Transcript Slide 1

High-alert Medications:
Understanding System Base
Causes and Practical Error
Reduction Strategies
Hedy Cohen, RN, BSN, MS
Institute for Safe Medication Practices
www.ismp.org
[email protected]
Order stated:
“Cytoxan 4 g/m2 days 1-4”
Administered as: 4 g/m2 EACH DAY for four days
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Are
medication
errors really
that bad…?
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The Institute of Medicine (IOM)
• 44,000 to 98,000 deaths per year from
medical errors
- more than from breast cancer or AIDS
• 7,000 to 16,000 deaths per year from
medication errors
- 1 out of 131 outpatient and
- 1 out of 854 inpatient deaths
To Err is Human:
Building a Safer Health System, 1999
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Agency for Healthcare Research
and Quality (AHRQ)
• 5 per 10,000 doses administered cause
serious harm
– translates into 50 serious ADEs per month
• 5.3% of orders written contain a
medication error
• Only 1.5% of ADEs in hospitals are ever
reported
AHRQ: www.ahrq.gov/qual/aderial/aderia.htm
“Research in Action: Reducing and Preventing Adverse Drug Events
to Decrease Hospital Costs”
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TJC National
Patient Safety Goal
3. Improve the safety of using high-alert
medications
– a. Remove concentrated electrolytes
(including, but not limited to, potassium
chloride, potassium phosphate, sodium
chloride >0.9%) from patient care units
– b. Standardize and limit the number of drug
concentrations available in the organization
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Verbal Order for
18 Month Old
“Get this kid morphine .8”
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Why do Medication
Errors Occur?
Human Factors
• The study of the interrelationships
between humans, the tools they
use and the environment in which
they live and work
• Success comes with improving the
human-system interface
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PARIS
IN THE
THE SPRING
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Individuals
• Limitation of human performance
– limited short-term memory
– time constraints
– normalization of deviance
– limited ability to multi-task
– interruptions
– stress
– heuristics
– fatigue and psychological factors
– environmental factors
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Medication System
Key Elements
• Patient Information
• Drug Information
• Communication of
Information
• Drug Labeling,
Packaging, and
Nomenclature
• Drug Storage, Stock,
Standardization, and
Distribution
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• Drug Device Acquisition,
Use, and Monitoring
• Environmental Factors,
Staffing Patterns and
Work Flow
• Staff Competency and
Education
• Patient Education
• Quality Processes and
Risk Management
Diagnosis or
allergy not
communicated
Patient
Information
System
Ambiguous
drug order
Communication
System
No
maximum
dose
warnings
Drug Info
System
Inadequate
patient
education
Other
systems
The latent failure model of complex system failure
modified from James Reason, 1991
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High-alert Medications
• Small number of medications that have a
high risk of causing injury if misused
• Errors may or may not be more common
with these than with other medications, but
the consequences of errors may be
devastating
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High-alert Medications
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Adrenergic agonists
Adrenergic antagonists IV
Anesthetics agents
Antiarhythmics IV
Antithrombotic agents
Carioplegic solutions
Chemotherapeutic agents
Dextrose, hypertonic
Dialysis solutions
Epidural or intrathecal drugs
Hypoglycemics, oral
• Inotropic drugs
• Liposomals
• Moderate sedation agents
IV, oral for children
• Narcotics/opiates
• Neuromuscular blocking
agents
• IV heparin and oral
warfarin, thrombolytics
• Radiocontrast agents, IV
• Total parenteral solutions.
Specific High-alert Medications
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Colchicine injection
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Epoprostenol (Flolan) IV
Insulin
Magnesium sulfate injection•
Methotrexate tablets
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Oxytocin IV
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Nitropruside injection
Potassium chloride
concentrate IV
Potassium phosphates
injection concentrate
Promethazine, IV
Sodium chloride for
injection concentrate
• Sterile water for injection,
inhalation and irrigation
High-alert Medications
• Collective thinking from:
– Reports submitted to USP-ISMP MERP
– Reports in the literature
– Input from practitioners
– Input from safety expertsISMP advisory board
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High Risk Patient Populations
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Patients with renal/liver impairment
Pregnant/breast feeding patients
Neonates
Elderly/chronically ill
Patients on multiple medications
Oncology patients
Primary Principles in
Error Reduction
• Reduce or eliminate possibility of errors
• Make errors visible
• Minimize the consequence of errors
Rank Order of Error
Reduction Strategies
Forcing functions and constraints
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Automation and computerization
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Standardization and protocols
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Checklists and double check systems
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Rules and policies
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Education / Information
Key Safeguarding Strategies
• Simplify - reduce steps and number of
options
• Standardize options
• Externalize or centralize error prone
processes
• Differentiate items (appearance,
location)
Key Safeguarding Strategies
• Reminders
• Improved access to information
• Use of constraints that limit access or
use
• Forcing functions
• Failsafe
• Use of defaults
• Failure analysis for new products and
procedures
Simplify
• Decrease number of available sizes and
concentrations
– a single heparin size/concentration is
available
– reduce the number of vials available
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Standardize Order Communication
• Create, disseminate and enforce ordering
guidelines
– create a negative list for dangerous
abbreviations
– eliminate trailing zeros; use leading zeros
– standard procedure for verbal orders
– standardized concentrations of critical care
drug infusions, weight-based heparin
protocol, etc
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Standardize Order Communication
• Eliminate acronyms, coined names,
apothecary system, use of non-standard
symbols, etc.
– TPN (IV nutrition or Taxol, Platinol,
Navelbine)
– Irrigate wound with TAB
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Externalize or Centralize
• Centralize preparation of intravenous
solutions
– prepare pediatric IV medications in pharmacy
– outsource
• Use commercially prepared premixed
products
• premixed magnesium sulfate, heparin, etc.
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finished files are the
result of years of
scientific study combined
with the experience of
many years
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Finished Files are the
result oF years oF
scientiFic study combined
with the experience oF
many years
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Differentiate
• Use tall man lettering
DOBUTamine
DOPamine
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Differentiate Items by Senses
• Tactile cues
– tape on regular insulin vial for blind diabetics;
octagonal shape of neuromuscular blocker container
• Use of color
– red color to “draw out” warnings; appearance
of solutions, tablets, etc.; “color coding”
• Sense of smell
– useful in conjunction with check systems
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Differentiate Similar Drugs
• Purchase one of the products from another
source
– hydroxyzine from company B when company A’s
hydroxyzine 50 mg/mL injection looks similar to their
hydralazine 50 mg/mL injection
• Apply upper case lettering to dissimilar portions
of the name
– Use other means to “make things look different” or
call attention to important information
– stickers, labels, enhancement with pen or marker
– Dopamine vs. Dobutamine
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Separate Problem Products
• Look-alike packaging
– store hydroxyzine 50 mg tablets and
hydralazine 50 mg tablets far apart
• Look-alike drug names
– computer mnemonics designed so similar
names do not appear on same screen i.e.,
carboplatin/cisplatin; vinblastine/vincristine not
listed in order on preprinted chemotherapy
form
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Reminders
• Place auxiliary labels on containers for
clinical warnings and error prevention
messages
– check for pregnancy, lactation
– note about cross allergy between aspirin and
ketorolac
– reminder on Norvasc container about Navane
confusion
– maximum dose warning
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Reminders
• Incorporate warnings into computer order
processing and selection of medications
from dispensing equipment
• Place labels on IV lines to prevent mix-ups
between IV lines and enteral feeding lines
• Protocols, checklists, visual and audible
alarms
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Sum the digits below reading
left to right:
1000+20+1000+30+1000+40+1000+10=?
Checklists and Double-checks
• Independent double-checks
• Develop checklists around the use of
high alert drugs
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Access to Information
• Use computerized drug information resources
• Information at point of care
• Computer order entry systems that merge
patient and drug information, provide warnings,
screen orders for safety, etc.
• Readily available texts in current publication
• Pharmacists presence in patient care areas
• Use of medical records librarian at CME and on
rounds
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Limit Drug Use
• Peer reviewed drug approval process
• Restricted therapy
– attending physician cosigns chemotherapy orders;
consult to specialty required
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Staff credentialing
Automatic reassessment of orders or rewrites
Prescribe autostop to limit dose or duration
Use medications with reduced dosing frequency
Parameters to change IV to PO as appropriate
Establish Area Specific
Guidelines for Unit Stock Medications
• Assess unit-specific needs and agree on
requirements, accounting for known safety issues
• Standardize and purchase pharmaceuticals in
unit dose or pre-mixed containers as much as
possible
• Acquire or enhance safety in use of automated
drug distribution systems
• Standardize emergency equipment and
medication storage on each unit
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Devices
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Forcing Functions
• Makes errors immediately visible. Ensures
that parts from different systems are not
interchangeable; forces proper methods of
use (lock and key design)
– oral syringe should not be able to fit onto an
intravenous line
– example: preprinted order forms or computer
options that “force” selection from limited
number of medications, available dosages,
etc.
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Failsafe
• Use products that design error out of the
system
– automatic fail-safe clamping mechanism on
intravenous infusion pumps
– dangerous order can’t be processed in
computer system (hard stops)
– smart pumps (hard stops)
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Redundancies
• Independent checks
– probability that two individuals will make the
same error is small; therefore, having one
person check the work of another is essential
• calculations for pediatric patients, high alert
medications, etc., performed independently
by at least two individuals, with identical
conclusions
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Use of Defaults
• Pre-established parameters take effect
unless action is taken to modify
– clinical pathways
– device defaults
• morphine concentration default for PCA pump
• Pharmacy IV compounder defaults to drug
concentrations available in pharmacy
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FMEA for New Products
• Formal safety review (e.g., formulary
committee, risk management committee)
of new medications and drug delivery
devices
– examine for ambiguous or difficult to read
labeling, error-prone packaging, sound-alike
product names, etc.
– use failure analysis to determining safety of
medications and devices and to guide error
prevention methods in a proactive manner
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Insanity is doing the same
things the same way and
expecting different results
Albert Einstein