NQF Safe Practices – Review 2005Pharmacy Director Taskforce Summary Feedback Analysis

September 2005Texas Medical

Institute of Technology

Texas Medical Institute of Technology

Safe Practice #5: Pharmacists should actively participate in the medication-use process.

Feedback summaryThis safe practice has strong potential benefit; the fact that medical errors has such a national and public focus and the pressure to reduce incidents is so great there should be no impediments to this safe practice; pharmacists and the pharmacy profession should seek out all opportunities for involvement.

IMPACT:Tremendous opportunity for pharmacy profession if SP widely adopted. Universally accepted that the Rx brings value to patient careMany opportunities for improvement and positive impact (hundreds weekly in a large university type hospital)Limited resources available for complete adoption both technology and humanSupply of pharmacists can not meet the demandGreat opportunity for pharmacy as a profession to impact both patient care and reduced costs secondary to drug mishapsThreats: Poor acceptance by CEO/CFO and resistance from medical staff

ADOPTION:Largely adapted at university settings with clinical staff; adapted to a lesser degree in smaller hospitalsMany hospitals do a very good job with this but the extent of participation in all aspects of med use review varies widelyThere are number of areas in the hospital where compliance is still problematic—ER’s, clinic areas, etc. Level of adoption in non-24 hour pharmacies could be limited.Regulatory requirements and public pressure helpAdoption of this SP can have significant impact on reducing medication errors if implementing industry wideThreats: Shortage of pharmacists; and hospital leadership does not see the value of pharmacist intervention

Current citations related to this safe practice Must reads include: “Pharmacist participation on physician rounds and ADEs in the ICU” (L.Leape: JAMA); “The economic impact of clinical pharmacists unsolicited recommendation” (N. Torok: Hosp Pharm); and “An eleven-year reveiw of the pharmacy literature: documentation of the value and acceptance of clinical pharmacy” (H. Hatoum: Drug Intell Clin Pharm.) Review of 22 interim articles: 5 identified with strong support ratings and 5 new additional references provided

Suggested “re-write”:Possibly establish a minimum, satisfactory, and maximum level of implementationShould be expanded to offer clearer understanding of “medication-use process”

NQF Safe Practices – Review 2005Pharmacy Director Taskforce Summary Feedback Analysis

September 2005Texas Medical

Institute of Technology

Texas Medical Institute of Technology

Safe Practice #7 Use only standardized abbreviations and dose designations.

Feedback summaryThis safe practice has weak benefit; is only moderately ranked among other medication safety needs and should move in the direction of the current JCAHO standard that focuses on a Do Not Use List of abbreviations.

IMPACT:Impact can be great---if dose is 10 times what was intended to be given (with trailing zero problem or “u”)Frequent for abbreviations not on the JCAHO list of unapprovedAlthough illegible handwriting has often been associated with error, there are few reports of errors occurring with a number of the abbreviations that are often listed in this SP (e.g. qd, hs, etc)Opportunity: Needs to be a national list that is applicable to all healthcare settings; MUST be taught in medical, pharmacy, and nursing schools Expansion of CPOE and other data entry type modalities is a powerful method for controlling this.Threats: Seen by physicians and nurses as an inconvenience versus an opportunity to improve safety.Computer vendors are slow to respond to requests to eliminate abbreviations

ADOPTION:Largely as a result of JCAHO requirementsHuge educational and tracking commitment to determine successVery difficult to adopt!!! For most hospitals this will only be accomplished with CPOENew residents and medical students get no training in how to write ordersThreat: Time restraints force providers to take shortcuts including abbreviations

Current citations related to this safe practiceNO additional interim evidence found by TMIT3 additional articles submitted by reviewers

Potential Recommendations for Consideration:Very difficult to make an inclusively list of what abbreviations are acceptable; easier to take the JCAHO approach for clarity in defining what is not acceptable. However as stated above this is very difficult to enforce w/o CPOE.Move the SP towards a Do Not Use list as opposed to a Standardized ListProhibit the use of non-approved abbreviations: Refer over to USP abbreviations universally for medications

Potential Re-write of the Safe Practice:“Eliminate the use of error prone abbreviations”Measure: Create a Do Not Use List and enforce compliance

NQF Safe Practices – Review 2005Pharmacy Director Taskforce Summary Feedback Analysis

September 2005Texas Medical

Institute of Technology

Texas Medical Institute of Technology

Safe Practice #18: Utilize dedicated anti-thrombotic services that facilitate coordinated care management.

Feedback summaryThis safe practice has strong potential benefit; if reimbursement and resources are available; would need considerable effort to get this universally available.

IMPACT:Many patients would and have benefited from a pharmacist directed anti-coagulation clinic. Huge need for service if can justifyNewer pharmacologic entities may reduce need for monitoring if patient’s can afford the newer agentsDepending on 3rd party reimbursement practices may not be cost effectiveLack of integrated communication tools between PCP and clinicsOpportunities: Have Rx in community as well as hospitals who manage these patients for drug interactions, diet and labs.Increased internet technology access for pts and providersPotential 3rd party reimbursement for internet accessThreats: Newer drugs in the pipelinePoor reimbursement for services

ADOPTION:Most major hospital systems have adopted some level of providing an anticoagulant programWell documented positive outcomesRequires dedicated resources, which can be costly; there are real challenges for most hospital systems to follow patients after they have been discharged from the hospitalOpportunity: Medicare Part D may provide some incentivesThreat: Competing resources a barrier to implementation and justification

Current citations related to this safe practice Must read: “Antithrombotic therapy in children: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. (Chest). Review of 7 interim articles: 2 identified with strong support ratings

Potential Recommendations for Consideration:Reviewers had mixed opinions as to whether or not this SP should be combined with SP 17: DVT; some concerns it would dilute the effectiveness

Potential Measure:•Readmission rates for non-compliance with anti coagulation therapy; adverse drug events related to coumadin toxicity or bleeding associated with readmissions; DVT/PE rates in the community/region/nation

NQF Safe Practices – Review 2005Pharmacy Director Taskforce Summary Feedback Analysis

September 2005Texas Medical

Institute of Technology

Texas Medical Institute of Technology

Safe Practice #28: Standardize the methods of labeling, packaging, and storing medications.

Feedback summaryThis safe practice has strong potential benefit; but stronger focus needs to be on manufacturers to do a better job of naming and labeling; with frequent changes in brands stocked it negates the value of color coding of products and identification

IMPACT:Many look-alikes out on the marketRx does a good job of labelingLargely done in major hospital at this point, especially those with robotics; Smaller hospitals likely have much more limited programsMost packaging errors come from the look-alike nature common from generic drug manufactures; cost effective, but the same white package with black ink.Labeling by RN, anesthesia and others outside of the Rx is often problematicOpportunities: Bar coding should help with tracking Exp date, lt #’s etcName of drug and dose should always be printed on a colored field with white lettering to make these elements stand out.Threats: Bar codling has to be considered here as it will take up real estate on already crowded labels; multiple drug shortages force pharmacies to label if only bulk is available.

ADOPTION:Less well adapted for oral liquids in which unit doses are costly and take up valuable space (eg, antacids)Color coding can be very problematic. Identifying products by color codes, caps, vial size etc can cause errorsThreat: Manufacturers may decide to reduce UD packaging if bar coding proves too costly or unruly

Current citations related to this safe practice Must reads include: None so farReview of 1 interim articles: no ranking provided

Recommendations for Consideration:Purchase ready-to-use products so that they are labeled until the final point of administrationPurchase pre-made labels for use in such places as the operating room and anesthesiaHave pharmacy draw-to-dose all products to minimize the potential for a nurse to draw something into an unlabeled syringe.