Medication Safety: An Overview
Medication Management Safety Team Medication Management Safety Team April 2015
L Learning Objectives i Obj ti By the end of this education module you should be able to By the end of this education module you should be able to understand and define: 1. The need for medication safety 2. The types of medication related events (adverse events, close calls, near misses)
3 Your role in medication safety, as a health care professional 3. Your role in medication safety as a health care professional (RLS reporting)
Medication errors kills 460 patients every week in Canada Would you fly if the airline industry had these statistics ?
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St ti ti Sh : Statistics Show
24% of MEDICATION ERRORS ARE PREVENTABLE
CANADIAN CANADIAN 37% adverse events INCLUDING MEDICATION highly preventable
Medical errors 9,000 ‐24,000 DIE every year from adverse events
1:9 adults will potentially be given the wrong th medication
Adverse events occurred in 7.5% of admissions to acute care hospitals
Canadian Statistics for Medication Related Errors
A hospital patient can expect to be subjected to more than ONE to more than ONE medication ERROR every day
4% of inpatients experiencing medication experiencing medication errors are related to dispensing or administration d i i t ti Up to 51% of adverse Up to 51% of adverse events are preventable
Research Shows That: A high number of Canadians have been seriously injured or conditions have worsen because of medication related incidents medication related incidents Errors involving the use of medications make up the largest single cause of medical errors in hospitals. largest single cause of medical errors in hospitals. Medication related incidents are often a symptom of system failure and can occur at any stage in the y y g medication management pathway ‐ most commonly in the prescribing, transcribing, dispensing, and administration. administration
Medication Related Events Important definitions to help understand Medication Related Events: a) Medication Error Medication Error b) Adverse Events (AE) c) Close Calls/ Near Misses/ Good Catches
Medication Error
Refers to any preventable event that may cause or lead to inappropriate medication use or patient harm
Medications may be in the control of the healthcare professional, the patient/customer, or the family/caregiver Examples: • A patient was taken to the Emergency after forgetting to take her scheduled afternoon dose of blood thinners. • A patient died because a dose of 20 units of insulin was abbreviated as “20 U,” but the “U” was mistaken for a “zero.” As a result, a dose of 200 units of insulin was accidently i j t d injected.
Adverse Events (AE)
Refers to an unanticipated/unplanned event that reaches Refers to an unanticipated/unplanned event that reaches the patient/resident
Results in no harm or undesired harm (minimal to severe) ( ) or death
Adverse events also includes allergic drug reactions Example: • A Nurse intending to grab ephedrine 5mg vial from the epidural, inadvertently grabbed and administered epinephrine 5mg to the patient. The patient experienced severe vomiting and blurred vision as a result of the mix‐up.
Close Call/ Near Miss/ Good Catch:
Refers to an event that could have caused harm, but was R f h ld h dh b prevented from reaching the patient. Examples: • An incorrect medication was identified prior to administration to the patient by a nurse. If the incorrect medication was administered, it may have resulted in patient death. • Penicillin was ordered for a patient allergic to the drug; however, the Pharmacist was alerted of the allergy during computer order entry The Prescriber was called and the computer order entry. The Prescriber was called and the penicillin was not dispensed or administered to the patient.
Why do Medication Errors Occur? There are several contributing factors There are several contributing factors o Medication errors are often due to the convergence of multiple contributing errors
The medication use process is a complex system o Includes both human and system factors
System failures not fully addressed Humans are fallible and human error is inevitable Humans are fallible and human error is inevitable Medication safety is a multidisciplinary and multi‐factorial approach h
Factors that may contribute to errors in the medication use process: • Rushing/ doing two things at once • Interruptions, poor lighting , no dedicated medication room high levels of noise and traffic high levels of noise and traffic • Fatigue, boredom, being on “automatic pilot” leading to f il failure to check and double‐ t h k d d bl check • Lack of checking and double checking habits
• Poor teamwork and/or communication between colleagues • Reluctance to follow policy and procedures policy and procedures and effective handovers • Motivation • Stress • Inexperience
System Errors: System Errors: Swiss Cheese Model of error causality The system
The patient The nurse and physician team
Modified from Reason 1991
Medication Safety Is… A Covenant Health strategic priority and commitment for patient and resident safety A process of incorporating error reduction strategies in the medication use process. W We need to make our systems safer, to protect our patients d k f i and our staff.
Everyone’s Everyone s responsibility to ensure safe medication responsibility to ensure safe medication practices
Why focus on Medication Safety? Reduce or minimize the possibility of error o Differentiate medications using typographic strategies (Tallman lettering) o Labelling of High Alert Medications (done by pharmacy to ensure a standardized approach) o Standardized medication concentrations ( e.g. Insulin) St d di d di ti t ti ( I li )
Make errors visible o Independent double checks Independent double checks o Barcode technology o “Expect to Check” posters
Minimize the consequences of medication errors o o o o
Reduce availability of certain products on units. E.g. High alert medications Monitor patients effects to identify errors Promote patient education by informing patient of Promote staff education and staff training
How do we focus on Medication Safety?
Standardized Medication Concentrations
Narcotics i Safety
Medication Reconciliation
High Alert Medication Safety Strategies
Medication Management g
Concentrated Electrolytes Safety
Heparin Safety
Antimicrobial Stewardship
Others?
Error Reduction Strategies Strategies to mitigate medication errors rely critically on the collection of error data/information on individual events (i.e. reporting of errors) C Covenant Health utilizes error reporting data/information H l h ili i d /i f i collection to: o Identify root causes of medication errors; o Allow trends related to medication errors to be tracked; o Identify system based issues/concerns that contribute to medication related occurrences; o Develop evaluation strategies to improve medication safety o Increase awareness of medication safety to health care professionals o Mitigate the likelihood of future medication related occurrences
D t Data reporting utilized by Covenant Health ti tili d b C t H lth Internal data collection and review of external data is key to y developing mitigating medication error strategies o Example: RLS data collected showed that the majority of medication related errors were attributed to insulin products ( wrong type of related errors were attributed to insulin products ( wrong type of insulin, wrong amount, etc…)
Several Several risk reduction strategies were developed as a result of risk reduction strategies were developed as a result of the data collection o Example: High Alert Medication suite of policy and procedures; Provincial Standardized Storage and Labelling Policy and Procedure; Provincial Standardized Storage and Labelling Policy and Procedure; annual audit for compliance to prohibited abbreviations, Tall Man lettering, etc.
D t Data reporting utilized by Covenant Health ti tili d b C t H lth Covenant health collects medication error data through the following : Internal Data o Reporting and Learning System (RLS) ‐ the organizations error reporting tool reports give details of each incident and reporting tool, reports give details of each incident and assigns a degree of severity o Data published from Accreditation Canada o Pharmacy Good Catch reporting system Pharmacy Good Catch reporting system o Event reviews and Root Cause Analysis External External Data: Data: o AHS medication reports from RLS are reviewed for trends o Institute of Safe Medication Practices (ISMP) reviews national and global data and global data
Covenant Health’s C t H lth’ Reporting and Learning System (RLS) Oct 1/13 – Sep 30/14 Oct 1/13 – Sep 30/14
RLS has revealed the Top 4 Reasons for Medication Errors in the past year (in order of frequency): past year (in order of frequency):
Wrong time Wrong time Wrong dose/strength Wrong drug Wrong patient Wrong patient
Your feedback in RLS matters!! Reporting any medication errors in RLS is important and will help the organization d l develop risk reduction strategies to help k d h l make our system safer for our patients.
RLS Reporting RLS Reporting You can access RLS to submit a report of a medication error p (adverse event and/or good catch, close call) through: o CompassionNet: http://www.compassionnet.ca/Page465.aspx p p // p / g p o InSite: http://insite.albertahealthservices.ca/1284.asp
Next slide shows an example of what the RLS report form looks like
RLS Report: Sample Form Sample Form