Transcript Rats in the Swiss Cheese Model

Rats in the Swiss
Cheese Model
Challenges with Integrated
Medication Management
Rhonda McManus, Pharm D
Director, Clinical Operations
Cardinal Health
The Swiss Cheese Model of
Systems Accidents
Objectives for Pharmacists
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Know the prevalence of technologies used in
medication management process
Describe synergies of integrated technologies
Explain challenges identified with integrated
technologies
Understand work-arounds end users have
established
Discuss opportunities for pharmacists created by
integrated automated systems
Objectives for Pharmacy
Technicians
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List three technologies used in the medication
management process
Describe techniques end users employ to
bypass safeguards in the medication use
process
Explain the role of the pharmacy technician in
monitoring the medication distribution process
Newest Thing in Integrated
Technologies
http://producten.hema.nl/
No machine will ever
take the place of
good clinical
judgment.
The Perfect Integrated Solution
CPOE*
PIS*
ADM*
BPOC*
* With step-specific and service specific
embedded decision support and
common formulary table
Billing
Supply Chain management
Clinical Decision
Support
ADT
Billing
ADC
CPOE
PIS
Lab, radiology, other
ancillary departments
Pharmacy storage
and packaging
BPOC
Charting
Medication Use Safety:
Foundational Functionalities
Provider Education and Baseline Assessment
CPOE
Information
Integration
Order
Management
Point-of-Care
Automation
Bedside
Verification
1 2 3 4 5
Prescribing
Transcribing
Information Integration
Dispensing
Information Integration
Drug Interaction Review
Administering
Information Integration
EUM
Replenishment
Information Integration
ADE Review
Patient Monitoring and Outcome Review
Patient
Monitoring
Phases of the medication management
process where errors occur
Process
Physician Orders
Order Management
Pharmacy Control and
Distribution
Patient-Specific Medication
Preparation and Dispensing
Medication Administration
at the Point of Care
* Leape, L.L., D.W. Bates, D.J. Cullen, et al. for the ADE Prevention Study Group, 1995.
“Systems Analysis of Adverse Drug Events.” Journal of the American Medication Association. 274: 35-43.
So How Many Health
Systems have
Implemented?
Adoption Rates: BCMA
Schneider, Philip. “Opportunities for Pharmacists” American Journal of
Health-system pharmacists, 64:s12-s16.
Adoption Rate: CPOE
Schneider, Philip. “Opportunities for Pharmacists” American Journal of
Health-system pharmacists, 64:s12-s16.
Decentralized Distribution Trends
Schneider, Philip. “Opportunities for Pharmacists” American Journal of
Health-system pharmacists, 64:s12-s16.
Benefits of CPOE
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Reduced errors related to handwriting
Decreased order turn around time
Decreased look-alike, sound-alike errors
Integration with medical records and decision
support systems
Decreased errors related to decimal point,
trailing zeros and use of apothecary measures
Easily linked to drug-drug interaction programs
Benefits of CPOE
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Link to ADE reporting systems
Links to lab for alerts
Standardization of therapy
Formulary control
Support for cost effective drug therapy choices
Decreased duplicate orders
Identification of prescriber
Access to data for analysis
Force inclusion of reason for therapy
Nine Unintended Consequences of
Computerized Order Entry
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More/new work for clinicians
Unfavorable work-flow issues
Endless demands by the system
Unwillingness to give up paper
Changes in communication patterns and practices
Negative feelings toward the system and those
responsible for it
Introduction of new errors
Unexpected changes in the power structure such as the
committee designing the computerized protocols
making judgments about best practices
Over-reliance on the technology
Source: “Types of Unintended Consequences Related to Computerized Provider Order
Entry,” Journal of the American Medical Informatics Association, June 23, 2006.
More Unintended Consequences
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Order sets created without nursing and
pharmacy; broad orders with clinical decisions
put nurses in jeopardy of practicing medicine
Order sets increase the number of orders
pharmacists review and dispense
Weak interfaces between CPOE and PIS make
pharmacy corrections necessary
Physicians use notes section to enter orders if
they cannot find the medication listed, so
pharmacists have to check the notes section
Examples of Errors Facilitated by
CPOE
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User errors
 Wrong
patient selection
 Wrong medication selection
 Unclear log-on and log-off
 Failure to renew medication post surgery
 Loss of data and time when CPOE system is down
 Late day orders lost for 24 hours
 Uncertainty regarding changing orders, discontinuing
orders and resuming orders
Examples of Errors Facilitated by
CPOE
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Systems errors
 Assumed
dose information
 Medication discontinuation failures
 Procedure-linked medication discontinuation
 Diluent options and errors
 Allergy information delay
 Conflicting or duplicate medications
CPOE Work-arounds
Increased verbal orders
 Enter orders in physicians’ notes section
 Override alerts and warnings
 Over-use of order sets
 Refuse to use CPOE and continue to use
paper orders
 Make less frequent adjustments to therapy
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Benefits of ADM
Medication is available on nursing unit as
soon as pharmacist verifies CPOE order
 Decreased missing doses
 Decreased chance for error due to
“borrowing” medications
 Warnings and alerts at medication
preparation phase- not at patient bedside
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ADM Challenges
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Adequate equipment
Profile-enabled
Single drug access
Refill accuracy
Management of inventory levels
Integrating with BCMA
Perception of nursing of decentralized
distribution model
ADM Work-arounds
Matrix drawers
 Pocket and belt bag stock
 “The Pumpkin” stock
 Cancel transactions
 Inventory feature
 Return to pocket feature
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ISMP ADM Focus Group
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Met in March 2007
Sponsored by Cardinal Health, McKesson and
Omnicell
Meeting of pharmacists users, nurse users and
vendors as well as ISMP
Purpose: to define best practice around the use
of automated dispensing devices
Report of findings posted on ISMP Website and
presented at ASHP in December 2007
ADC Core Processes
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Provide ideal environmental conditions for the
use of ADCs
Ensure ADC system security
Use pharmacy-profiled ADCs
Identify information that should appear on the
ADC screen
Select and maintain proper ADC inventory
Select appropriate ADC configuration
ISMP, 2008
ADC Core Processes
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Define safe ADC restocking processes
Develop procedures to ensure the accurate
withdrawal of medications from the ADC
Establish criteria for ADC system overrides
Standardize processes for transporting
medications from the ADC to the patient’s
bedside
Eliminate the process for returning medications
directly to their original ADC location
Provide staff education and competency
validation
ISMP, 2008
BPOC Benefits
5 Rights
 Billing accuracy
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BPOC Challenges
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Bar codes
 Purchase
 Preparation
 Unexpected
changes in bar codes
 Readable
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Patient ID
Pharmacy Order Entry changes
Medication Management in BPOC world
BPOC Work-arounds
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List of patients with bar codes
 Patient
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“stickers”
List of medications with bar codes
Pick from patient list
Pick from medication list
Remove from ADM, no documentation of
medication administration: Bad documentation
or diversion?
Opportunities for Pharmacists
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Take an active, leadership role in any and all
technology implementations and upgrades
Clinical Decision support
Database management
Process redesign
Ongoing maintenance
Data to knowledge to action
Monitor process changes for new errors
Opportunities for Pharmacy
Technicians
System maintenance
 Data management
 Process redesign
 Increasing role in distribution
responsibilities
 Monitor for new errors, process workarounds
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Questions and Comments