Transcript Key Initiatives in Medication Safety at LUHS

Key Initiatives in Medication Safety
at LUHS
Kathryn R. Montanya, PharmD, MS
Medication Safety Specialist
Opportunity Statement
• Errors and patient harm associated with medication
treatment is a major issue for all healthcare organizations.
• Medication safety is a major part of Loyola’s overall
patient safety plan.
• Key activities underway at LUHS are summarized here.
Committee Structure for
Medication Safety
Medication Use Safety Improvement
Committee (MUSIC)
Pharmacy and Therapeutics
Committee (P&T)
As needed – also,
quarterly report.
Medical Care Evaluation and
Analysis Committee (MCEAC)
Event analyses.
Other Committees
As recommended by MUSIC members.
Medication Safety Targets and Tactics
(from LUHS Patient Safety Plan FY 06)
Target
Meet JCAHO patient
safety goals
Implement selected
practices from ISMP
Consult
Tactic
Medication reconciliation
Identify and prevent errors with look/sound alike
medications
Label meds on operative fields
Reduce/eliminate buretrols
Establish time frame for now, stat, and routine
orders
Analysis of at least
one ADE per month
Implement ADE analysis tool.
Updated policies on:
- High alert
medications
- Floor stock
medication inventory
Review/revise selected policies/procedures
Medication Reconciliation
• Research indicates that a large fraction of medication
errors occur during admission, transfer and discharge when
new orders are written.
• Medication reconciliation is a JCAHO National Patient
Safety goal directed at preventing these errors.
• The essence of reconciliation is making sure that there is a
single list of medications on which the patient, family and
caregivers agree.
Medication Reconciliation
• JCAHO requirement: The patient’s home medication list must
be:
– Accurately recorded with the involvement of pt.
– Reconciled with any new orders that are written
– Communicated to the next provider on transfer or discharge
• A physician-led process has been designed, which is based in
the Epic Medical Record
• Currently pilots are underway - full implementation will
coincide with physician documentation in EMR
Preventing errors with
look-alike/sound-alike (LASA) medications
• Many errors are due to the fact that numerous medications
have names that look and/or sound alike (for example:
vincristine and vinblastine).
• JCAHO requires that we identify a list of name pairs and
implement safe practices to prevent errors.
• The LUHS high-alert medication policy identifies our current
LASA list, and current action to prevent errors includes:
• Tallman lettering on pharmacy labels and computer
screens. (i.e. vinCRIStine, vinBLAStine)
• Storage separation in pharmacy and on nursing units
Reduce or eliminate the use of buretrols
Reduce or eliminate the use of buretrols
• A buretrol is a plastic cylinder used for many years to
regulate the flow of intravenous fluid or medication.
• Buretrol use increases the risk of medication being infused
without being properly prepared and labeled in the
pharmacy.
• In addition, modern intravenous infusion pumps make
buretrols obsolete.
• Therefore, over the next 6-12 months buretrols use will be
eliminated from LUHS except in those very few areas
where buretrol use is known to improve the safety of
medication delivery.
Establish standard turnaround times for
medication orders
• Delayed medication doses are by far the most commonly
reported adverse medication event. One facet of the problem
is misunderstanding among healthcare practitioners about what
is an appropriate turnaround time.
• In order to establish a standard and promote realistic
expectations on the part of caregivers as to when a medication
may be anticipated to be delivered to the patient care area from
the pharmacy, standard turnaround times have been established
for NOW, STAT and routine orders.
• The draft policy is under review.
Adverse Drug Event Analysis
• The goal of analysis is to identify what the underlying
cause of the problem was and develop solutions to prevent
future incidents.
• Trends in medication adverse event data are also reviewed
regularly to identify opportunities for improvement.
• For example, recently a number of errors were made
involving two commonly used opiates medications,
morphine and hydromorphone.
• To improve safety, the number of different medication
strengths available to nursing (floor stock) will be reduced
to the minimum needed.
Medication event reported
by caregiver via
Patient/Visitor Safety and
Quality Report
Event reviewed by
medication safety
specialist
Was the patient
harmed?
YES
NO
Could the patient have
been harmed?
YES
Medication event
analysis
NO
Is the event likely to be
repeated frequently?
NO
Event entered into
database
YES
High-Alert Medications
• High-alert medications are those that are more likely to be
associated with harmful adverse effects
– e.g. chemotherapy drugs, insulin, and anticoagulants like heparin
• JCAHO states that hospitals must identify a list of high-alert
medications and implement special safe practices with those
medications to prevent errors,
– e.g. have two nurses independently check the dose of the medication
before it is given
• The LUHS high-alert medication policy is currently
undergoing a thorough revision . An expanded list of high alert
medications is being identified with specific safe practices to
reduce the chance of an adverse medication reaction.