Medication Safety 2013:

Stony Brook Medicine

Joseph D DeCristofaro, MD

Assistant Medical Director for Patient Safety and Quality

joseph.decristofaro@stonybrookmedicine.edu

Why is this topic so important?

Medical Errors are common and often preventable

Institute of Medicine Report (IOM) 1999: • Estimated that 44,000-98,000 annual deaths are a result

of medical errors – Medication errors top this list

• Two percent (2%) of admissions experience an adverse

drug event (ADE) that results in an increased length of

stay and nearly $4,700 for the cost of each event

IOM: 2006

Updated report from IOM:

• Estimated that 1.5 MILLION people

are harmed each year as a result of

a Medication Error

• Focus ought to be on

PREVENTION

Definition of Medication (Joint Commission)

• Any prescription medications

• Sample medications

• Herbal remedies

• Vitamins

• Nutriceuticals

• Over-the-counter drugs

• Vaccines

• Radioactive medications

• Respiratory therapy treatments

• Blood derivatives

• Parenteral nutrition

• Intravenous solutions (plain, with electrolytes and/or drugs)

• Diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions

• Any product designated by the Food and Drug Administration (FDA) as a drug.

This definition of medication does not include enteral nutrition solutions which are considered food products, oxygen, and other medical gases.

What Is A Medication Error?

Adverse Drug Event (ADE) = Medication Error:• Any preventable event that may cause or lead to an

inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer.

At Stony Brook, ADE’s are reported on the patient safety net (PSN) website.

Every medication error is reviewed and changes have been made to processes or systems to prevent future errors.

Why are Medication Errors so Common?

The process of medication ordering and

dispensing is complicated. There are many steps:

• The medication order is written

• Nurse transcribes the order

• Delivered to the pharmacy

• Pharmacist transcribes the order

• Pharmacist prepares the medication

• Delivered to the point of care

• Administered to the patient

With many

hands along

the way

CPOE Prevents Medication Errors by Eliminating Steps in

the Medication Process:

• The medication order is ordered by computer

• Nurse transcribes the order

• Delivered to the pharmacy

• Pharmacist transcribes the order

• Pharmacist prepares the medication

• Delivered to the point of care

• Administered to the patient

Examples of Medication Errors

• Prescribing incorrectly (most common before CPOE)• Omission• Wrong time• Wrong administration technique• Wrong patient• Wrong route• Wrong dosage form• Wrong drug preparation• Improper dose/quantity• Unauthorized drug

Source: USP Pharmacopeia

What is an acceptable error rate?

• No benchmarks in medicine, but zero is the goal

• Relate safe to other industries

– 99.9% safe means:

• 84 unsafe plane landings per day

• 16,000 lost pieces of mail per hour

• 32,000 bank errors per hour

Paradox Regarding Error in Medicine

• Zero error standard

• Inherent toxicity with medication use

• Unwillingness to accept that healthcare workers are

human and make mistakes

• Errors result in a paralysis of the healthcare workers-

reports are inconsistent and often go unreported.

Unwilling to report to avoid “trouble”

• Prevention strategies are difficult to develop and

sustain

The biggest challenge is to get people in hospitals – physicians, pharmacists, nurses and administrators –

to recognize that errors are system problems – NOT people problems.

-----Lucian Leape

Professor, Harvard School of Public Health

How do we prevent errors?

• Standardize the medication system

• Simplify the process

• Evaluate processes at risk before an error occurs

(human factors engineering, redesign, use failure

mode effects analysis [FMEA])

• Make it difficult to err

• Report all errors to see where systems failed and

make improvements on these processes

Cerner and CPOE

• Computerized physician order entry (CPOE) was implemented in 2009

– The Cerner system involves several components including the pharmacy section (Pharmnet), the nursing section (e-MAR), CPOE, surgical section (surginet), and powernotes.

– The paperless medical record is the goal, linking the ambulatory and hospital record computerized .

Commonly Used Cerner Order Functions

1. Cancel/Reorder

2. Copy

3. Delete

4. Cancel D/C

5. Modify

6. Suspend

7. Resume

Cerner Tutorials

• CPOE is not always self-explanatory

• The physician portal intranet page, bottom

left under “Education/Instructions”

Education / Instructions•» CME Saturday: Lung Cancer Update 2011•» CME Online (Continuing Medical Ed.)•» Documentation Improvement Updts•» EPR/STARS Cerner PowerChart

• »Education Videos• »Job Aides

•» HANYS ACOG Fetal monitoring materials•» Remote access setup instructions•» Tracheostomy PowerPlan

Cerner Educational Videos:

How to order

Ordering Medications in Cerner

• Enter Patient Factors on admission before entering

medication orders. If not, your orders will be rejected.

• Always use an order sentence or PowerPlan. You

can modify these orders (dose, frequency).

– If you use an order sentence pick the drug name and

route desired. Do not change the route, change the

dose or frequency!

• Resources are available on line to check dosing

(Lexi-Comp, Micromedex, NeoFax) and references

may be available in the reference tab in Cerner

Frequency • After finding the DRUG & ROUTE, choose

a frequency from the drop down menu

• There are hospital standard times for

dosing frequency

• Know what the standard times are when

you order a medication

– BID is not the same as every 12 hours

– “Now” means at the time of order entry (STAT)

STAT MEDS• When ordering any Medication STAT you must

also notify the nurse or it may not be seen until

the next round of care

• When you order the “first dose now” the second

dose will follow the hospital frequency unless you

change the time of the second dose.

– If you order Imuran now and q6h, the first dose is due

immediately and the next dose could be due in the

next hour following the hospital q6h schedule.

CPOE Alerts

• Cerner offers many different types of alerts for

prescribers as they order medications.

• These many alerts can result in alert fatigue

and result in the prescriber ignoring an

important alert and result in a critical error.

• Read the alert before passing through it

Medication Reconciliation• Admission medication orders starts with an

accurate home medication list

• The Cerner system was designed to turn the list of

home medications into new admission medication

orders

• When medication orders are placed prior to the home

medications, complete the admission medication

reconciliation as soon as possible to avoid missing

critical home medications (eg. patient with Myasthenia

admitted for acute chest pain but Mestinon not

ordered)

Medication Reconciliation

• The Joint Commission requires that medications

are reconciled across the continuum of care

• This means a complete medication history is

obtained upon entry into the organization

• The medications are reconciled with every transfer

in level of care and between services

• Medications are reconciled at time for discharge

• A final list of medications is given to the patient

and communicated to the next provider of care.

Safe Medication UseMedication safety processes in place:• Look-alike Sound-alike (LASA) medications, found on the

pharmacy website, are reviewed every year

– Tall man lettering is used to help distinguish between LASA medications (DOPamine and DOBUTamine)

– LASA meds are stored separately throughout the hospital

• Label all medications administered to patients

• “ACLIPS” is our list of high risk medications (Anti-coagulants, Calcium IV, Lanoxin IV, Insulin IV, Potassium IV rapid replacement, Sodium Chloride 3% IV) require additional attention

• Prohibited abbreviations cannot be used anywhere in the medical record (see next slide)

• Verbal orders are not accepted

Prohibited Abbreviations - 2013

Must Use: Never Use:

No zero after a whole number (e.g., 2 mg) Trailing zero after a whole number

(e.g., 2.0 mg)

Zero for all numbers less than one (e.g., 0.2 mg) Decimal point without a leading zero

(e.g., .2 mg)

Metric system (mg, grams, or g, etc.) Apothecary symbols (drams, grains,

etc.)

Micrograms (written out), mcg µg

Units (written out) U

International Units IU

Twice a week (designate days of week) BIW

Three times a week (designate days) TIW

Once Daily QD, Q.D., qd, q.d.

Every other day QOD, Q.O.D., qod, q.o.d.

Morphine Sulfate MSO4, MS

Magnesium Sulfate MgSO4

Patient SafetyConcerns about Patient Safety should be reported to:

- Immediate Supervisor

- Department Head

- Associate Director for Area

- AD Patient Safety & Regulatory (4-1956)

- CEO Office (4-2701 or fax 4-8925)

- Patient Safety Officer Safety Hotline (4-Care)

If your concerns have not been addressed, or if you prefer, you may

contact the Joint Commission (TJC) at 1-800-994-6610

No disciplinary action will be taken because an employee reports safety or

quality concerns to TJC

*For concerns related to workplace safety please contact Jill Kavoukian EH&S 4-

6783

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