Transcript No Slide Title

Decreasing Medication Errors in Pediatric Subspecialty Clinics
Eve L. Taylor, RN, BSN, CPHRM, CPHQ
Nemours Quality and Safety Department
OBJECTIVES
Medication errors in pediatric subspecialty clinics can cause morbidity and
mortality in complex pediatric patients (1). A total of 15% of pediatric
prescriptions have potential dosing errors (2). Our objective is to identify
the most common causes of medication errors, as well as introduce
methods to mitigate and prevent errors. Our focus is on process
improvement, not persons. Nemours has had an electronic medical record
and computerized order entry for 15 years, so legibility is not relevant to
this study. According to Leapfrog, computerized physician order entry
(CPOE) and barcoding may reduce medication errors by 50% (3).
METHODS
We reviewed several scholarly articles related to pediatric medication
errors and queried our event database for retrospective self-reported
medication errors (including near-miss events) in the outpatient
subspecialty pediatric clinic for a period of 7 years (2004-2011).
ERRORS BY CLASS AND FREQUENCY
UNORDERED MED
3
UNDER DOSAGE
•Providing Nursing staff with clear and concise reports of medication
errors that relate to their area of practice helps prevent errors from
lessons learned.
4
OVER DOSAGE
•Frontline staff are area experts and can provide insight into failure mode
effectiveness assessment (FMEA) for new processes.
5
OTHER MEDICATION RELATED
17
ORDERED, NOT DONE
1
OMITTED DOSE
1
Medication “other” events included delivery issues from the pharmacy and
any signs of off-color or broken seals, etc. These events may have had an
impact on the timing of medication but did not reach or harm a patient.
3
•Use the Ten Rights of Medication Safety.
INCORRECT TIME
2
12
REFERENCES
INCORRECT ROUTE
2
INCORRECT PATIENT
1
INCORRECT NARCOTIC PROCESS
1
1. Rinke et al. Interventions to reduce pediatric medication errors. AAP
Pediatrics, August 2014 P338
2. McPhillips HA, Stille CJ, Smith D et al. Potential medication dosing
errors in outpatient pediatrics. Journal of Pediatrics 2005;147;761-7
3. American Nurse Today March 2010 P27
4. Kuehn BM. Group urges going metric to head off dosing mistakes.
JAMA.COM Jamanetwork.com. Online published 21 May 2014.
4
INCORRECT DRUG
5. Santell JP, Hicks R. Journal of Quality and Patient Safety. June 2005.
Volume 31, Number 6, 348-353
5
EXPIRED MEDICATION
1
COMPUTER ENTRY INCORRECT
1
ADVERSE DRUG REACTION
17
WRONG DRUG
2
0
Nemours is an internationally recognized children’s health system that owns and operates the Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE, along with major
pediatric specialty clinics in Delaware, Florida, Pennsylvania, and New Jersey. In October, 2012, it opened the full-service Nemours Children’s Hospital in Orlando, Florida. To learn
more about Nemours, visit www.Nemours.org.
•Continued research is needed in the outpatient pediatric setting so that
we can continue to work towards error-free care.
INCORRECT STRENGTH OR
CONCENTRATION
INCORRECT FREQUENCY
The next most frequent type of event was incorrect strength or
concentration, which can be caused by weights that are not correct (weight
should be in kilograms) or outside community pharmacies that do not
specialize in pediatric dosing (4). Pharmacies are many times unaware that
the pediatric dose of the drug cannot safely be attained without using an
oral syringe that shows the pediatric dose in milliliters. Family education
and syringes marked for the proper dosing in the clinics or from pharmacies
and sent home with the families help mitigate these types of events.
Outpatient settings need to have rigorous sample medication auditing
processes for expired/recalled medications, as there is usually no
pharmacist on-site. Documentation of quantity, lot number, and expiration
dates of the samples is a minimum requirement. All patients receiving
samples require documentation of lot number and quantity recorded in the
electronic medical record (EMR). Auditing this process decreases the
likelihood of patients receiving expired medication and allows the ability to
contact patients if there is a recall.
•Educate staff to make copies of medication labels that come from
community pharmacies with errors so that when errors occur, the Risk
Managers at the outpatient pharmacy and their staff can be provided
documents showing the cause of errors.
•Independent checks for high-alert medications by two staff members
must be truly independent to be effective. As the majority of errors (54%)
occur during administration, this is the last step to catch potential errors
(5).
RESULTS
Adverse drug reactions are difficult to prevent but can be managed with
appropriate protocols or countermeasures, such as preparation of drugs to
counteract the effect of anaphylaxis before giving any new high alert
medication and patient observation for 1 hour with vital signs every 15
minutes. Preemptive development of procedural consents that educate
families about the possibilities of events and the related signs and
symptoms is suggested. A physician-led informed consent process is
critical for the patient and their family.
•CPOE eliminates legibility errors, but technology has its own group of
potential exposures including keystroke errors and multiple charts open at
one time.
•Provide staff and parents with the right to stop any process when they
feel a mistake may be occurring, and encourage them to speak out.
LABELING ISSUE
The two most frequent events that affected patients were adverse drug
reaction related to anaphylaxis that was previously unknown for the patient
and medication “other” events.
CONCLUSION
2
4
6
8
10 12 14 16 18
Acknowledgements: I thank Dr. Stephen Lawless, VPQS; Patricia Mullan, Administrative
Director, VPQS; Rachelle Ciarrocchi, Operations Manager, VPQS; and all of my fine team
members at Nemours Risk and Quality Department for their support in this project.