Transcript Creating a Culture of Safety to Reduce Medication Harm

Creating a Culture of Safety to
Reduce Medication Harm
International Safety Symposium
November 10th, 2011
Megan Winegardner, Pharm.D.
Medication Safety Coordinator
Henry Ford Hospital, Detroit MI
Objectives
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Describe the incidence and severity of adverse drug
events in the United States
Explain the differences between a Punitive Culture, a
Blame-Free Culture, and a Just Culture
List steps that can be taken to establish a culture of
safety to reduce medication harm
Number of deaths per year
Causes of Death in the US
Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.
Adverse Events in
Hospitalized Patients
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13.5% of Medicare patients experience a serious
adverse event during hospitalization
(134,000 pts/month)
Most common causes:
• Bleeding
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Medications (31%)
Ongoing patient care (28%)
Surgery (26%)
Infection (15%)
• Delirium
• Hypoglycemia
• Acute renal failure
• Hypotension
• Respiratory complications
• Allergic reaction
Office of Inspector General. Adverse events in hospitals:
National incidence among Medicare beneficiaries. November 2010.
Adverse Events in
Hospitalized Patients
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An additional 13.5% of Medicare patients experience
temporary harm during hospitalization
Most common causes:
• Delirium
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Medications (42%)
Ongoing patient care (36%)
Surgery (18%)
Infection (4%)
• Hypoglycemia
• Opportunistic infection
• Allergic reaction
• Others
50% of medication-related events considered
preventable
Office of Inspector General. Adverse events in hospitals:
National incidence among Medicare beneficiaries. November 2010.
Recommendations
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Enhance patient safety leadership and knowledge
Use error reporting systems to learn from errors
Set performance standards
Create safety systems
Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.
Culture of Safety Timeline
Before 1990s
Mid 1990s
Punitive Culture
Blame-Free Culture
• Fear of retribution
• Lack of accountability
2000s
Just Culture
• Decreased reporting
• Work-arounds
Institute for Safe Medication Practices.
Medication Safety Alert. Sept 7, 2006.
Just Culture
Type of Behavior
Description
Human Error
Unintentional acts
Suggested
Response
Console
At-Risk
Short-cuts
Coach
Reckless
Intentional
Substantial risk
Outside the norm
Discipline
Institute for Safe Medication Practices.
Medication Safety Alert. September 21, 2006.
Just Culture
During a busy shift, a pharmacist fails to check
a patient’s renal function when entering an
order for an antibiotic.
The patient is not harmed.
Type of Behavior
Human error
At-risk
Reckless
Response
Console
Coach
Discipline
Just Culture
A pharmacist inadvertently hits the zero key an
extra time and enters an order for 100 mg
instead of 10 mg. The patient receives an
overdose and must be transferred to the ICU.
Type of Behavior
Human error
At-risk
Reckless
Response
Console
Coach
Discipline
Response is dictated by type of behavior, not outcome of patient.
Creating a Culture of Safety
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Critically evaluate your reporting system
Increase medication safety incident reporting
Develop a system for follow-up of reports
Analyze incident report data
Provide feedback to staff members
1. Evaluating a Reporting System
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Standard fields:
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Patient
Date/time/location
Description of event
Outcome
Additional fields to consider for medication-related
events
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See NCC MERP Taxonomy of Medication Errors
Provides standard language and structure
NCC MERP Taxonomy for
Medication Errors
Product Information
Dosage form
Packaging
Drug Class
Type of Error
Wrong drug
Wrong patient
Dose omission
Causes
Communication
Name confusion
Contributing Factors
Lighting
Interruptions
Labeling
Staffing
* Not an all-inclusive list
National Coordinating Council for Medication Error Reporting
and Prevention, 1998.
Maximizing Output
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Minimize free-text fields
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Lose ability to “pull” data
May be necessary for description of event
Sortable/retrievable lists:
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Drug name (generic or brand)
Drug class
Type of error
Process node (prescribing, dispensing, administration)
Causes / contributing factors
2. Increasing Incident Reporting
Classen DC et al. Health Affairs 2011;30:581-589.
Ideas to Increase Reporting
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Provide education
Set targets
Provide incentives
Pharmacy Department Incident Reporting
3. Incident Report Follow-up
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Required follow-up
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Division of responsibility
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Does a pharmacist review ALL medication incidents?
Large group: smaller workload, hard to spot trends
Small group: larger workload, easier to spot trends
Ensuring accuracy of information in report
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Example: severity level often too “high”
Garbage in = garbage out
4. Analyzing Your Data
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Create a medication safety dashboard
January
Total # of reports
# of reports submitted by your dept.
# of high severity reports
Types of errors
Medication class involved
Process node
Patient location
Causes
Contributing factors
Type of response (system-based?)
February
March
Analyzing Your Data
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Create dashboard cross-tabs to answer questions
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Medication class most commonly reported to cause
patient harm?
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Wrong patient errors occurring during medication
prescribing?
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Medication class x “High severity” incidents
“Wrong patient” error type x “Prescribing” process node
Compare yourself to national data
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USP MEDMARX database
IHI 5 million lives campaign
Others
5. Providing Feedback to Staff
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Share examples of system-based changes
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Create a medication safety annual report
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New manufacturer for look-alike vials
Change to instruction field of MAR
Summarize dashboard data
Point out high risk medications, processes
Identify areas for future quality improvement activities
Establishes a non-punitive culture of openness,
transparency
Creating a Culture of Safety
1.
2.
3.
4.
5.
Critically evaluate your reporting system
Increase medication safety incident reporting
Develop a system for follow-up of reports
Analyze incident report data
Provide feedback to staff members
Challenges
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Criminal penalties for medication errors
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2006:
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Wisconsin nurse charged with criminal neglect for an epidural
error that resulted in the death of a pregnant patient
2009:
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Ohio pharmacist sentenced to prison for a chemotherapy error
that resulted in the death of a child
www.ismp.org
Creating a Culture of Safety to
Reduce Medication Harm
International Safety Symposium
November 10th, 2011
Megan Winegardner, Pharm.D.
Medication Safety Coordinator
Henry Ford Hospital, Detroit MI