Medication SafetyMedication Safety

The Good Hospital Practice Training Series 2009

The Medical City

In this presentation…In this presentation…

The roles of the Medical City staff in ensuring the safe use of medications– Prescription writing– Verbal and phone orders– High risk medication monitoring– Medication reconciliation– Adverse drug event reporting and analysis

The problem of The problem of medication errorsmedication errors

44,000 - 98,000 people in the US die annually as the result of medical errors

19% of all medical errors are medication related.

Only 1-10% of medication errors are voluntarily reported

Medication errors reported do not reflect patient harm

The problem of medication safetyThe problem of medication safety

Every day more than 4,000 people have ADRs so serious that they need to be admitted to American hospitals

In addition, every day about 2,000 hospitalized patients suffer from ADRs.

About 50% of these ADRs are preventable.

Common medication errorsCommon medication errors

1. Math error when calculating dose.

2. Wrong patient weight.

3. Patient’s armband not checked.

4. Wrong drug amount drawn in syringe.

5. Wrong strength bolus administered.

6. No double check of pump completed.

7. Double checking of dose is only cursory.

Root causes of Root causes of medication errorsmedication errors

Lack of clear and adequate communication among doctors, nurses, pharmacists and patients

Illegible, incomplete prescriptionsMultiple drugsLook alike sound alike drugs

The roles of ALL doctorsThe roles of ALL doctors

1. Use drugs rationally. More drugs, more errors. Be evidence-based.

2. Educate patients on rational drug use.3. Write all drug orders legibly. Print if in

doubt. Don’t use Forbidden Abbreviations.

4. Stick to medications in the formulary.5. Order by generic names, correctly

spelled. Allow generic substitution.

The roles of ALL doctorsThe roles of ALL doctors

6. Write the therapeutic indication for every new drug ordered (e.g. losartan for hypertension)

7. Demand READ-BACK after ordering drugs. Confirm that you are understood.

8. Practice medication reconciliation. Compare drugs ordered on admission AND on discharge with drugs taken before admission. Be clear with what you want continued or stopped.

The role of residents

1. Write drug orders ON TIME. No phone or verbal orders please.

2. Write orders LEGIBLY. Print if in doubt. Write the generic names and indications. Avoid abbreviations.

3. READ BACK written and verbal orders of consultants immediately to confirm if you got it right before executing them

The role of nurses

1. Order drugs in SHAMAN by GENERIC NAMES.

2. READ BACK the complete drug order to the prescriber and insist on confirmation.

3. Before administering drugs, confirm the identity of the patient AND the drug.

4. Administer all medications promptly.

5. Report any adverse drug event.

Writing perfect prescriptionsWriting perfect prescriptions

A drug order or prescription must have the ff legibly written parts:

Generic nameDose, frequency and routeIndicationSignature, printed nameTime and dateNo abbreviations please!

Do Not Use

Potential Problem

Use Instead

U (unit) Mistaken for “0” (zero), the number “4” (four) or “cc”

Write "unit"

IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten)

Write "International Unit"

Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d, qod, EOD (every other day)

Mistaken for each other Period after the Q mistaken for "I" and the "O" mistaken for "I"

Write "daily" Write "every other day"

Trailing zero (X.0 mg)* Lack of leading zero (.X mg)

Decimal point is missed Write X mg Write 0.X mg

MS MSO4 and MgSO4

Can mean morphine sulfate or magnesium sulfate Confused for one another

Write "morphine sulfate" Write "magnesium sulfate"

> (greater than) < (less than)

Misinterpreted as the number “7” (seven) or the letter “L” Confused for one another

Write “greater than” Write “less than”

Abbreviations for drug names

Misinterpreted due to similar abbreviations for multiple drugs

Write drug names in full

μg Mistaken for mg (milligrams) resulting in one thousand-fold overdose

Write "mcg" or “micrograms”

cc Mistaken for U (units) when poorly written

Write "ml" or “milliliters”

Avoid these Forbidden Abbreviations

Avoid verbal and phone Avoid verbal and phone ordersorders

A phone order is permitted if an AP can’t write an order promptly AND if a patient urgently needs an order.

AP must communicate phone order to the RIC. Nurses are last resort for giving phone orders.

MDs and Nurses can help avoid phone orders by going on rounds together and discussing the care plan. This way, the team understands what to do if an urgent need arises.

If you REALLY must give a If you REALLY must give a verbal or phone order,…verbal or phone order,…

Ask for a READ BACK from the receiver of the order.

Listen carefully and verbally confirm that your order has been correctly understood.

Do not hang up until you are sure.

What is medication reconciliation?What is medication reconciliation?

Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking.

This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, MD or level of care.

How is medication How is medication reconciliation done?reconciliation done?

1. Use the Drug Database Form.2. Nurse asks patient to list all meds taken before

admission.3. AP compares this list with the drugs ordered.4. AP decides which medications will be continued

and which will be stopped.5. AP re-writes orders if needed.6. AP communicates the new list to appropriate

caregivers and to the patient.

When is medication reconciliation done? Some examples

1. On admission2. After a surgical or high risk diagnostic procedure3. Transfer to or from the ICU or another unit4. Every 7th hospital day5. Every 3rd hospital day for patients with more

than 3 MDs6. After change of AP or RIC7. After resuscitation8. Before discharge from hospital

An example of medication reconciliation

AP lists and compares drugs to determine which will be continued, replaced or stopped.

Drugs before admission:

Metoprolol

Glibenclamide

Aspirin

Calcium

Senokot

Drugs during confinement:

Telmisartan

Insulin

Aspirin

Calcium

Drugs on discharge:

Telmisartan

Glibenclamide

Aspirin

Calcium

Senokot

Why do medication reconciliation?Why do medication reconciliation?

More than half of serious medication errors in the JCI database are due to breakdowns in communication that could have been avoided through effective medication reconciliation.

Numerous reports of errors due to failure in medication reconciliation have been received by the Institute for Safe Medication Practices (ISMP) since 2005 and by the United States Pharmacopeia (USP) since 2004.

High risk medication monitoringHigh risk medication monitoring

High risk drugs are those that have potent cardiovascular, neurologic or metabolic effects. Some of these drugs have narrow margins of safety so that minor medication errors can have catastrophic consequences. The JCI database maintains a list of high risk drugs.

The Medical City Drugwatch ListThe Medical City Drugwatch List

All staff must be careful in using these drugs and report any ADVERSE EVENTS involving them.

1. Insulin2. KCl3. MgSO44. Ca gluconate5. NaHCO36. Lidocaine7. Dopamine8. Dobutamine9. Heparin 10. Coumadin

How to prescribe and How to prescribe and administer high risk drugs safelyadminister high risk drugs safely

Write complete orders legibly. Limit the number of doses to a minimum. Reconcile with other drugs. Have the head nurse check the drug to be

administered. Have the clinical pharmacist review the drug

order. Monitor patient status after every

administration.

What are adverse drug events What are adverse drug events (ADEs)? (ADEs)?

Any unexpected, unintended, undesired, or excessive response following drug administration that results in 1 of the following:

A.    Stopping or changing drug

B.    Changing drug dose

C.    Admission (for ambulatory patients) or prolonged length of stay (for inpatients)

D.    Starting supportive treatment

E.    Complicated diagnosis or bad prognosis

F.    Temporary or permanent harm, disability, or death

G. Therapeutic failure.

Institute of Medicine, National Academy Press, 2000Lazarou J et al. JAMA 1998;279(15):1200–1205Gurwitz JH et al. Am J Med 2000;109(2):87–94

Why ReportWhy ReportAdverse Drug Events (ADEs)?Adverse Drug Events (ADEs)?

Because YOUR patients may be the next victim Over 2 MILLION serious ADEs yearly 100,000 DEATHS yearly ADEs 4th leading cause of death ahead of lung

disease, diabetes, AIDS, pneumonia, accidents and automobile deaths

Ambulatory patients ADE rate — unknown Nursing home patients ADE rate —

350,000 yearly

Johnson JA et al. Arch Intern Med 1995;155(18):1949–1956Leape LL et al. N Engl J Med 1991;324(6):377–384Classen DC et al. JAMA 1997;277(4):301–306

Costs Associated with ADEsCosts Associated with ADEs

$136 BILLION yearlyGreater than total costs of

cardiovascular or diabetic care ADEs cause 1 out of 5 injuries or

deaths per year to hospitalized patientsMean length of stay, cost and mortality

for ADE patients are DOUBLE that for control patients

Schappert SM. Nat. Center Health Statistics. 1999, Series 13 No. 143National Association of Chain Drug Stores. 2001Jacubeit T et al. Agents Actions Suppl 1990;29:117–125

Why Are There So Many ADEs?Why Are There So Many ADEs?

Two-thirds of patient visits result ina prescription

2.8 BILLION outpatient prescriptions(10 per person in the United States) filled in 2000

ADEs increase exponentially with4 or more medications

Friedman MA et al. JAMA 1999; 281(18):1728–1734

New drugs approved by FDA / BFAD New drugs approved by FDA / BFAD are safe, right? Wrong!are safe, right? Wrong!

Most drugs approved by FDA with average of 1500 patient exposures

Some drugs have rare toxicity profiles (bromfenac hepatotoxicity 1 in 20,000 patients)

For drugs with rare toxicity, more than 100,000 patients must be exposed to generate a signal i.e. after drug is marketed

Figueiras A et al. Med Care 1999;37(8):809–814Eland I A et al. Br J Clin Pharmacol 1999;48(4):623–627Chyka PA et al. Drug Saf 2000;23(1):87–93

Myths about ADE ReportingMyths about ADE Reporting

All serious ADEs are documented by the time a drug is marketed, right?

It is difficult to determine if a drug is responsible, right?

ADEs should only be reported if absolutely certain, right?

One reported case can’t make a difference, right?

Liver diseaseRenal disease Cardiac disease ( hepatic blood flow)Acute myocardial infarction?Acute viral infection?Hypothyroidism or hyperthyroidism?

Drug-Disease InteractionsDrug-Disease Interactions

Drug-Food InteractionsDrug-Food Interactions

Tetracycline and milk productsWarfarin and vitamin K-containing foodsGrapefruit juice

Interactions Before AdministrationInteractions Before Administration

Phenytoin precipitates in dextrose solutions (e.g. D5W)

Amphotericin precipitates in salineGentamicin is physically/chemically

incompatible with most beta-lactams, resulting in loss of antibiotic effect

Interaction with the GI TractInteraction with the GI Tract

Sucralfate, some milk products, antacids, and oral iron preparations

Omeprazole, lansoprazole,H2-antagonists

Didanosine (givenas a buffered tablet)

Cholestyramine

Block absorptionof quinolones, tetracycline, and azithromycin

Reduce absorptionof ketoconazole, delavirdine

Reduces ketoconazole absorption

Binds raloxifene,thyroid hormone, and digoxin

Spectrum of Consequences Spectrum of Consequences of Drug Metabolismof Drug Metabolism

Inactive productsActive metabolitesSimilar to parent drugMore active than parentNew action Toxic metabolites

You must report suspected ADEsYou must report suspected ADEs

ADEs may or may not be related or caused by drug intake and this may be difficult to determine.

The important thing is to alert The Medical City that a patient on a particular set of drugs has experienced an adverse event so that appropriate preventive actions can be carried out.

What should you do if you What should you do if you suspect an ADE?suspect an ADE?1. Stop the medication immediately.

2. Fill out the ADE Reporting Form and hand it over to the Clinical Pharmacist. Reporting may be done anonymously.

3. Coordinate with the Clinical Pharmacist in managing the patient’s ADE.

How will your report be How will your report be handled? handled?

ADE reports are monitored and analyzed by the Therapeutics Committee.

ADE reports provide the basis for drug alerts to the hospital staff.

ADE reports are also sent to the manufacturer and/or BFAD.

Are you a safe medication Are you a safe medication practitioner?practitioner?1. Which of the following are in the Medical City Drugwatch list?

a. Potassium chlorideb. Insulinc. Magnesium sulfated. All of the aboveAnswer: ?D

2. Which of the following practice/s promote/s medication safety?a. Writing orders and prescriptions legiblyb. Insisting that the pharmacy stock up your brand of antibioticc. Arranging drugs alphabetically by brand names d. All of the aboveAnswer: ?A. Choices b and c lead to mixing up sound-alike drugs.

Are you a safe medication Are you a safe medication practitioner?practitioner?3. Which of the following will lead you to report a possible ADR?

a. The drug needed to be stopped or changed. b. A significant dose modification is required. c. The patient suffered temporary or permanent harm.d. All of the aboveAnswer: ?D

4. When reporting a possible ADRa. You must be absolutely sure that it was caused by a drug.b. You must always sign the report with your name.c. You must immediately file the report while patient is confined.d. all of the aboveAnswer:? C. You don’t have to be sure of drug causation and you can file the report anonymously.

Are you a safe medication Are you a safe medication practitioner?practitioner?5. Which of the following is an inexpensive but effective intervention to help the

pharmacist screen for medication errors?a. Write the side effects on the prescriptionb. Write the drug indication on the prescriptionc. Avoid the forbidden abbreviations.d. all of the aboveAnswer: ?B

6. Which among the following is a/are good way/s to prevent ADRs?a. Have nurses read back orders to MDsb. Reprimand nurses who make erroneous computations.c. Suspend residents who write illegibly.d. all of the aboveAnswer: ?A

Are you a safe medication Are you a safe medication practitioner?practitioner?7. Which strategy is the LEAST effective way for preventing ADEs?

a. Physical (Forcing Functions)b. Natural (Distance, Time)c. Information (Labels, Signs)d. Administrative (Checklists, Policies)Answer: ?D. Forcing functions are the most effective. Policies can be broken.

8. The following is/are reason/s why elderly are more prone to ADEs:a. Old people have trouble remembering their drugs.b. Old people have poor liver and kidney drug handling capacities. c. Old people have lower fat deposits in which drugs are stored.d. All of the aboveAnswer: ?D

Are you a safe medication Are you a safe medication practitioner?practitioner?

8 out of 8 – your patients are safe from medication errors!6 or 7 out of 8 – your patients safety level is above average4 or 5 out of 8 – your patients safety level is just about

barely adequate2 or 3 out of 8 – you can improve the safety of your

medication practice!*0 or 1 out of 8 – let us try again; meanwhile try to keep your

medication use on patients to the bare minimum!** Please go over the slides again.

Summary of this presentationSummary of this presentation

Our ability to ensure the safe use of medications can spell the difference between health and illness, even life and death, for many patients.

Our staff have critical roles to play in promoting medication safety

We must report, monitor and prevent adverse drug reactions to spare our patients from further harm.

This SIM Card certifies This SIM Card certifies thatthat

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has successfully has successfully completed the completed the

Self Instructional Module Self Instructional Module on Medication on Medication

Management and UseManagement and Use

(Sgd) Dr Alfredo Bengzon (Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose Acuin(Sgd) Dr Jose AcuinPresident and CEOPresident and CEO Director, Medical Quality ImprovementDirector, Medical Quality Improvement