Transcript Improving Vaccine Administration Accuracy in the Primary Care

Improving Vaccine Administration
Accuracy in the Primary Care Setting
By
Joan Kramer PhD, RN
Angela Y Mackell RN, BS
Susan Crocetti RN BS CPHQ
JOHNS HOPKINS COMMUNITY
PHYSICIANS
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Affiliate of Johns Hopkins Health System
Provide primary care (FP and IM) in 15 centers
across MD; several offer peds and OB/GYN
More than 400,000 patient visits per year
575 employees including physicians, nurses,
ancillary personnel, and administrative staff
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120 Medical Assistants
Largely fee-for-service; less than half is managed
care
Immunizations
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Approximately 60,000 immunizations given in
CY 2003
High volume activity in primary care
Medical Error Data in Outpatient
Settings
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Not well published
Often considers only provider error
3.5% outpatients have serious medication
events (2.6% in hospitals)
75.6 errors/1000 primary care visits
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86% attributed to “system”
14% to knowledge and skills
Recommendations for error prevention
in outpatient settings
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Standardization
Record-keeping
Tracking
Culture of safety
Systems approach
LA/SA medication management
Phone advice training; message-taking
Event reporting system
JHCP Error Tracking
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8 year database
Self-report
Data used in
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Re-credentialing
Training
Multidisciplinary review
Newsletter
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Educate
Communicate
JHCP’s Error/Events Analysis,
2003
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25% were medication errors
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21% attributed to PCP knowledge/skills
79% attributed to support staff or “systems”
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Types of Immunization Errors
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Verbal orders
No chart; Failure to document
Parent requests
Injection technique/site selection/restraint
Wrong amount
Sound-alikes
Siblings
PPD-Td-DT-DTaP
Sound - alikes?
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Td - PPD
Pedvax - Pediarix
– HIB vs. DTaP/ Hib / IPV
HepB -HIB
Infanrix - Pediarix
– DTaP vs. DTaP/ HepB/ IPV
Decavac - Daptacel
– Td vs. DTaP
PPD-Td
Does PPD sound like Td?
 Does the mental notion of
– “give the patient a TB (PPD) test”
seem too much like…
– “give the patient Td”
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Siblings
Parent or guardian comes with 3-4
siblings…all in exam room
 MA gets chart from MD
 Goes in to room and gives vaccines
to the wrong child
 Parent rarely objects
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Vial colors and sizes?
Many vaccine vials have similar
color tops
 Some multi-dose vials are same size
 Labeling?
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Concerns: from specifics to
the big picture
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Increased reliance on nonlicensed clinical
staff
– Increasing expectations for MA’s as new
medications, POC testing, and
treatments are introduced
– Providers concerned about competence
of MA’s
Difficulty attracting and retaining
outstanding MA’s
What is a Medical Assistant at
JHCP?
 9-10
month certificate program,
post-HS
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A&P; med terminology, pharmacology; CPR;
EKG’s; phlebotomy; medical records; office mgmt
skills; VS; injections; 160-hour externship
MA completes national certification test--> CMA
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under physician license
Solution
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Goal: Patient Safety
MA Career Ladder
– Three levels with increasing hourly
wages
– Intensive education to standardize,
improve and expand competencies
– Promote and retain individuals who
demonstrate excellence
– Classroom and on-line programs
– Incorporate reported errors in training
CMA I Course
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Patient prep for visits
Provider Support Visits, e.g. BP check, flu shot
PPD’s
BP
Peak Flow
Lab tests
Immunizations
Allergy shots
EKG’s
Inhalers
CMA I Course: Immunizations
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Video: Immunization Techniques: Safe
Effective, Caring
Interpretation of schedules; adults and
children with examples
Safe handling
ADE’s, VAERS; VIS sheets
Vaccine errors at JHCP
Documentation
Restraint
CMA II: Medications and
Dosages Course
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Pkg inserts & labels
Reconstituting
Needle safety
Injection sites & tech
Orders
Errors
Immunizations
Selected Injectable Meds
Medications Course: Vaccines
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Video: Vaccines and Your Baby
– www.vaccine.chop.edu
Product guide
Vaccine “game”
Practical test
– Interpretation of provider orders
Outcomes of training
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MA turnover decreased 40%->6%
Provider confidence increased
EOC scores improved
– biannual inspections of medications,
infection control, lab, general safety,
etc
High employee satisfaction
CMA I…all in first 6 months; CMA II…22 in
one year; CMA III…2 in 6 months
Integrating Lessons Learned
into Operations
Clinical Care Committee: vaccine
error review
 Policy for Medication Administration
 Safety Fair “Put Yourself in Their
Shoes”
 Ambulatory Care Newsletter
 “One Liners”
 SAFE awards
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One-liners
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DON’T JUDGE A VIAL BY ITS COLOR.
That green cap... is it Hep B or PPD?? Is the blue
cap HIB or Prevnar??
READ ALL THE “INGREDIENTS”
– Both DTaP vaccine and Pediarix vaccine labels
list “DTaP”, but Pediarix has two additional
vaccines.
DO YOU REACH FOR VACCINES BY “SIZE”?
– Beware: Meningococcal and Polio vaccines are
in similar sized multi-dose vials.
SAFE Awards: Promoting a
Culture of Safety
The SAFE Program rewards
employees who make suggestions
that enhance the quality and safety
of patient care.
 Cash rewards for first and second
place
 Quarterly
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SAFE winner
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System of involving the patient in
safety checks when giving allergy
shots. Patient checks serum bottle
and the dose drawn up.
No errors noted in the six months
Patient satisfaction
Application to Immunizations
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Show parent empty (single dose)
vials of vaccine you just drew up
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Parent can see they match the VIS(s)
How can vaccine accuracy be
improved in primary care?
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MA skill assessment
Training; Career Ladder
Policy e.g. no verbal orders
Track errors; use errors in training
Culture of safety….SAFE award
Documentation standards
Multidisciplinary review of errors
One-liners
Newsletter