Medication Error Reduction Strategies Afshan A. Ali, MD Jonathan Jacques Children’s Cancer Center Miller Children’s Hospital & Long beach Memorial Medical Center & Children’s Cancer Alliance

Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Error Reduction Strategies

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Background Process review CPOE Guidelines for Institutional Practice Discussion

Afshan A. Ali, MD: 4/25/09: ASPHO

Definition of Medication Error The committee on Data standards for patient safety defines an error as: • The failure of a planned action to be completed as intended (error of execution) • Use of a wrong plan to achieve an aim (error of planning) • Error may be an act of comission or omission Afshan A. Ali, MD: 4/25/09: ASPHO

Definition of Medication Error • The error may occur any time in the medication-use process – Wrong dosage prescribed – wrong dosage administered – Failure to give (by provider) – Failure to take (by patient) a medication

Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Errors 1991 Harvard Medical Practice Study – Adverse event rate of 3.76% – Medical errors was 19.4% of all adverse events

1995, Adverse Drug Event (ADE) prevention study -ADE rate 6.5 per 100 admissions -28% were determined to be preventable -For every preventable ADE, 3 times as many potential ADE’s or near misses

Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Errors 1999--To err is Human, Institute of Medicine (IOM) -44,000 to 98,000 patients died annually as a result of errors -1,000,000 patients or more injured annually

2004 Health Grades Incorporated -reviewed 37 million patient records between 2000 and 2002 -Determined that as many as 195,000 people in the U.S. died as a result of potentially avoidable medical errors

Afshan A. Ali, MD: 4/25/09: ASPHO

United States Pharmacopeia (USP) MEDMARX • Voluntary med error reporting 5 yr analysis • 235,000 med errors in 2003 in the U.S. • 2% significant harm to patient including death • No improvement in safety outcomes even five years from Institute of Medicine report of 1999 Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Errors & Cost • Institute of Medicine (IOM) formed a committee to look at costs associated with med errors – ALOS increase due to complications is 4.6 days – $5,857 (adjusted for 2006 is $8750) – Conservative estimate of 400,000 preventable ADE’s per year, translated to $3.5 billion annually Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Errors & Public • General public is aware and there is growing concern 2002 : Survey by the American society of Health-system pharmacists – 85% of Americans are concerned about at least one medication related issues such as: – wrong medication, being given – 2 or more meds that negatively interact – Cost of prescriptions – Potential harmful side effects Afshan A. Ali, MD: 4/25/09: ASPHO

Medication errors lead to Adverse Drug Events Afshan A. Ali, MD: 4/25/09: ASPHO

ADE • Adverse drug event (ADE) results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient

Afshan A. Ali, MD: 4/25/09: ASPHO

Preventable and Non Preventable ADE’s • Potential ADE or near miss is a medication error that has the potential to cause harm but does not because • It is intercepted • The patient is just lucky

• Preventable: allergic to amox and develops anaphylaxis because given the med • A non preventable ADE: amox given and patient develops diarrhea or rash as a side effect of the drug Afshan A. Ali, MD: 4/25/09: ASPHO

ADE Prevention Study • 1995, Inpatient settings • In 264 preventable events – 49% occurred at the ordering stage – 26% during administration – 11% at the transcription stage – 14 % during dispensing process

Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Safety (crit care clin 22 (2006) 273-290)

• Ordering/prescribing: most errors in hospitalized patients • Transcribing/documenting • Dispensing: failure in drug identity, checking, & stocking/delivery problems • Administering • monitoring

Afshan A. Ali, MD: 4/25/09: ASPHO

Methods of Medication Error Detection (crit care clin 22 (2006) 273-290)

• Submission of voluntary or solicited incidence reports • Direct observation of the medication processes, drug, dose, route and time administered compared with the original order • Direct chart/medical administration record review; multiple factors reviewed (labs, patient response, staffing, etc) Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Errors • Common Challenges: – Poor handwriting – Abbreviations of medication/trade names – Unclear verbal medication orders – Memory lapses – Large volumes of medication • (Schulmeister L-Clin J Oncol Nurs-01-02-2006; 10(1):35-41)

Afshan A. Ali, MD: 4/25/09: ASPHO

Medication Errors Institute for safe medical practices (www.ismp.org) Look-alike drug names • vancomycin 1.5 g IV every 12 hours was prescribed for a patient, pharmacist couldn’t read writing, dispensed vecuronium

Unsafe storage Unlabeled Syringes Look-alike packaging • Pancuronium reconstituted with BCG vaccines instead of normal saline

Afshan A. Ali, MD: 4/25/09: ASPHO

Safe Practice Recommendation: • • • • • • • •

Limit access Segregate storage Warning labels Safeguard storage in the pharmacy Manufacturer warnings Standardize prescribing Computer reminders Redundancies Afshan A. Ali, MD: 4/25/09: ASPHO

Safe Practice Recommendation: • Supervision during initial administration • Drug verification • Prompt removal of discontinued products • Increase awareness

Afshan A. Ali, MD: 4/25/09: ASPHO

Computerized Physician Order Entry (CPOE) & Impact on Medication Errors

Afshan A. Ali, MD: 4/25/09: ASPHO

CPOE & ADE’s •

adverse drug events (ADEs) mostly occur at the stage of prescribing and ordering

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In one estimate, 64.4% of errors (including 43% of potentially harmful errors) were considered preventable by the use of CPOE

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CPOE demonstrate significant reductions in prescription errors and the need for pharmacist clarification

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To optimize CPOE implementation, a proactive, multidisciplinary method of anticipating problems should be used Afshan A. Ali, MD: 4/25/09: ASPHO

CPOE & ADE’s • • • • • • • • •

Improve legibility Reduce transcription errors Use standard names, catalogues, and dictionaries Link patient-specific data and information Provide evidence-based order sets Automate calculations Provide alerts and reminders Monitor for adherence to best practice Screen populations at risk

Afshan A. Ali, MD: 4/25/09: ASPHO

CPOE & ADE’s • Workflow changes may have unintended consequences on patient care • Unexpected post implementation errors • short-term increases in errors during deployment • Unanticipated responses to interfaces (such as increased orders for laboratory tests) • Creation of new error types • CPOE also changes communication patterns with remote ordering by prescriber Afshan A. Ali, MD: 4/25/09: ASPHO

CPOE & ADE’s Evaluate incidence of errors present in electronic vs manual prescriptions (Huertas, Fernandez MJ-Cli Transl Oncol-01-NOV-2006; 8(11): 821-5)

Types of Errors evaluated: prescription, omission, commission, interpretation of dates, abbreviations, and illegible handwriting Results: At least 1 error in 100% of handwritten – 1 error in 13% of computerized prescriptions – Median error in computerized prescriptions: 0 (range 0-1) – Median error in handwritten prescriptions: 5 (range 1-12) (p