Transcript Critical Access Hospital Medication Safety Project: A

Critical Access Hospital
Medication Safety Project:
A Review of the Florida
Experience
Kyle Campbell, PharmD
Thomas Johns, PharmD, BCPS
Objectives
• List the components of and barriers to an
effective medication safety program as
discovered in the Florida experience.
• Describe resources that define medication safety
components relevant to critical access hospitals
(CAHs) and select effective assessment
techniques.
• List commonly encountered medication-related
quality deficits found in CAHs.
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Presentation Overview
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Project Background
Methods
Commonly Encountered Safety Deficits
Key Recommendations
Lessons Learned
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Project Background
• Joint effort
– Florida Department of Health (DOH)
– FMQAI
– University of Florida College of Pharmacy
• Funding source
– Florida DOH Office of Rural Health
• Project goal
– Improve the safety of medication use in Florida’s 11
CAHs
• Currently completing project year 8
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Florida CAH Locations:
Graceville
Bonifay
Chipley
Blountstown
Apalachicola
Madison
Live Oak
Lake Butler
Starke
Wauchula
Clewiston
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Pharmacy Services in CAHs
• Consultant pharmacist with minimal involvement
(3-10 hours/wk)
• Onsite pharmacist (40 hours/wk)
• Remote pharmacist coverage (24/7)
– Cardinal
– ePharmPro
– Healthsystem (Shands, Florida Hospital)
• Combination of onsite and remote
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Methods
• Annual site visits / medical staff meetings
– Standardized assessment tool
– Facility-specific reports
• Annual summit
– Site visit summary report
– Clinical and administrative topic discussions
– CAH networking
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Methods
• Ongoing technical
support
– Website
– E-mail discussion
group
• Push important patient
safety information to
hospitals
• Encourage discussion
between groups
– Teleconferences
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Methods
• Site visit components
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Visual inspection of medication storage areas
Patient chart review
Nurse shadowing during medication administration
Conference with DON, RM, Pharmacy, CFO, CEO
QI-related documentation review
Policy review
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Methods
• Medication Safety Assessment Tool (MSAT)
– ISMP Medication Safety Self-Assessment
• Antithrombotic therapy
• Automated dispensing cabinets
– 2009 The Joint Commission
• National Patient Safety Goals (CAH)
• Medication management standards
– Institute for Healthcare Improvement (IHI) high-alert medications
– Other sources
• Clinical guidelines
• Various medication safety initiatives
– Adapted for CAH setting
– Best practice tool
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Methods
• Demographics
• 24 clinical domains
– A = There has been no activity or it has been formally discussed
and considered, but it has not been implemented.
– B = This item has been partially implemented in some or all
areas of the organization.
– C = This item is fully implemented throughout the organization.
– N/A = Not applicable or not able to assess during site visit.
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Methods
Method
MEDICATION DISPENSING
Visual
Inspection
Commercially prepared parenteral medications
are dispensed whenever available. Includes
heparin, antibiotics, maintenance IV infusions,
TPN, potassium boluses, saline and heparin
flushes, LMWH.
Specially designed oral syringes, which cannot
be connected to IV tubing, are used for oral
liquid solutions not available in unit of use
dosing cups.
Visual
Inspection
Visual
Inspection
A
B
C
N/A
Medications are dispensed in the most readyto-administer forms available, and, if feasible, in
unit dose. This includes less or more than a full
tablet & warfarin doses.
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Methods
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Site Visit Report to Facility
– Detailed Assessment
– Top 10 Recommendations
• Track Quality Improvement
– Set Relative Improvement Goals by Facility
– Track Composite Scores over time
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Average Scores Across Facilities
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Common Medication
Safety Deficits
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Pharmacy security (locks, nursing access)
Implementation of automated dispensing cabinets
Pharmacist review of medication orders
Removal of concentrated electrolytes
Removal of heparin 10,000 unit/mL vials
Storage and labeling of neuromuscular blockers
Increased use of unit dose packaging
Increased use of pre-mixed IV solutions
Standardization of emergency drug supplies and references
Availability of drug references
Increased use of pre-printed, standardized medication orders
Increased medication error reporting and investigation
Enhanced medication reconciliation process
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Recommendation Categories
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Standardization of physician orders
Quality improvement teams
Pharmacist review of medication orders
Investment in infrastructure
Use of high-risk medications
Prescribing best practices
Process improvements
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Standardization Of
Physician Orders
Develop, implement, and monitor use of
standardized pre-printed physician order forms
for unfractionated heparin, warfarin reversal,
venous thromboembolism (VTE) prophylaxis,
and subcutaneous insulin therapy with sliding
scale component
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VTE Prophylaxis Initiative –
Ideas for Evaluation and Follow-Up
• Percent admissions with VTE risk screening
• Percent admissions with VTE risk rescreening
• Percent admissions with risk-appropriate
prophylaxis selection
• Percent discharges on appropriate
prophylaxis (agent and duration)
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Quality Improvement Teams
• Multidisciplinary team, including medical staff, to
formally evaluate blood glucose control and pain
management in the inpatient setting
• Goals
– Establish a standard organizational care process
– Implement necessary policies and procedures
– Develop and implement process tools (e.g., preprinted physician order forms)
– Monitor outcomes of the program
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Quality Improvement Teams
“To do” list
1. Assign team leader (part of annual performance appraisal)
2. Assign team participants (include medical staff and
administrator)
3. Set goals and timetable for process implementation
4. Obtain medical staff buy-in/approval
5. Implement program
6. Require monitoring to determine effectiveness (provide
incentives)
7. Provide individualized feedback for area/individual noncompliance
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Quality Strategic Plan
• Identify quality indicators important to the
organization (external and internal)
• Develop scorecard for measuring performance
• Acquire Board of Directors’ approval
• Establish quality agenda item at each BOD
meeting
• Develop performance improvement teams to
address each quality indicator (leadership, MD
and administrator participation)
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Pharmacist Review of Medication
Orders
• Formally evaluate the ability of the organization
to provide 24/7 pharmacist review of all
medication orders prior to medication
administration
– Review current resources
– Review services provided by commercial vendors
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Pharmacist Review of Medication
Orders
• Revaluate override medication policy
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If medication orders are not reviewed by a
pharmacist, ensure nursing staff are only retrieving
and administering medications if harm would come
to the patient due to the delay or provider is
physically located at the patient bedside.
• Document a reason for each overridden
medication and review by management as part
of an ongoing QI program
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Investment in Infrastructure
1. Replace current crash carts with a
commercially manufactured emergency cart.
2. As a component of the new emergency cart,
purchase and implement a standardized
medication tray that effectively separates drugs
and allows for effective labeling to prevent
errors.
3. Ensure drug references are not outdated.
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Investment in Infrastructure
4. Develop a process to require all medications in
oral solid dosage forms to be dispensed from
pharmacy in unit dose packaging.
5. Review procedures for sterile product
compounding. Ensure IV preparation
compounding outside of a class 5 environment
are administered within one hour of preparation.
6. Ensure IV compounding takes place in a
functionally separate area that is free of clutter.
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Investment in Infrastructure
7. Purchase and install an automated
dispensing cabinet for use in the inpatient
nursing unit.
8. Require nursing staff to retrieve medications
for patient administration directly from
automated dispensing cabinet.
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Investment in Infrastructure
9. Eliminate the use of medication carts as a
component of the medication distribution
system.
10.Only allow a licensed pharmacist to enter
the pharmacy unescorted.
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Access to the Pharmacy –
Florida Law
• 465.019(2)(b), F.S.
– ……However, a single dose of a medicinal drug may be obtained
and administered to a patient on a valid physician's drug order
under the supervision of a physician or charge nurse, consistent
with good institutional practice procedures. The obtaining and
administering of such single dose of a medicinal drug shall be
pursuant to drug-handling procedures established by a consultant
pharmacist……
• 64B16-28.602, F.A.C.
– …..A single dose of medicinal drugs based upon a valid physician’s
drug order may also be obtained and administered under the
supervision of the nurse in charge consistent with good institutional
practice procedures as established by the consultant pharmacist
and written in the policy and procedure manual which shall be
available within the pharmacy.
• 64B16-28.604, F.A.C.
– ….When the pharmacy department is closed, no person other than
a Florida licensed pharmacist shall enter, except as authorized by
subsection 465.019(2)(b), F.S., and Rule 64B16-28.602, F.A.C.
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Access to the Pharmacy –
Joint Commission & ISMP
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Joint Commission Standard MM.05.01.13 The critical access hospital safely obtains medications
when the pharmacy is closed.
– When non-pharmacist health care professionals are allowed by law or regulation to obtain
medications after the pharmacy is closed, the following occurs:
• Medications available are limited to those approved by the critical access hospital.
• The critical access hospital stores and secures the medications approved for use
outside of the pharmacy.
• Only trained, designated prescribers and nurses are permitted access to approved
medications.
• Quality control procedures (such as an independent second check by another individual
or a secondary verification built into the system such as bar coding) are in place to
prevent medication retrieval errors.
• The critical access hospital arranges for a qualified pharmacist to be available either oncall or at another location (for example, at another organization that has 24-hour
pharmacy service) to answer questions or provide medications beyond those accessible
to non-pharmacy staff.
Darryl Rich Dec 2009: No one is allowed access to pharmacy but a “pharmacist” after the
pharmacy is closed.
ISMP
– Only a licensed pharmacist is allowed to enter the pharmacy unescorted.
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Investment in Infrastructure
11.Complete refrigerator temperature logs
(daily / twice daily for vaccines). Record
actions to temperature deviations.
12.Organize medication refrigerators to prevent
product selection errors.
13.Organize the pharmacy to reduce the
potential for retrieval errors (separate bins;
high-alert drugs flagged; appropriate labels).
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Use of High-Risk Medications
• Continue to develop and implement high-risk
medication policy
– Consistency of labeling practices in all medication
storage areas
– Inclusion of warning information at order entry into
ADC
– Double-checks by nursing personnel during order
entry and removal of medications from ADC
– Administration procedures (including IV pump
programming)
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Use of High-Risk Medications
• Remove promethazine 50 mg/mL injectable vials
from the pharmacy and delete from the
formulary
– Create comment that appears on pre-printed
medication orders, labels and MAR...“dilute in 10 mL
and infuse over 10 minutes”
– Prohibit IV route of administration
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Use of High-Risk Medications
• Utilize oral unit dose syringes for all oral liquid
medications drawn up in nursing unit
– Oral unit dose syringes should be stocked and readily
available in the nursing unit.
– Nurses should not utilize injectable (luer lock)
syringes for oral liquid preparation.
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Use of High-Risk Medications
• Evaluate policies and procedures for
neuromuscular blockers storage and labeling
– Should be stored to segregate them from all others
– Use small, red box to store in refrigerators
• Should have a lid
• Should contain a warning sticker: “Warning: Paralyzing
Agent – Causes Respiratory Arrest”
– Place each vial in a shrink-wrap sleeve that also
contains the above warning language
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Use of High-Risk Medications
• Use diverse insulin vials / pens to prevent lookalike/sound-alike errors
• Do NOT place insulin vials back in original boxes
for storage after opening
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Prescribing Best Practices
• Remove Darvocet® from the hospital formulary
and prohibit use of the patient’s own supply
during the inpatient admission
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Prescribing Best Practices
• Develop and implement a policy to prohibit the
use of fentanyl transdermal patches for the
treatment of acute pain or in those patients who
are not opioid tolerant
– Develop a drug-specific pre-printed physician order
form for prescribing fentanyl transdermal patches
– Require use of this form
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Process Improvements
• Medication administration
– Evaluate current medication administration policy and
procedure to ensure it contains a reliable system
• Nursing personnel to take the MAR to the bedside
during the administration process
• Enforce two patient identifiers
• Require medications to remain in the unit-dose
packaging until the point of administration
• Verify expiration dating
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Lessons Learned
• A standardized assessment tool improves
ability to quantitatively assess
improvements
• Site visit success centers on adapting
style to match CAH needs and personnel
• Recommendations must be customized to
account for differences in CAHs
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Acknowledgements
Special Thanks
Bob Pannell, MSP and Joel Libby, MHA
Florida DOH – Sponsorship
Almut Winterstein, PhD
University of Florida – Co-PI
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For More Information
Kyle Campbell, PharmD
Project Director, FMQAI
[email protected]
Thomas Johns, PharmD, BCPS
Coordinator, Drug Use Policy and Medication Safety
Department of Pharmacy
Shands at the University of Florida
[email protected]
Project Website
http://www.fmqai.com/PatientSafety-CAH.aspx
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