Transcript The Good Hospital Practice Training Series

Medication Safety
The Good Hospital Practice Training
Series 2009
The Medical City
In this presentation…

The roles of the Medical City staff in
ensuring the safe use of medications
– Prescription writing
– Verbal and phone orders
– High risk medication monitoring
– Medication reconciliation
– Adverse drug event reporting and analysis
The problem of
medication errors
44,000 - 98,000 people in the US die
annually as the result of medical errors
 19% of all medical errors are medication
related.
 Only 1-10% of medication errors are
voluntarily reported
 Medication errors reported do not reflect
patient harm

The problem of medication safety
Every day more than 4,000 people
have ADRs so serious that they need
to be admitted to American hospitals
 In addition, every day about 2,000
hospitalized patients suffer from
ADRs.
 About 50% of these ADRs are
preventable.

Common medication errors
1. Math error when calculating dose.
2. Wrong patient weight.
3. Patient’s armband not checked.
4. Wrong drug amount drawn in syringe.
5. Wrong strength bolus administered.
6. No double check of pump completed.
7. Double checking of dose is only cursory.
Root causes of
medication errors
Lack of clear and adequate
communication among doctors, nurses,
pharmacists and patients
 Illegible, incomplete prescriptions
 Multiple drugs
 Look alike sound alike drugs

The roles of ALL doctors
Use drugs rationally. More drugs, more
errors. Be evidence-based.
2. Educate patients on rational drug use.
3. Write all drug orders legibly. Print if in
doubt. Don’t use Forbidden
Abbreviations.
4. Stick to medications in the formulary.
5. Order by generic names, correctly
spelled. Allow generic substitution.
1.
The roles of ALL doctors
6.
7.
8.
Write the therapeutic indication for every new
drug ordered (e.g. losartan for hypertension)
Demand READ-BACK after ordering drugs.
Confirm that you are understood.
Practice medication reconciliation. Compare
drugs ordered on admission AND on
discharge with drugs taken before admission.
Be clear with what you want continued or
stopped.
The role of residents
Write drug orders ON TIME. No phone or
verbal orders please.
2. Write orders LEGIBLY. Print if in doubt.
Write the generic names and indications.
Avoid abbreviations.
3. READ BACK written and verbal orders of
consultants immediately to confirm if you
got it right before executing them
1.
The role of nurses
1.
2.
3.
4.
5.
Order drugs in SHAMAN by GENERIC
NAMES.
READ BACK the complete drug order to
the prescriber and insist on confirmation.
Before administering drugs, confirm the
identity of the patient AND the drug.
Administer all medications promptly.
Report any adverse drug event.
Writing perfect prescriptions
A drug order or prescription must have the
ff legibly written parts:
 Generic name
 Dose, frequency and route
 Indication
 Signature, printed name
 Time and date
 No abbreviations please!
Avoid these Forbidden Abbreviations
Do Not Use
U (unit)
IU (International Unit)
Q.D., QD, q.d., qd (daily)
Q.O.D., QOD, q.o.d, qod,
EOD (every other day)
Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)
MS
MSO4 and MgSO4
> (greater than)
< (less than)
Abbreviations for drug
names
μg
cc
Potential Problem
Mistaken for “0” (zero), the
number “4” (four) or “cc”
Mistaken for IV (intravenous)
or the number 10 (ten)
Mistaken for each other
Period after the Q mistaken for
"I" and the "O" mistaken for "I"
Decimal point is missed
Can mean morphine sulfate or
magnesium sulfate
Confused for one another
Misinterpreted as the number
“7” (seven) or the letter “L”
Confused for one another
Misinterpreted due to similar
abbreviations for multiple
drugs
Mistaken for mg (milligrams)
resulting in one thousand-fold
overdose
Mistaken for U (units) when
poorly written
Use Instead
Write "unit"
Write "International Unit"
Write "daily"
Write "every other day"
Write X mg
Write 0.X mg
Write "morphine sulfate"
Write "magnesium sulfate"
Write “greater than”
Write “less than”
Write drug names in full
Write "mcg" or “micrograms”
Write "ml" or “milliliters”
Avoid verbal and phone
orders
A phone order is permitted if an AP can’t write
an order promptly AND if a patient urgently
needs an order.
AP must communicate phone order to the RIC.
Nurses are last resort for giving phone
orders.
MDs and Nurses can help avoid phone orders
by going on rounds together and discussing
the care plan. This way, the team
understands what to do if an urgent need
arises.
If you REALLY must give a
verbal or phone order,…
Ask for a READ BACK from the receiver
of the order.
 Listen carefully and verbally confirm that
your order has been correctly
understood.
 Do not hang up until you are sure.

What is medication reconciliation?
Medication reconciliation is the process of
comparing a patient's medication orders to all of
the medications that the patient has been
taking.
This reconciliation is done to avoid medication
errors such as omissions, duplications, dosing
errors, or drug interactions.
It should be done at every transition of care in
which new medications are ordered or existing
orders are rewritten. Transitions in care include
changes in setting, service, MD or level of care.
How is medication
reconciliation done?
1.
2.
3.
4.
5.
6.
Use the Drug Database Form.
Nurse asks patient to list all meds taken before
admission.
AP compares this list with the drugs ordered.
AP decides which medications will be continued
and which will be stopped.
AP re-writes orders if needed.
AP communicates the new list to appropriate
caregivers and to the patient.
When is medication reconciliation
done? Some examples
1.
2.
3.
4.
5.
6.
7.
8.
On admission
After a surgical or high risk diagnostic
procedure
Transfer to or from the ICU or another unit
Every 7th hospital day
Every 3rd hospital day for patients with more
than 3 MDs
After change of AP or RIC
After resuscitation
Before discharge from hospital
An example of medication
reconciliation
AP lists and compares drugs to determine which
will be continued, replaced or stopped.
Drugs before
admission:
Drugs during
confinement:
Drugs on
discharge:
Metoprolol
Telmisartan
Telmisartan
Glibenclamide
Insulin
Glibenclamide
Aspirin
Aspirin
Aspirin
Calcium
Calcium
Calcium
Senokot
Senokot
Why do medication reconciliation?
More than half of serious medication errors in
the JCI database are due to breakdowns in
communication that could have been avoided
through effective medication reconciliation.
Numerous reports of errors due to failure in
medication reconciliation have been received
by the Institute for Safe Medication Practices
(ISMP) since 2005 and by the United States
Pharmacopeia (USP) since 2004.
High risk medication monitoring
High risk drugs are those that have potent
cardiovascular, neurologic or metabolic
effects. Some of these drugs have
narrow margins of safety so that minor
medication errors can have catastrophic
consequences. The JCI database
maintains a list of high risk drugs.
The Medical City Drugwatch List
All staff must be
careful in using
these drugs and
report any
ADVERSE
EVENTS
involving them.
Insulin
2. KCl
3. MgSO4
4. Ca gluconate
5. NaHCO3
6. Lidocaine
7. Dopamine
8. Dobutamine
9. Heparin
10. Coumadin
1.
How to prescribe and
administer high risk drugs safely






Write complete orders legibly.
Limit the number of doses to a minimum.
Reconcile with other drugs.
Have the head nurse check the drug to be
administered.
Have the clinical pharmacist review the drug
order.
Monitor patient status after every
administration.
What are adverse drug events
(ADEs)?
Any unexpected, unintended, undesired, or excessive
response following drug administration that results in
1 of the following:
A.
B.
C.
Stopping or changing drug
Changing drug dose
Admission (for ambulatory patients) or prolonged length of
stay (for inpatients)
D. Starting supportive treatment
E. Complicated diagnosis or bad prognosis
F. Temporary or permanent harm, disability, or death
G. Therapeutic failure.
Why Report
Adverse Drug Events (ADEs)?






Because YOUR patients may be the next victim
Over 2 MILLION serious ADEs yearly
100,000 DEATHS yearly
ADEs 4th leading cause of death ahead of lung
disease, diabetes, AIDS, pneumonia, accidents
and automobile deaths
Ambulatory patients ADE rate — unknown
Nursing home patients ADE rate —
350,000 yearly
Institute of Medicine, National Academy Press, 2000
Lazarou J et al. JAMA 1998;279(15):1200–1205
Gurwitz JH et al. Am J Med 2000;109(2):87–94
Costs Associated with ADEs
$136 BILLION yearly
 Greater than total costs of
cardiovascular or diabetic care
 ADEs cause 1 out of 5 injuries or deaths
per year to hospitalized patients
 Mean length of stay, cost and mortality
for ADE patients are DOUBLE that for
control patients

Johnson JA et al. Arch Intern Med 1995;155(18):1949–1956
Leape LL et al. N Engl J Med 1991;324(6):377–384
Classen DC et al. JAMA 1997;277(4):301–306
Why Are There So Many ADEs?
Two-thirds of patient visits result in
a prescription
 2.8 BILLION outpatient prescriptions
(10 per person in the United States)
filled in 2000
 ADEs increase exponentially with
4 or more medications

Schappert SM. Nat. Center Health Statistics. 1999, Series 13 No. 143
National Association of Chain Drug Stores. 2001
Jacubeit T et al. Agents Actions Suppl 1990;29:117–125
New drugs approved by FDA / BFAD
are safe, right? Wrong!

Most drugs approved by FDA with average of
1500 patient exposures
 Some drugs have rare toxicity profiles
(bromfenac hepatotoxicity 1 in 20,000
patients)
 For drugs with rare toxicity, more than
100,000 patients must be exposed to
generate a signal i.e. after drug is marketed
Friedman MA et al. JAMA 1999; 281(18):1728–1734
Myths about ADE Reporting
All serious ADEs are documented by
the time a drug is marketed, right?
 It is difficult to determine if a drug is
responsible, right?
 ADEs should only be reported if
absolutely certain, right?
 One reported case can’t make a
difference, right?

Figueiras A et al. Med Care 1999;37(8):809–814
Eland I A et al. Br J Clin Pharmacol 1999;48(4):623–627
Chyka PA et al. Drug Saf 2000;23(1):87–93
Drug-Disease Interactions
Liver disease
 Renal disease
 Cardiac disease ( hepatic blood flow)
 Acute myocardial infarction?
 Acute viral infection?
 Hypothyroidism or hyperthyroidism?

Drug-Food Interactions
Tetracycline and milk products
 Warfarin and vitamin K-containing foods
 Grapefruit juice

Interactions Before Administration
Phenytoin precipitates in dextrose
solutions (e.g. D5W)
 Amphotericin precipitates in saline
 Gentamicin is physically/chemically
incompatible with most beta-lactams,
resulting in loss of antibiotic effect

Interaction with the GI Tract
 Sucralfate,
some
milk products,
antacids, and oral
iron preparations
 Omeprazole,
lansoprazole,
H2-antagonists
 Didanosine (given
as a buffered tablet)
 Cholestyramine
 Block
absorption
of quinolones,
tetracycline, and
azithromycin
 Reduce absorption
of ketoconazole,
delavirdine
 Reduces
ketoconazole
absorption
 Binds raloxifene,
thyroid hormone, and
digoxin
Spectrum of Consequences
of Drug Metabolism
Inactive products
 Active metabolites
 Similar to parent drug
 More active than parent
 New action
 Toxic metabolites

You must report suspected ADEs
ADEs may or may not be related or
caused by drug intake and this may be
difficult to determine.
 The important thing is to alert The
Medical City that a patient on a
particular set of drugs has experienced
an adverse event so that appropriate
preventive actions can be carried out.

What should you do if you
suspect an ADE?
1.
2.
3.
Stop the medication immediately.
Fill out the ADE Reporting Form and
hand it over to the Clinical Pharmacist.
Reporting may be done anonymously.
Coordinate with the Clinical
Pharmacist in managing the patient’s
ADE.
How will your report be
handled?



ADE reports are monitored and analyzed by the
Therapeutics Committee.
ADE reports provide the basis for drug alerts to
the hospital staff.
ADE reports are also sent to the manufacturer
and/or BFAD.
Are you a safe medication
practitioner?
1.
2.
Which of the following are in the Medical City Drugwatch list?
a. Potassium chloride
b. Insulin
c. Magnesium sulfate
d. All of the above
Answer: ?
D
Which of the following practice/s promote/s medication safety?
a. Writing orders and prescriptions legibly
b. Insisting that the pharmacy stock up your brand of antibiotic
c. Arranging drugs alphabetically by brand names
d. All of the above
Answer: ?
A. Choices b and c lead to mixing up sound-alike drugs.
Are you a safe medication
practitioner?
3. Which of the following will lead you to report a possible ADR?
a. The drug needed to be stopped or changed.
b. A significant dose modification is required.
c. The patient suffered temporary or permanent harm.
d. All of the above
Answer: ?
D
4. When reporting a possible ADR
a. You must be absolutely sure that it was caused by a drug.
b. You must always sign the report with your name.
c. You must immediately file the report while patient is confined.
d. all of the above
Answer:?
C. You don’t have to be sure of drug causation and you can file
Are you a safe medication
practitioner?
5. Which of the following is an inexpensive but effective intervention to
help the pharmacist screen for medication errors?
a. Write the side effects on the prescription
b. Write the drug indication on the prescription
c. Avoid the forbidden abbreviations.
d. all of the above
Answer: ?
B
6. Which among the following is a/are good way/s to prevent ADRs?
a. Have nurses read back orders to MDs
b. Reprimand nurses who make erroneous computations.
c. Suspend residents who write illegibly.
d. all of the above
Answer: ?
A
Are you a safe medication
practitioner?
7. Which strategy is the LEAST effective way for preventing ADEs?
a. Physical (Forcing Functions)
b. Natural (Distance, Time)
c. Information (Labels, Signs)
d. Administrative (Checklists, Policies)
Answer: ?
D. Forcing functions are the most effective. Policies can be broken.
8. The following is/are reason/s why elderly are more prone to ADEs:
a. Old people have trouble remembering their drugs.
b. Old people have poor liver and kidney drug handling capacities.
c. Old people have lower fat deposits in which drugs are stored.
d. All of the above
Answer: ?
D
Are you a safe medication
practitioner?
8 out of 8 – your patients are safe from medication errors!
6 or 7 out of 8 – your patients safety level is above average
4 or 5 out of 8 – your patients safety level is just about
barely adequate
2 or 3 out of 8 – you can improve the safety of your
medication practice!*
0 or 1 out of 8 – let us try again; meanwhile try to keep your
medication use on patients to the bare minimum!*
* Please go over the slides again.
Summary of this presentation

Our ability to ensure the safe use of
medications can spell the difference
between health and illness, even life and
death, for many patients.
 Our staff have critical roles to play in
promoting medication safety
 We must report, monitor and prevent
adverse drug reactions to spare our
patients from further harm.
This SIM Card certifies that
______(please overwrite with your name, thank you)__,
MD
has successfully completed the
Self Instructional Module on
Medication Management and Use
(Sgd) Dr Alfredo Bengzon
President and CEO
(Sgd) Dr Jose Acuin
Director, Medical Quality Improvement