : S.C and I.V.
Magnesium sulfate injection.
Methotrexate : oral ( non – oncologic use ) .
Oxyticin I.V.
Nitroprusside sodium for injection.
Potassium chloride for injection .
Promethazine I.V.
Sodium chloride for injection.
Top five High Alert Medications
(HAM)
• Insulin
• Opiate and Narcotics
• Injectable Potassium chloride or phosphate
• Injectable Anticoagulant
• Sodium chloride solution above 0.9%
– Errors in the administration of these medications can have
catastrophic clinical outcomes.
Ways to Minimize Medication Errors
1. Perform Independent Double Check (IDC)
2. “5-Rights” of Medication Administration
3. Listen for bells and whistles
1. Perform Independent Double Check (IDC)
– Used to detect potentially harmful errors before they
reach patients.
– Is a primary way to identify all high-alert drugs
– Reduces medication administration errors by up to 95%.
– Requires two people to separately and independently
check each component of the work.
– This is done to reduce the risk of bias when a person is
preparing and checking medications
– Is an all-around effective approach to prevent errors and
make errors visible, thus reducing unnecessary harmful
situations for patients and hospitals alike.
1. Perform Independent Double Check (IDC)
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The first healthcare provider who will be administering the medication will prepare the
medication as per hospital policy.
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The first provider will then communicate to the second provider the rationale for use of
the medication and any pertinent clinical findings or lab values.
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The second healthcare provider will then conduct an IDC of the medication. Once the
second provider performs the double check and both providers are satisfied that the
medication is accurate, the double check will be documented.
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The second provider should write “checked by” or similar wording next to his/her
initials to indicate that she/he performed this check. The double check will be
conducted prior to the medication being administered. Additional checks may be
conducted at the discretion of the healthcare provider
2. “5-Rights” of Medication Administration
Putting it all Together
• The primary reason for implementing IDC for HAM in the perioperative
period is improving efficiency with regards to medication administration
and patient outcomes.
• They are not perfect and will sometimes fail
• They should be bundled with other risk-reduction strategies, and system
changes must also be made to reduce the frequency of errors
• Even though they are not foolproof; when performed judiciously and
properly, they will reduce the risk of an error reaching the patient.
References
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Baldwin, K., & Walsh, V. (2014). Independent double-checks for high-alert medications: Essential practice.
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Grissinger, M. (2012). Color-coded syringes for anesthesia drugs - Use with care. Pharmacy and
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References
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Institute of Medicine. (1999). To err is human: Building a safer health system
Institute of Medicine. (2006). Preventing medication errors. Washington, DC: The National Academy
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Institute of Medicine. (2009). Independent double-checks are vital, not perfect. Medication Safety Alert!
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