Managing HighManaging High--Alert Alert Medications Medications Brought to you by the Brought to you by the

Washington Patient Safety CoalitionWashington Patient Safety CoalitionJune 10, 2009June 10, 2009

Goals of High Alert Medication Goals of High Alert Medication Policies and ProcessesPolicies and Processes

To eliminate harm to the patient from the use of high alert medicationsTo develop standardized medication handling processes for high alert medicationsTo monitor and continually improve the standardized delivery process for high alert medications

High Alert MedicationsHigh Alert Medications

Based on 3,184 reports submitted to the US Pharmacopeia MedMarxdatabase involving parenteral routes during 2000 – 2004.

Narcotics/opioids, insulin and heparin combined for 33.7% of the errors in this review.

Between 3-5% of these errors actually caused harm to the patient.

Topics / PresentersTopics / Presenters

InsulinInsulin–– Carol Lyn Carol Lyn VanevenhovenVanevenhoven, , PharmDPharmD, Pharmacy Clinical , Pharmacy Clinical

Operations Assistant Manager/Medication Safety Operations Assistant Manager/Medication Safety Officer, Yakima Valley Memorial HospitalOfficer, Yakima Valley Memorial Hospital

Narcotics/Narcotics/OpioidsOpioids–– Tim LynchTim Lynch, , PharmDPharmD, MS, FABC, Pharmaceutical , MS, FABC, Pharmaceutical

Services Manager, St. Joseph Medical CenterServices Manager, St. Joseph Medical Center

HeparinHeparin–– Jackie Jackie BieryBiery, , PharmDPharmD, Medication Safety Pharmacist, , Medication Safety Pharmacist,

University of Washington Medical Center University of Washington Medical Center

Yakima Valley Memorial Yakima Valley Memorial HospitalHospital

Medication Safety ProgramsMedication Safety Programs

6

Yakima, WA225 bed acute care community hospital

Admission and Discharge rate: 50-80/day

Yakima Valley Memorial HospitalYakima Valley Memorial Hospital

AnesthesiaAnesthesia--based Interventions for based Interventions for Error Reduction Error Reduction

Medication Safety ProgramsMedication Safety Programs

Medication Safety OfficerMedication Safety Officer

QuantrosQuantros: Online error reporting: Online error reporting

MERT: Medication Error Review TeamMERT: Medication Error Review Team–– 2 Pharmacy Representatives2 Pharmacy Representatives

Safety and OperationsSafety and Operations

–– 3 Nursing Representatives3 Nursing RepresentativesMed/Med/OncOnc, ICU/Tele, Surgery, ICU/Tele, Surgery

High Alert MedicationsHigh Alert Medications

Insulin, narcotics, sedatives, Insulin, narcotics, sedatives,

anticoagulants, potassium, chemoanticoagulants, potassium, chemo

Tracked quarterly for trendsTracked quarterly for trends

Proactive focus on actionable itemsProactive focus on actionable items

InsulinInsulin

Where we startedWhere we started

Initiation of BedInitiation of Bed--Side Side BarcodingBarcoding

–– Switching to pensSwitching to pens

–– New problemsNew problems

New ProcessNew Process

New ProcessNew Process

Long Acting InsulinsLong Acting Insulins

Vs.Vs.

Short Acting InsulinsShort Acting Insulins

Continuing EducationContinuing Education

Insulin Fast Facts Insulin Fast Facts Rapid acting insulin (Rapid acting insulin (aspartaspart) and short acting insulin ) and short acting insulin (regular) are kept in the (regular) are kept in the AccudoseAccudose cabinets on most cabinets on most floors. They require a nursing double check documented floors. They require a nursing double check documented in MAK.in MAK.Intermediate acting insulin (NPH) and long acting insulin Intermediate acting insulin (NPH) and long acting insulin ((GlargineGlargine) are sent from the pharmacy in pre) are sent from the pharmacy in pre--drawn up drawn up syringes. They do not require a nursing double check in syringes. They do not require a nursing double check in MAK because pharmacy is the double check.MAK because pharmacy is the double check.IF a Patient is ever put on BOTH IF a Patient is ever put on BOTH aspartaspart and regular and regular insulin please call pharmacy to clarify the order.insulin please call pharmacy to clarify the order.You are part of every safe patient day!You are part of every safe patient day!

University of Washington Medical University of Washington Medical CenterCenter

Seattle, WASeattle, WA400 bed academic 400 bed academic medical centermedical centerRegional referral Regional referral center center

Medication Safety StructureMedication Safety Structure

Medication Safety OfficerMedication Safety OfficerSafe Medication Practices CommitteeSafe Medication Practices Committee–– Patient Safety CommitteePatient Safety Committee–– Pharmacy & Therapeutics CommitteePharmacy & Therapeutics Committee

Patient Safety Net (PSN): Online incident Patient Safety Net (PSN): Online incident reporting system through UHCreporting system through UHCH.E.A.T. : Husky Event Analysis TeamH.E.A.T. : Husky Event Analysis Team–– Center for Clinical Excellence, Patient Safety Officer, Center for Clinical Excellence, Patient Safety Officer,

Medication Safety Officer, Risk Management, Nursing, Medication Safety Officer, Risk Management, Nursing, Transfusion, RadiologyTransfusion, Radiology

UWMC High Alert MedicationsUWMC High Alert Medications

HeparinHeparinInsulinInsulinConcentrated ElectrolytesConcentrated ElectrolytesChemotherapyChemotherapyOpioidsOpioids

Medication Errors with Harm at UWMC Medication Errors with Harm at UWMC FY2008FY2008

0

2

4

6

8

10

12N

umbe

r of E

vent

s

Insuli

nHyd

romorp

hone

Hepari

nIV flu

id/TPN

Dobuta

mineLe

voflo

xacin

Morphin

ePain

Coc

ktail

Antiinf

lammato

ryChe

mothera

py

Drug Name

y

RISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORD

CONFIDENTIAL PURSUANT TO RCW 4.24.240-250 AND 70.41.200

Heparin Drip Errors at UWMC Heparin Drip Errors at UWMC FY2008FY2008

0123456789

dose omiss

ionwro

ng dose

monitorin

g erro

rwro

ng drug

wrong ra

te

other med

erro

rex

tra dose

wrong ro

utewro

ng time

unauthorized

RISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORD

CONFIDENTIAL PURSUANT TO RCW 4.24.240-250 AND 70.41.200

Heparin Infusion Protocol

X

Protocol Errors

Monitoring Errors

Using the UWMC Heparin ProtocolUsing the UWMC Heparin ProtocolNursing EducationNursing Education

Mandatory Nursing EducationMandatory Nursing EducationCaseCase--basedbasedSelfSelf--study or Nursing Ed Days study or Nursing Ed Days PresentationPresentationOnline competency examOnline competency exam

CASE 2CASE 2

JA is a 65 year old male with a history of atrialfibrillation who was admitted to the hospital for an acute exacerbation of heart failure. He is receiving heparin by IV infusion as a substitute for his usual outpatient warfarin therapy, which is used for stroke prevention, and to prevent left ventricular thrombus formation. He has been on heparin for several days at a stable rate, with aPTTs all between 60 and 100.

1. Drip running at 1800 units/hr 0100

2. qam aPTT blood draw due 0700

3. aPTT results available 0900(aPTT = 200)

5. Turn off heparin infusion 0900

4. HOLD HEPARIN INFUSION until aPTT<200

5. Redraw aPTT immediately = 0900

6. aPTT results available 1000(aPTT = 96)

7. Resume drip at 1800 units/hr 1000

Medication Errors with Harm at UWMC Medication Errors with Harm at UWMC FY2009FY2009

0

1

2

3

4

5

6

7

8

9

10

Num

ber o

f Eve

nts

Drug Name

RISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORD

CONFIDENTIAL PURSUANT TO RCW 4.24.240-250 AND 70.41.200

Heparin Drips Errors at UWMCHeparin Drips Errors at UWMCFY2008 vs. FY2009FY2008 vs. FY2009

0

1

2

3

4

5

6

7

8

9

Num

ber o

f Eve

nts

Error Category

FY2008 FY2009

RISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORD

CONFIDENTIAL PURSUANT TO RCW 4.24.240-250 AND 70.41.200

UWMC Anticoagulation Services UWMC Anticoagulation Services WebsiteWebsite

http://http://uwmcacc.orguwmcacc.org//

Additional Heparin Safety InitiativesAdditional Heparin Safety Initiatives

Limiting Heparin ConcentrationsLimiting Heparin ConcentrationsLimiting the use of Heparin FlushesLimiting the use of Heparin FlushesNeuraxialNeuraxial Guidelines and Order Entry AlertGuidelines and Order Entry AlertHeparin Induced Thrombocytopenia AlertHeparin Induced Thrombocytopenia AlertSmart Pump Infusion TechnologySmart Pump Infusion Technology

Franciscan Health System (FHS)Franciscan Health System (FHS)

5 Hospitals located in Pierce and King County5 Hospitals located in Pierce and King County

–– St. Joseph Medical Center 320 Beds, Level II TraumaSt. Joseph Medical Center 320 Beds, Level II Trauma

–– St. Francis Hospital 130 Beds, Level IV TraumaSt. Francis Hospital 130 Beds, Level IV Trauma

–– St. Clare Hospital 110 BedsSt. Clare Hospital 110 Beds

–– St. Anthony Hospital 65 BedsSt. Anthony Hospital 65 Beds

–– Enumclaw Regional Hospital 23 Beds, Critical AccessEnumclaw Regional Hospital 23 Beds, Critical Access

Inpatient Hospice FacilityInpatient Hospice Facility

Medication Safety Leadership Team Medication Safety Leadership Team (MSLT)(MSLT)

Regional committee charged with improving Regional committee charged with improving medication safety throughout FHSmedication safety throughout FHSMeets monthly to review quality information Meets monthly to review quality information related to medication safety.related to medication safety.Composed of VP of Quality, Safety Officer, Composed of VP of Quality, Safety Officer, Directors of nursing from all hospitals, the chairs Directors of nursing from all hospitals, the chairs of the nursingof the nursing--pharmacy committees from all pharmacy committees from all hospitals and educators.hospitals and educators.Chaired by a pharmacy manager and nursing Chaired by a pharmacy manager and nursing director.director.

Med Safety Process for NarcoticsMed Safety Process for NarcoticsIRISIRIS--Incident Reporting Information SystemIncident Reporting Information System

Electronic system where errors are reported via the FHS Electronic system where errors are reported via the FHS intranet for review by department managers and risk intranet for review by department managers and risk managers.managers.

Data from events collected and reviewed for tending and Data from events collected and reviewed for tending and problem identification.problem identification.

Events classified by standard error reporting nomogram Events classified by standard error reporting nomogram as category D and above reviewed by nursingas category D and above reviewed by nursing--pharmacy pharmacy committee to identify system issues. committee to identify system issues.

System problems and solutions are brought to MSLT for System problems and solutions are brought to MSLT for discussion and possible implementation systemdiscussion and possible implementation system--wide.wide.

NarcoticsNarcotics

In early 2007 anecdotal reports were In early 2007 anecdotal reports were presented to MSLT of increased over presented to MSLT of increased over sedation events associated with narcotics.sedation events associated with narcotics.–– A proposed cause for this was the movement A proposed cause for this was the movement

from meperidine to hydromorphone. from meperidine to hydromorphone. –– Lack of familiarity with dosing of Lack of familiarity with dosing of

hydromorphone by all providers was thought hydromorphone by all providers was thought to be the reason for increased events.to be the reason for increased events.

–– Increased focus on pain related issues and Increased focus on pain related issues and aggressive treatment.aggressive treatment.

Narcotics Narcotics -- HFMEAHFMEA

MSLT determined that an HFMEA process MSLT determined that an HFMEA process would be used to identify issues and would be used to identify issues and provide recommendations for preventing provide recommendations for preventing over sedation events.over sedation events.An HFMEA team, chaired by pharmacy and An HFMEA team, chaired by pharmacy and nursing was formed in October 2007.nursing was formed in October 2007.–– Included physician, pharmacy and nursing Included physician, pharmacy and nursing

representation.representation.

Narcotics Narcotics -- HFMEAHFMEA

Review of incident reports and analysis of events Review of incident reports and analysis of events to determine scope of problem.to determine scope of problem.Review of literature as well as other hospitals to Review of literature as well as other hospitals to determine benchmark rate.determine benchmark rate.–– Literature referenced over sedation rate between 0.1 Literature referenced over sedation rate between 0.1

and 1 %and 1 %–– Literature supported our observation of increased Literature supported our observation of increased

over sedation events associated with narcotics.over sedation events associated with narcotics.–– Links drawn towards new standard of care with pain Links drawn towards new standard of care with pain

as the fifth vital sign and aggressive management of as the fifth vital sign and aggressive management of pain issues.pain issues.

Narcotics Narcotics -- HFMEAHFMEAFHS Baseline rate determined through analysis of Code FHS Baseline rate determined through analysis of Code Green events (rapid response team) and IRIS reports.Green events (rapid response team) and IRIS reports.HFMEA performed on PCA administration process from HFMEA performed on PCA administration process from prepre--op screening to postop screening to post--op care, including PCA without op care, including PCA without surgery.surgery.–– Focus on items with hazard score >16 (Severity and probability)Focus on items with hazard score >16 (Severity and probability)–– Areas for improvement identified:Areas for improvement identified:

H & P, high risk screeningH & P, high risk screeningOR hand off to PACUOR hand off to PACUPCA set up and admin PACUPCA set up and admin PACUPACU hand off to floorPACU hand off to floorRN knowledge and skillRN knowledge and skillProtocols and proceduresProtocols and procedures

Narcotics Narcotics --HFMEAHFMEAFY07 rate of 0.47 established (Rate (%) = OSD (patients FY07 rate of 0.47 established (Rate (%) = OSD (patients with over sedation by PCA) per PDC (adults/peds with over sedation by PCA) per PDC (adults/peds discharges) / 1000discharges) / 1000Goal of HFMEA reduce rate of over sedation events by Goal of HFMEA reduce rate of over sedation events by 50% for FY0850% for FY08HFMEA Goals:HFMEA Goals:–– Improved patient selection and screening toolImproved patient selection and screening tool–– Patient/family education on both PCA and postPatient/family education on both PCA and post--op pain expectationsop pain expectations–– Policy, procedure, protocol, flow sheet review and revision.Policy, procedure, protocol, flow sheet review and revision.

Increased nurse double checks, increase patient monitoring.Increased nurse double checks, increase patient monitoring.–– Nurse competency validationNurse competency validation

Skill testing with pump set up and problem solvingSkill testing with pump set up and problem solvingPain management; sedation assessmentPain management; sedation assessment

–– EquipmentEquipmentSmart PCA pumps at all sitesSmart PCA pumps at all sitesContinuous pulseContinuous pulse--ox/heart rate monitoring on all postox/heart rate monitoring on all post--op patientsop patients

Narcotics: Outcomes of HFMEANarcotics: Outcomes of HFMEARate declined from a high of 1.8 to current rate of 0.5 at Rate declined from a high of 1.8 to current rate of 0.5 at one of our hospital and from 1.65 to 0.25 at another.one of our hospital and from 1.65 to 0.25 at another.Current overall FHS rate approximately 0.23, down from Current overall FHS rate approximately 0.23, down from 0.47 FY070.47 FY07Implemented pulseImplemented pulse--ox and heart rate monitoring for all ox and heart rate monitoring for all postpost--op patients for 24hrs after surgery and for all PCA op patients for 24hrs after surgery and for all PCA patients for duration of PCA therapy.patients for duration of PCA therapy.–– Ideally, capanography was the desired monitoring tool as it is aIdeally, capanography was the desired monitoring tool as it is a

better measure of oxygenation but cost concerns did not allow better measure of oxygenation but cost concerns did not allow for implementation.for implementation.

–– HFMEA indicated that postHFMEA indicated that post--op patients at greatest risk for up to op patients at greatest risk for up to 24hs post surgery and for duration of therapy for PCA patients.24hs post surgery and for duration of therapy for PCA patients.

–– Alarms:Alarms:Oxygen sat <90, HR >120, <50Oxygen sat <90, HR >120, <50

Narcotics: Event MonitoringNarcotics: Event Monitoring

With HFMEA conclusion, still need for additional With HFMEA conclusion, still need for additional monitoring for over sedation eventsmonitoring for over sedation eventsIRIS system not used consistently for reporting events.IRIS system not used consistently for reporting events.Use of PYXIS CDC for all naloxone removal to capture Use of PYXIS CDC for all naloxone removal to capture possible over sedation events.possible over sedation events.–– All naloxone removals documented as All naloxone removals documented as ““treatment for over treatment for over

sedationsedation”” reviewed by nursereviewed by nurse--pharmacy committee and by pharmacy committee and by department where events occur.department where events occur.

–– Results reported to MSLT on monthly basis to identify system Results reported to MSLT on monthly basis to identify system issues and make recommendations for corrective action.issues and make recommendations for corrective action.

Narcotics Narcotics –– High Risk MedicationsHigh Risk MedicationsPYXIS CDCPYXIS CDC–– Good tool to track removal and alert nursingGood tool to track removal and alert nursing–– Identified over sedation events associated with Identified over sedation events associated with

unfamiliarity with dosing differences between unfamiliarity with dosing differences between hydromorphone and morphine.hydromorphone and morphine.

Implemented CDC to alert nursing when removing Implemented CDC to alert nursing when removing hydromorphone: hydromorphone: ““hydromorphone 1.5mg IM/IV = 10mg hydromorphone 1.5mg IM/IV = 10mg morphine IM/IVmorphine IM/IV””

–– Force Force ““yes, I am awareyes, I am aware”” response upon removalresponse upon removal

–– All High Risk medications (insulin's, heparins, All High Risk medications (insulin's, heparins, warfarin, narcotics, etc.) have CDC alert:warfarin, narcotics, etc.) have CDC alert:

““High Risk Med***Double check requiredHigh Risk Med***Double check required””

–– All LASA medications have CDC alert: All LASA medications have CDC alert: ““look look alike/sound alike alertalike/sound alike alert””

NarcoticsNarcotics

Still room for improvement!Still room for improvement!

–– HFMEA work continues with goals of HFMEA work continues with goals of

implementing all recommended implementing all recommended

improvements.improvements.

–– Increased awareness of over sedation Increased awareness of over sedation

–– Better use of technology to track and trend, Better use of technology to track and trend,

resulting in improved patient safety.resulting in improved patient safety.

ResourcesResources

Go to Washington Patient Safety CoalitionGo to Washington Patient Safety Coalition–– http://www.wapatientsafety.org/http://www.wapatientsafety.org/

–– TodayToday’’s slide sets slide set

–– YVMH Insulin YVMH Insulin ““Fast FactsFast Facts””

–– UWMC Heparin Infusion ProtocolUWMC Heparin Infusion Protocol

The Institute for Safe Medication PracticesThe Institute for Safe Medication Practices–– ISMP.orgISMP.org

–– Lists, Newsletters, process improvement ideasLists, Newsletters, process improvement ideas

Your turn.Your turn.QuestionsQuestions

Thanks to Carol, Jackie Thanks to Carol, Jackie and Tim!and Tim!

Please submit your evaluationsPlease submit your evaluations