MEDICATION SAFETY

Meeting HFAP Accreditation Standards for Pharmacy Services and Medication Use

Part One

HFAP Chapter 25 keeps you in compliance with the Medicare Conditions of Participation

Medication Safety Series

1. Prescribing challenges

2. Procurement in an era of drug shortages – keeping it safe

3. Preparation and dispensing – includes sterile preparation

4. Administration of medications – timing, unit dose, bedside medication verification

5. Monitoring of therapy, Medication Use Evaluations

Prescribing Challenges - Objectives Describe the optimal environment for

safe prescribing List the necessary tools for enhancing

the knowledge of medications Discuss the advantages and

disadvantages of computerized physician order entry (CPOE)

The Problem

The Institute of Medicine Report revealed that errors in medical care are responsible for many deaths

Many health care providers are not aware of their responsibilities

Medication errors responsible for numerous adverse outcomes, including death

This results in high cost (emotional and financial)

Who are the participants?

Physicians Nurses Pharmacists Respiratory Therapists Patients The casual observers who can alert the

care providers about opportunities for errors

RESPONSIBILITIES

Physicians Nurses Pharmacists Respiratory Therapists

Prescribing X X

Preparation X X X X

Dispensing X X X X

Administration X X X X

Monitoring X X X X

Regulatory Standards

HFAP – Chapter 25 CMS Conditions of Participation 482.25

The Medication Use Process Components Prescribing Procurement Preparation Dispensing Administration Monitoring

Where Do Errors Occur?

Prescribing 39%Transcribing 11%Dispensing 12%Administering 38%

Where Do Errors Occur?

Prescribing 39%Transcribing 11%Dispensing 12%Administering 38%

PRESCRIBING25.01.12, 25.01.13

Is a collaborative effort There is an increasing body of

knowledge– New therapeutic entities– Drug interactions– Allergies database– Food-drug interactions– Post-marketing data

PRESCRIBING Physician (and other prescribers)

responsibilities:– Diagnosis

– Drug and dosing choices

– Medication reconciliation Pharmacist responsibilities (25.01.15, 25.01.16)

– Drug information

– Protocol-based management of patient medications

– Review of physician orders

Training, Memory and Best Efforts As Safety System Tools

1980: medical school graduates needed to really know 60 drugs well

2000: this number was estimated at 600 drugs

2012: add another 100-200 drugs Drug-drug interactions increase

exponentially with these numbers

Training, Memory and Best Efforts As Safety System Tools

DDI = drug-drug interaction

Karas S. Ann Emerg Med 1981; 10:627-630

Medications Potential DDIs

2 11

4 66

8 2828

16 120120

HIGH ALERT MEDICATIONS25.01.01, 25.01.20

Adrenergic agonists Intravenous adrenergic antagonists Amiodarone/Amrinone Benzodiazepines (especially

midazolam) Intravenous calcium Chemotherapeutic agents

THE ABBREVIATION PROBLEM U ug q.d. qod SC TIW

Medication Prescribing ProcessComponents: Communication

Written Prescription Orders Medication Ordering Systems Electronic Order Transmission Dosage Calculations Verbal Orders Medication reconciliation

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Written Medication Orders: Illegible Handwriting 16% of physicians have illegible handwriting.1 Common cause of prescribing errors.2, 3, 4 Delays medication administration.5

Interrupts workflow. 5

Prevalent and expensive claim in malpractice cases.3

1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8; 3. Cabral JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm 1993; 50: 305-14; 5. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Illegible Handwriting: Error Prevention Prescribers’ Obligation Write/Print More Carefully Computers Verbal Communications

Written Medication Orders: Complete Information Patient’s Name Patient-Specific Data Generic and Brand Name Drug Strength Dosage Form Amount Directions for Use Purpose Refills

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Written Medication Orders: Patient-Specific Information Age Weight Renal and Hepatic Function Concurrent Disease States Laboratory Test Results Concurrent Medications Allergies Medical/Surgical/Family History Pregnancy/Lactation Status

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Written Medication Orders: Do Not Use Abbreviations Drug names “QD” or “OD” for the word daily Letter “U” for unit “µg” for microgram (use mcg) “QOD” for every other day “sc” or “sq” for subcutaneous “a/” or “&” for and “cc” for cubic centimeter “D/C” for discontinue or discharge

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. Jones EH. Clev Clin J Med 1997; 64: 355-9.

Written Medication Orders: Decimals Avoid whenever possible1

– Use 500 mg for 0.5 g– Use 125 mcg for 0.125 mg

Never leave a decimal point “naked” 1, 2, 3

– Haldol .5 mg Haldol 0.5 mg

Never use a terminal zero– -Colchicine 1 mg not 1.0 mg

Space between name and dose1,3

– Inderal40 mg Inderal 40 mg

1. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

2. Jones EH. Clev Clin J Med 1997; 64: 355-9.3. Cohen MR. Am Pharm 1992; NS32; 32-3.

Written Medication Orders: Drug Names

“Look-Alike” or “Sound-Alike” Drug Names

“Confirmation Bias” Addition of Suffixes

– Example Adalat CC 30 mg vs. Adalat 30 mg

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.Cohen MR. Am Pharm 1992; NS32: 21-2.

Look-alike And Sound-alike Drug Names

USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.

Zyrtec®Zantac®

Prilosec®Plendil®

Neoral®Nizoral®

Lomotil®Lamisil®

Fosamax®Flomax®

Cardura®Cardene®

LorazepamAlprazolam

Accutane®Accupril®

Medication Prescribing Process: Computerized Prescriber Order Entry (CPOE)

– Computer with 3 Interacting Databases• Drug History• Drug Information/Guidelines Database• Patient-Specific Information

– Avoids• Illegible Prescriptions or orders• Improper Terminology• Ambiguous Orders• Incomplete Information

Schiff GD. JAMA 1998; 279: 1024-9.

Computerized Physician Order Entry (CPOE)

Provides Decision Support Warns of Drug Interactions

– Drug-Drug– Drug-Allergy– Drug-Food

Checks Dosing Reduces Transcription Error Reduces number of lost orders Reduces duplicative diagnostic testing Recommends cost effective, therapeutic

alternatives

CPOE Advantages

Automate ordering process Reduces Order Errors

– Standardized, legible complete orders

– Alerts Data collected on variances in practice

Improved Quality

CPOE allows for physician reminders of best practice or evidence-based guidelines

Indiana University study– Pneumococcal vaccine in eligible patients

0.8% 36.0%

– Heparin prophylaxis18.9% 32%

CPOE Disadvantages

Errors still possible Alerts Multiple steps Access

Dosage Calculations

Recognized cause of medication errors Use patient-specific information

– height– weight – age– body system function

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Dosage Calculations: Error Prevention

Avoid calculations Cross-checking

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. ISMP Medication Safety Alert 1996; 1 (15).

Verbal Orders: Error Prevention Avoid when possible Enunciate slowly and distinctly State numbers like pilots

(i.e., “one-five mg” for 15 mg) Spell out difficult drug names Specify concentrations

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Conflict Resolution

Communication is essential No one is right all the time Take the time to listen Beware of instilling an atmosphere of

fear Interdisciplinary collaboration

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Patient Education

Educate patients about their medications Purpose of each medication Name of drug, dose, how to take, etc. Provide patients with understandable written

instructions Lack of involving patients in check systems Inform patients about potential for error with

drugs known to be problematic

PRESCRIBING REVIEW

Right indication Right drug choice Correct dosage Absence of contraindications

– Allergies– Drug interactions (food, other drugs)– Pregnancy and lactation

HIGH ALERT MEDICATIONS

Insulin Lidocaine Intravenous magnesium sulfate Opiate narcotics Neuromuscular blocking agents Intravenous potassium Intravenous sodium chloride (high

concentration)

PROBLEMS

Lack of knowledge of proper dose Outdated information Illegible handwriting Incomplete orders Use of the apothecary system Order on the wrong chart Nameless prescription

PROBLEMS

Ordering a total course of therapy instead of daily doses

Lack of knowledge about proper routes of administration

Ability to bypass controls in automated systems

Verbal orders poorly communicated

SOLUTIONS

Clear handwriting (Print) Avoid abbreviations when errors could

occur Prescriber order entry Avoid verbal orders Double check doses Review cases of polypharmacy

SUMMARY

Prescribing inappropriately can result in serious medication errors.

Major advances have been made in improving prescribing safety

Technology is our friend Interdisciplinary interactions go a long

way toward preventing errors

NEXT SESSION

Medication procurement in an era of medication shortages

Compounding pharmacies – friend or foe?