Medication Error Reduction Plan Program

Loriann De Martini, Pharm.D.Chief Pharmaceutical Consultant

Michael Alexander, M.Sc.Pharmaceutical Consultant II

Michael Alexander

MERP Task Force Lead

Presentation Goals

• Provide an update on MERP program• Provide information which may help you to

decrease medication errors • Relate some important findings during MERP

surveys• Provide overview of Med-SET project• Provide CDPH with recommendations for

medication safety focus areas for next triennial survey cycle starting January 2012

MERP Survey Summary January 2009 – December 2011

• 374 – Hospitals to be surveyed• 368 – Exited surveys (98 %)• 346 – Survey data received (94 %) • 323 – Noted deficiencies (93 %) • 23 – In compliance ( 7 %)

Data as of 01/23/2012

Common Deficiencies

• 68 % - Develop and implement P&Ps for safe and effective use of medications [CCR 70263(c)(1)]

• 63 % - Conduct an annual review to assess effectiveness of the implementation of MERP [HSC 1339.63 (e)(2)]

• 46 % - Identify weakness or deficiencies that could contribute to errors [HSC 1339.63 (e)(1)]

• 45 % - Include a multidisciplinary process to regularly analyze all errors [HSC 1339.63 (e)(6)]

Issues:

• Fentanyl patches

• Droperidol

• Insulin

• IV infusion devices Smart pumps; PCAs

Issues:

• Automated Dispensing Cabinets Discrepancies, overrides, profiling (e.g., Radiology,

PACU, ED)

• Emergency medications (MH, carts, boxes) Sealed, list of meds, exp. date

• Refrigerators (storage); warmers in OR

Issues:

• Lack of policies and procedures

• Policies and procedures not followed

• Recent medication deaths: heparin, morphine, warfarin, fentanyl

Issues:

• Limit access to medications

• Drawing up emergency medications correctly

• Preprinted orders – include parameters for dose changes (e.g., norepinephrine, nitroprusside)

Expired Drugs

• Operating room areas • Transport boxes, kits• Emergency department (succinylcholine?)• Clinics• Unit inspections

Malignant Hyperthermia

• Do nurses, pharmacists, physicians know how to treat MH?

• Do nurses, pharmacists, physicians know where to get drugs to treat MH?

• Do you have all of the MHAUS recommended drugs in your cart?

IV preparation in the ED

• Are nurses compounding/mixing activase and tenecteplase?

• Has pharmacy conducted in-service programs and developed quality control procedures for compounding IVs?

MERP Activities

• Surveyors visit: ED PACU OR Med/Surg Clinics Pediatrics Pharmacy

MERP Activities

• NICU• Radiology• Nuclear Medicine• Conduct med pass observations• Anywhere meds are stored/used

Loriann DeMartini

Chief Pharmaceutical Consultant

Department of Health and Human Services

OFFICE OF INSPECTOR GENERAL

ADVERSE EVENTS IN HOSPITALS:

NATIONAL INCIDENCE AMONG MEDICARE

BENEFICIARIES 11/2010

How the numbers add up

• 15,000 • 180,000 • 44• 324• Number 1 cause of adverse events 50

Department of Health and Human Services

OFFICE OF INSPECTOR GENERAL

HOSPTIAL INCIDENT REPORTING

SYSTEMS DO NOT CAPTURE

MOST PATIENT HARM

January 2012

Office of Inspector General Report

• 14% of events are reported Reason – don’t see the outcome as an error

• 11% of events that led to death reported• Medication = 38% of adverse events 13% reported Changes in mental status (delirium); excessive

bleeding, hypoglycemic event

CDPH Administrative Penalties

• AP amounts: $50,000 - $100,000• Issuance of an AP is accompanied with a press

release and posting on CDPH internet• Events generating administrative penalties: Medication or pharmacy related errors: 30% Patient care issues: 20% Retention of foreign object: 22%

Best Practices

“The department may work with the facility's health care community to present an annual symposium to recognize the best practices for each of the procedures and systems.”

[HSC 1339.63 (g)]

Can Medication Safety System Vulnerabilities be identified proactively and objectively?

Medication Safety Event Tracking Med SET

Launched September 2011

Med SET

• Objectives: Collect, quantify, and analyze medication safety data

reported from deficiencies written by Pharmaceutical Consultants

Categorize types of medication–related events associated with Federal/State deficient practices .

• Goals: Identify medication safety system vulnerabilities and

their trends Use Med SET data to inform and educate internal and

external providers on medication safety issues

Med SET

• Data extracted from Statement of Deficiencies• All facility types: SNF, GACH, Clinics, ESRD, etc.• Used MERP defined systems or procedures and

expanded• 12 categories with 85 sub-categories• Compare different facility types• Present level of harm

1. Prescribing2. Prescription order

communication3. Product labeling4. Packaging and

nomenclature5. Compounding6. Dispensing7. Distribution8. Administration9. Education10.Monitoring 11.Use

1. Prescribing2. Prescription order communication3. Product labeling, packaging and

nomenclature4. Compounding5. Dispensing6. Distribution7. Administration8. Monitoring 9. Competency10.Use11.Technology12.Transitions in care

MERP Med SET

28

Med SETMedication System Event Tracker

Error Categories - 20XX15

1

6

1 2 3 2 31 2 1

02468

101214161820

Presc

ribing

Rx Ord

er Comm

Produc

t Lab

el, P

ack..

.Compou

nding

Dispen

sing

Distrib

ution

Administrat

ionMon

itorin

gCompete

ncy UseTec

hnolog

y

Error Category

Num

ber o

f AP

Occ

urre

nces

Med SETMedication System Event Tracker

Prescribing

12

1

3 32 2

1 1

34

8

4

7

1

0123456789

10

Failure

to O

rder

Unauthoriz

ed Pres

cr...

Wrong Patien

t

Contra

indicate

d Med

...

Wrong Dosag

e Form

Wrong Dose

Wrong Freque

ncyWrong Rou

te

Wrong Duratio

n

Wrong Rate of In

fusion

Wrong Indica

tion

Unclea

r Orders

Informed

Consent

Unnec

essa

ry Med

Order S

ets

Error Subcategories

No.

of O

ccur

renc

es

MERP Program

A story of collaboration

MERP Program

• 2002 2005 2007 2008 2009• Stakeholder input meetings : 6 and 72 Notification AFL Simulation surveys: Survey Process AFL Surveys pre-announced

• 2010 – Program enhancement Survey Evaluation Survey Process – Document request Survey Questionnaire

• Medication Safety Symposium – 4 - 5

Collaboration: Its working…So what's next?

MERP 2012-2014

What can we do to help you reduce/eliminate medication errors?