Transcript RPA medication errors and omissions

MODULE 3 Medication Omissions or Errors
Medication Omissions or Errors
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Medication Omissions or Errors
Preventing Medication Omissions and
Errors Is Key to
Keeping Kidney Patients Safe
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ESRD Patient Statistics
• The average dialysis patient takes 6 to 10
medicines a day.1
• On average, each patient required 4.7 ±1.8
type of medications
- Average was 10.0 ± 4.9 tablets per day
- 15.0% needed at least 7 types of medication
- 12.4% had to take more than 15 tablets each day2
• Medications commonly given with dialysis
include ESAs, iron preparations, vitamin D
preparations and antibiotics.
1. Curtin RB, Svarstad BL, Keller TH. Hemodialysis patients’ noncompliance with oral medications. ANNA J. 1999;26:307-316.
Kaplan B, Mason NA, Shimp LA, Ascione FJ. Chronic hemodialysis patients, part I: Characterization and drug-related
problems. Ann Pharmacother. 1994;28:316-319.
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Medication Errors
• Administering the wrong medication or the
wrong dosage
• Giving medication at the wrong time
• Patient failing to receive one of his/her
medications
• Failing to reconcile medications when patients
return to the facility from hospital or other
facility
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Consequences of Medication Errors
1. Harm from receiving a wrong medicine
2. Harm from omitting a prescribed medication
3. Harm from Poor Medication Reconciliation
• Omitting previously prescribed medications
• Prescribing duplicate medications or
several drugs in the same class
• Prescribing medications that are contraindicated (e.g., allergies)
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Facts About Medication Errors
A study of medication-related problems in hemodialysis
patients found adverse drug events correlated with the
number of co-morbidities. The results showed one
medication-related problem for every 3.1 medication
exposures. Most common problems were:
- drug use without indication (30.9%)
- lack of laboratory testing to monitor medication therapy
(27.6%)
- indication without drug use ( 17.5%) dosing errors (15.4%).1
1. Manley HJ et al. Factors Associated With Medication-Related Problems in Ambulatory Hemodialysis Patients. American
Journal of Kidney Disease. February 2003;41(2):386-393.
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Facts About Medication Errors
• Warfarin is frequently cited as a leading drug involved in
adverse drug events. Patients who reported receiving
medication instructions from a physician, nurse or
pharmacist, had 60% fewer warfarin-related
hospitalizations in the subsequent two years.1
• The most common medication error: a patient failing to
receive one of their medications (63% sometimes or
rarely) or being given the wrong dose of medication
(37% sometimes or rarely).2
1. Metlay JP, Hennessy S, Localio AR, Han X, Yang W, Cohen A, et al. Patient reported receipt of medication instructions for
warfarin is associated with reduced risk of serious bleeding events. Journal of General Internal Medicine. October 2008;23:
1589-94.
2. Garrick R, Kliger A, Stefanchik B. Patient and Facility Safety in Hemodialysis: Opportunities and Strategies to Develop a
Culture of Safety. CJASN. April 2012; 4:680-8.
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Facts About Medication Errors
• Health professionals who continually update their knowledge of drugs
make fewer medication errors than those who do not.1
• Drug types associated with medication errors:
– Anticoagulants (inadequate therapeutic dosing, no laboratory
follow-up)
– Cardiovascular agents (overdose)
– Chemotherapeutic agents (overdose)
– Diuretics (overdose, no laboratory follow-up)
– Diabetic medications (overdose, wrong type of insulin)
– Nonsteroidal anti-inflammatory drugs (extended use, overdose)
– Total parenteral nutrition solutions (given peripherally, inaccurate
component amount)2
1. Pié A, Warholak TL. Medication Safety: What You Can Do to Prevent Errors. Renal Business Today. December 2008;3(12): 28-31.
2. Hughes RG, Ortiz E. Medication Errors: Why They Happen, and How They Can be Prevented. American Journal of Nursing.
2005;105(3):14-24.
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When Medication Errors Occur
Ordering and transcription stage: failure to consider drug interactions or
allergies, misinterpretation of drug prescriptions.
Dispensing and administration stage: failure to ensure concordance with
prescribed medication, and failure to accurately record the drug name
and formulation, dose, route of administration, time and
administration technique in the medical record.
Discharge summaries: failure to record in the discharge summary an
accurate list of medications prescribed at discharge, failure to assure
this list is the same as recorded in the medical record and failure to
assure that the discharge medication list is the same as the list given
to the patient.
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Factors Contributing to Medication Errors
• Failure of the person administering a medication to read
the label before it is dispensed or restocked: “grab and
go"
• Failure to adjust dosage based on a patient’s decreased
renal function
• Not labeling or poor labeling of syringes/solutions/other
medication packages
• Intimidation or reluctance to ask for help or clarification
• Failure to educate patients about indication and dosage
regimen
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Factors Contributing to Medication Errors
• Using medications without complete knowledge of the
medication and potential interactions
• Failure to double check high-alert medications, such as
heparin, before dispensing or administering
• Not communicating important information (e.g., patient
allergies, diagnosis/co-morbid conditions, weight, renal
function, etc.)
• Failure to use tools or procedures to ensure medication
continuity
• Overriding computer alerts without due consideration
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Why Reconcile Medications?
Medication reconciliation is an effective process to
reduce errors and harm associated with loss of
medication information, as patients transfer
among community-based and hospital providers.
It may prevent up to 70% of all potential errors
and 15% of all adverse drug events.
-Joint Commission (2006)
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Medication Reconciliation in
Hemodialysis Patients
A 2008 study evaluated the potential impact of medication
reconciliation and optimization in the ambulatory care
setting at the time of patient transfer from an in-center
dialysis unit to a satellite dialysis unit.
– 78.8% of patients had at least one unintended
medication variance
– The majority of unintended variances (56%) were
caused by the physician/nurse practitioner omitting
an order for medication that the patient was taking 1
1. Ledger S, Choma G, “Medication reconciliation in hemodialysis patients.” CANNT J. 2008;18(4):41-3.
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Components of Medication Reconciliation
• Collect an accurate medication history, including
what has been ordered for the patient, and what
the patient is really taking
• Make certain medications and doses are
appropriate for patients with decreased renal
function and co-morbidities
• Document changes made at each treatment
venue – CKD care to dialysis unit, dialysis unit to
hospital, and hospital to dialysis unit.
• Educate patients about medications, including
name, indication and dosage regimen
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Medication Reconciliation Summary
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Medication reconciliation is important in providing
quality patient care
In dialysis units medication reconciliation is particularly
important due to the complexity of the patients
Components of medication reconciliation include:
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Collecting an accurate medication history
Making certain the medications and the doses are appropriate
Educating the Patients about the Medications
Documenting each change that is made along the way
There are several approaches to reducing medication
errors and each facility should develop processes that
best fit
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Developing Policies and Procedures
• Review current policies and procedures to ensure they
meet current recommendations for preventing medication
omissions and errors, including:
– Standardized process for medication reconciliation
– Review of medication changes after each provider visit
– Standardized handoff after hospitalization
• Review CMS Conditions for Coverage for ESRD Facilities
• Consider using a process analysis fishbone to examine
policies and procedures
• Review examples of Quality Improvement Projects (QIPs)
and develop QIPS appropriate for your facility.
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Process Analysis Fishbone
A process analysis fishbone is a diagrammatic way
to examine the policies, procedures, people, and
equipment involved in a process leading to an
outcome.
Providers may use the process analysis to develop
Quality Improvement Projects (QIPs)
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Focused Education Program for Patients,
Caregivers and Staff
Educate patients and caregivers on their medications and encourage the following:
• Know your medicines. Keep a list of the names of your medicines, how much you take, and
when you take them. Include over-the-counter medicines, vitamins, and supplements and
herbs. Take this list to all your doctor visits.
• Follow the directions. Take your medicines exactly as prescribed. Don't take medications
prescribed for someone else.
• Ask questions. If you don't know the answers to these questions, ask your doctor or
pharmacist.
- Why am I taking this medicine?
- What are the common problems to watch out for?
- What should I do if they occur?
- When should I stop this medicine?
- Can I take this medicine with the other medicines on my list?
Provide patients and caregivers with Dialysis Safety: What Patients Need to Know as a
take-home guide.
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Medication Safety Best Practices
Improving medication systems should result in a reduction in harm to
patients. Achieving breakthrough levels of improvement in reducing
harm from medications requires that an organization make changes to
improve four fundamental areas in parallel:
Culture: Develop a culture of safety where staff and leaders are
committed to safety and staff are safety conscious and freely report
concerns.
High-Hazard Medications: Decrease risk of harm from those
medications known to cause the most severe adverse drug events
(ADEs).
Core Medication Processes: Improve processes for ordering,
dispensing, and administering medications.
Reconciliation: Ensure that medication information is reconciled at
transition points, including arrival, transfer and discharge/departure.
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Medication Safety Best Practices
• Ensure medication continuity with tools such as
Discharge Instructions Template
• Avoid using abbreviations and symbols on the
Joint Commission “Do Not Use” list (put as next
slide)
• Educate patients and care givers about
medication safety
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The Joint Commission - Official “Do Not Use” List
Do Not Use
Potential Problem
Use Instead
U (unit)
Mistaken for “0” (zero), the
number “4” (four) or “cc”
Write "unit"
IU (International Unit)
Mistaken for IV (intravenous) or
the number 10 (ten)
Write "International Unit"
Q.D., QD, q.d., qd (daily)Q.O.D.,
QOD, q.o.d, qod (every other
day)
Mistaken for each other Period
after the Q mistaken for "I" and
the "O" mistaken for "I“
Write "daily“
Write "every other day"
Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)
Decimal point is missed
Write X mg
Write 0.X mg
MSMSO4 and MgSO4
Can mean morphine sulfate or
magnesium sulfate Confused for
one another
Write "morphine sulfate“
Write "magnesium sulfate"
1
1 Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.
*Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for
laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other
medication-related documentation.
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Which of the following abbreviations
is on the “Do Not Use” list?
A.
B.
C.
D.
E.
U
IU
QD
QOD
All of the above
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Which of the following abbreviations
is on the “Do Not Use” list?
A.
B.
C.
D.
E.
U
IU
QD
QOD
All of the above
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What is the most common
medication error?
A.
B.
C.
D.
Receiving the wrong drug dose
Receiving the wrong drug
Failing to receive drug dose
Failing to record dose
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What is the most common
medication error?
A.
B.
C.
D.
Receiving the wrong dose
Receiving the wrong drug
Failing to receive dose
Failing to record dose
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How many medications do most
ESRD patients take per day?
A.
B.
C.
D.
1-3
3-5
6-10
11-15
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How many medications do most
ESRD patients take per day?
A.
B.
C.
D.
1-3
3-5
6-10
11-15
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When should a patient’s medications
be reconciled?
A. When the patient moves from CKD
care to the dialysis unit
B. When the patient moves from the
dialysis unit to the hospital
C. When the patient moves from the
hospital to dialysis unit
D. All of the above
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When should a patient’s medications
be reconciled?
A. When the patient moves from CKD
care to the dialysis unit
B. When the patient moves from the
dialysis unit to the hospital
C. When the patient moves from the
hospital to dialysis unit
D. All of the above
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True or False:
Warfarin is frequently cited as a leading
drug involved in adverse drug events.
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True or False:
Warfarin is frequently cited as a leading drug
involved in adverse drug events.
TRUE
Warfarin is frequently cited as a leading drug
involved in adverse drug events. Patients who
reported receiving medication instructions
from a physician or nurse, as well as a
pharmacist, had a 60% reduced rate of a
warfarin-related hospitalization in the
subsequent two years.
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Additional Resources About Medication
Omissions or Errors
• The Joint Commission
http://www.jointcommission.org
• National Coordinating Council for Medication
Error Reporting and Prevention
http://www.nccmerp.org/councilRecs.html
• California HealthCare Foundation
http://www.chcf.org/topics/hospitals/index.cfm?itemID=12682
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Additional Resources About Medication
Omissions or Errors
• Agency for Healthcare Quality and Research
http://www.ahrq.gov/qual/errorsix.htm
• US Food and Drug Administration
http://www.fda.gov/medwatch/how.htm
• Keeping Kidney Patients Safe, Discharge Instructions
Template
http://www.kidneypatientsafety.org/pdf/bestpractices/Nephrophiles_medication.pdf
• Keeping Kidney Patients Safe, Dialysis Safety: What Patients
Need to Know
http://www.kidneypatientsafety.org/toolkit.aspx