High risk, High Return … Investing in Medication Safety ...€¦ · High risk, High Return …...
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High risk, High Return … Investing in Medication Safety Penny Thornton Pharmacy Services Manager
Transcript of High risk, High Return … Investing in Medication Safety ...€¦ · High risk, High Return …...
High risk, High Return …Investing in Medication Safety
Penny ThorntonPharmacy Services Manager
Westmead Adult Hospital
The Hospital:a DANGEROUS place for patients
First National Patient Safety Report Aug 2001
Second National Report on Patient Safety – Improving Medication Safety July 2002
SIIP projects 2003-4
Collaboratives 2004
Safety & Quality Council Working Party – 2002_4
Safety & Quality Commission 2005 - ?
Focusing on medication safety ….
USADisguised Observer Studies …
• Barker & McConnell 1962 15%• Many US studies ~ 1982 ~ <5%
Medication safety: How to measure?
Unit dose drug distribution ….Introduced in the USA 1970s to facilitate charging per dose of medication
Chart Analysis Studies …• Harvard Medical Practice Study 1991Brennan TA, Leape LL, Laird NM et al. NEJM 324:370-63.7% admissions suffered adverse events, more than half of these were medication related
“……… It couldn’t apply here! ”
The Quality in Australian Health Care Study 1995
Wilson R McL, Runciman WB, Gibberd RW et al Med J Aust 163:458-71
~ 2% of hospital admissions associated with ADEs =140,000 hospital admissions annually are associated with problems in the use of medicines
“……… It couldn’t apply here! ”Disguised Observer StudiesAustralia: Ward stock distribution
Community Systems Foundation Study, 1973-4 55%Goodman, Woodbridge (Liverpool Hosp) 1979 13%Rippe, Hurley, (PANCH) 1988 17%Stewart, Naismith, Biro et al (RMH) 1991 18.3%McNally et al, (Sir Charles Gairdner) 1997 15.4%
Australia: Individual patient-based distribution
Thornton, Koller (Westmead) 1994 7.4%deClifford et al (Mornington Peninsula) 1994 6.1%McNally et al (Sir Charles Gairdner) 1997 4.8%
Reported incidentsReported incidents
DeathsChange in clinical management - ↑ LOS
No obvious effect
Inconvenience
Hospital Incidents
Patient SafetyIdentify and eliminate risks
Which risks?High Risk Groups? .. per ISMP
• adrenergic agonists, IV (e.g., epinephrine, phenylephrine, norepinephrine)
• adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)• anaesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)• antiarrhythmics, IV (e.g., lidocaine, amiodarone)• antithrombotic agents (anticoagulants), including warfarin, low-
molecular-weight• heparin, IV unfractionated heparin, Factor Xa inhibitors
(fondaparinux), direct• thrombin inhibitors (e.g., argatroban, lepirudin, bivalirudin),
thrombolytics (e.g.,• alteplase, reteplase, tenecteplase), and glycoprotein IIb/IIIa inhibitors
(e.g., eptifibatide) cardioplegic solutions• chemotherapeutic agents, parenteral and oral
High Risk Groups ? .. per ISMP• dextrose, hypertonic, 20% or greater• dialysis solutions, peritoneal and hemodialysis• epidural or intrathecal medications• hypoglycemics, oral• inotropic medications, IV (e.g., digoxin, milrinone)• liposomal forms of drugs (e.g., liposomal amphotericin B)• moderate sedation agents, IV (e.g., midazolam)• moderate sedation agents, oral, for children (e.g., chloral hydrate)• narcotics/opiates, IV, transdermal, and oral (including liquid
concentrates, immediate and sustained-release formulations)• neuromuscular blocking agents (e.g., succinylcholine, rocuronium,
vecuronium)• radiocontrast agents, IV• total parenteral nutrition solutions
High Risk Drugs ?ISMP’s High Risk list
• colchicine injection• epoprostenol (Flolan), IV• insulin, subcutaneous and
IV• magnesium sulfate
injection• methotrexate, oral, non-
oncologic use• opium tincture• oxytocin, IV• nitroprusside sodium for
injection
• potassium chloride for injection concentrate
• potassium phosphates injection
• promethazine, IV• sodium chloride for
injection, hypertonic (greater than 0.9% concentration)
• sterile water for injection, inhalation, and irrigation (excluding pour bottles) in
containers of 100 mL or more
High risk situationsCurrent threats…..• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE
Medicine patches are not Medicine patches are not bandband--aids!aids!
DonDon’’t let kids in your t let kids in your house copy you house copy you by sticking these on by sticking these on ……....The dose in this patchThe dose in this patchcan kill a child. can kill a child. Dispose of patches safely.Dispose of patches safely.
Patch labelling
Patch Trade Name Strength expression
Glyceryl trinitrate Nitro-Dur® 5mg/24hrs (10cm2)10mg/24hrs (20cm2)15mg/24hrs (30cm2)
Transiderm Nitro® 5mg/24hrs (25mg)10mg/24hrs (50mg)
High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE
Morphine & Oxycodone products
Watch the “C” look-alikes!
A patient was recently admitted with INR > 8, after she had inadvertently
been dispensed Coumadin 5mg instead of Coversyl 5mg in the community..
[Australian Incident 60 – April 2007]
Trademark Labelling
High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE
Promethazine extravasation
Line Labelling
?
High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE
Mixture strengths
High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE
High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE
High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE
Low risk – should we be concerned?
• Ignore?• Report near miss data, interventions?• Report incidents centrally, nationally? (e.g. IIMs
NSW, AIMS SA)
• Look at trends• Use case studies proactively to prevent further
occurrence• Prevent alignment of holes in Swiss cheese • Use failure mode analysis
Australianmedication incident
reporting –can we use it proactively?
High Returns• Clinical pharmacists
– Performing pharmaceutical review & reconciliation
• Continuity & efficiency in dispensing between healthcare sectors
• Individualised medication distribution systems• Accountable drug distribution – robotics?• Accountable prescribers
– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible
A prospective multicentre study of pharmacist initiatedchanges to drug therapy and patient management inacute care government funded hospitalsMichael J. Dooley, Karen M. Allen,Christopher J. Doecke,Kirsten J. Galbraith,George R. Taylor,Jennifer Bright & Dianne L. CareyBr J Clin Pharmacol 2003: 57 :4 513–521 513
$ 23:1 saving through utilisation of clinical pharmacy services
High Returns• Clinical pharmacists
– Performing pharmaceutical review & reconciliation
• Continuity & efficiency in dispensing between healthcare sectors
• Individualised medication distribution systems• Accountable drug distribution – robotics?• Accountable prescribers
– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible
High Returns• Clinical pharmacists
– Performing pharmaceutical review & reconciliation
• Continuity & efficiency in dispensing between healthcare sectors
• Individualised medication distribution systems• Accountable drug distribution – robotics?• Accountable prescribers
– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible
Distribution in hospitals
• Full ward stock
• Individual patient supply
• Unit dose Safety
USA
Australia
Investment in individual patient drug distribution
• Vastly improved error rates• Valuable drug utilisation reporting• Dramatically decreased cost of
distributed inventory• Workforce intensive
– Extended pharmacy service hours?– Automation?
High Returns• Clinical pharmacists
– Performing pharmaceutical review & reconciliation
• Continuity & efficiency in dispensing between healthcare sectors
• Individualised medication distribution systems• Accountable drug distribution – automation? robotics?• Accountable prescribers
– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible
Ward- based dispensing machines
Robotic dispensing
High Returns• Clinical pharmacists
– Performing pharmaceutical review & reconciliation
• Continuity & efficiency in dispensing between healthcare sectors
• Individualised medication distribution systems• Accountable drug distribution – automation? robotics?• Accountable prescribers
– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible
Human factors engineering
Trapping error• Human factors
– Pilots have to pass a 2 day course in human factors as part of qualification process
– Junior staff empowered to warn seniors of impending problems– Senior staff trained to listen and share accountability
• Assertiveness• Teamwork• Expert decision making• Efficiency• Use of simulation to rehearse
strategies for dealing with unexpected emergencies
• Use of graded assertiveness focusing on WHAT is wrong rather than WHO is wrong.
What can we easily change for maximum benefit?
• Targeted alerts – Promethazine injection– Anticoagulants– LASA products
• Use pre-mixed electrolyte IV solutions• Simplification and continuity of systems
– NIMC
What can we easily change for maximum benefit?
• TALLman letters– oxyNORM, oxyCONTIN, msCONTIN– loSEC, laSIX– ValACIclovir, ValGANciclovir
• Use generic name/route identification– Oxycodone sustained release oral tabs
What is harder to change but possible in the workplace? - Culture
Nursing– checking processes– drawing up oral mixtures in IV syringe
Prescribing– Understanding accountability in prescribing– Best use of pharmaceutical reforms
Pharmacy practices– Clinical pharmacy to all patient beds– Pharmacists’ desire to play a key role in drug
distribution?
What is harder to change in the bigger picture?
• Therapeutic product labelling– Generic name prominence– User oriented terminology
• Osmolality?? SI units – µg?– Strength expression
• Consistent mixture strength per mL?• Global standards – e.g. colour coding
– Parenteral line labelling– Brand packaging– Oral dispensers/syringes
Achieving System Change
• a practical approach - use efficiency!
• make it easy for Doctors, Pharmacists and Nurses to do the right thing -choose the safest option
• be non-punitive• a quality process • find measurable outcomes - errors
avoided? MSSA score?
Quality Assurance is the most accessible strategy
MSSA tool www.cec.health.nsw.gov.au/tools
Value of learning from near-miss incidents
• Rate of error occurrence is too low to obtain meaningful data from one site
• Best value is learning from qualitative• Encourage centralised reporting of
near misses• Use local failure mode analysis
(FMEA)
….. thank you
