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MEDICATION SAFETY Meeting HFAP Accreditation Standards for Pharmacy Services and Medication Use Part One MEDICATION SAFETY Meeting HFAP Accreditation Standards for Pharmacy Services and Medication Use Part One

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

Medication Safety Series 1. 2. 3. 4. 5. Prescribing challenges Procurement in an era Medication Safety Series 1. 2. 3. 4. 5. Prescribing challenges Procurement in an era of drug shortages – keeping it safe Preparation and dispensing – includes sterile preparation Administration of medications – timing, unit dose, bedside medication verification Monitoring of therapy, Medication Use Evaluations

Prescribing Challenges Objectives n n n Describe the optimal environment for safe prescribing List Prescribing Challenges Objectives n n n 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 n n The Institute of Medicine Report revealed that errors in medical The Problem n n The Institute of Medicine Report revealed that errors in medical care 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? n n n Physicians Nurses Pharmacists Respiratory Therapists Patients The Who are the participants? n n n Physicians Nurses Pharmacists Respiratory Therapists Patients The casual observers who can alert the care providers about opportunities for errors

RESPONSIBILITIES RESPONSIBILITIES

Regulatory Standards n n HFAP – Chapter 25 CMS Conditions of Participation 482. 25 Regulatory Standards n n HFAP – Chapter 25 CMS Conditions of Participation 482. 25

The Medication Use Process Components n n n Prescribing Procurement Preparation Dispensing Administration Monitoring The Medication Use Process Components n n n Prescribing Procurement Preparation Dispensing Administration Monitoring

Where Do Errors Occur? Prescribing Transcribing Dispensing Administering 39% 11% 12% 38% Where Do Errors Occur? Prescribing Transcribing Dispensing Administering 39% 11% 12% 38%

PRESCRIBING 25. 01. 12, 25. 01. 13 n n Is a collaborative effort There PRESCRIBING 25. 01. 12, 25. 01. 13 n n 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 n Physician (and other prescribers) responsibilities: – Diagnosis – Drug and dosing choices PRESCRIBING n Physician (and other prescribers) responsibilities: – Diagnosis – Drug and dosing choices – Medication reconciliation n 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 n n 1980: medical school Training, Memory and Best Efforts As Safety System Tools n n 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 Medications Potential DDIs 2 1 Training, Memory and Best Efforts As Safety System Tools Medications Potential DDIs 2 1 4 6 8 28 16 120 DDI = drug-drug interaction Karas S. Ann Emerg Med 1981; 10: 627 -630

HIGH ALERT MEDICATIONS 25. 01, 25. 01. 20 n n n Adrenergic agonists Intravenous HIGH ALERT MEDICATIONS 25. 01, 25. 01. 20 n n n Adrenergic agonists Intravenous adrenergic antagonists Amiodarone/Amrinone Benzodiazepines (especially midazolam) Intravenous calcium Chemotherapeutic agents

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

Medication Prescribing Process Components: Communication n n n Written Prescription Orders Medication Ordering Systems Medication Prescribing Process Components: Communication n n n 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 n n n 16% of physicians have illegible handwriting. Written Medication Orders: Illegible Handwriting n n n 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 n n Prescribers’ Obligation Write/Print More Carefully Computers Verbal Communications Illegible Handwriting: Error Prevention n n Prescribers’ Obligation Write/Print More Carefully Computers Verbal Communications

Written Medication Orders: Complete Information n n n n Patient’s Name Patient-Specific Data Generic Written Medication Orders: Complete Information n n n n 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. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8. 1 -8. 23.

Written Medication Orders: Patient-Specific Information n n n n Age Weight Renal and Hepatic Written Medication Orders: Patient-Specific Information n n n n 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 n n n n n Drug names Written Medication Orders: Do Not Use Abbreviations n n n n n 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 n Avoid whenever possible 1 – Use 500 mg for Written Medication Orders: Decimals n Avoid whenever possible 1 – Use 500 mg for 0. 5 g – Use 125 mcg for 0. 125 mg n Never leave a decimal point “naked” 1, 2, 3 – Haldol. 5 mg Haldol 0. 5 mg n Never use a terminal zero – -Colchicine 1 mg not 1. 0 mg n Space between name and dose 1, 3 – Inderal 40 mg 1. 2. 3. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8. 18. 23. Jones EH. Clev Clin J Med 1997; 64: 355 -9. Cohen MR. Am Pharm 1992; NS 32; 32 -3.

Written Medication Orders: Drug Names n n n “Look-Alike” or “Sound-Alike” Drug Names “Confirmation Written Medication Orders: Drug Names n n n “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; NS 32: 21 -2.

Look-alike And Sound-alike Drug Names Accupril® Accutane® Alprazolam Lorazepam Cardene® Cardura® Flomax® Fosamax® Lamisil® Look-alike And Sound-alike Drug Names Accupril® Accutane® Alprazolam Lorazepam Cardene® Cardura® Flomax® Fosamax® Lamisil® Lomotil® Nizoral® Neoral® Plendil® Prilosec® Zantac® Zyrtec® USP Quality Review. www. usp. org/reporting/review/qr 66. pdf accessed on February 6, 2001.

Medication Prescribing Process: Computerized Prescriber Order Entry (CPOE) – Computer with 3 Interacting Databases 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) n n Provides Decision Support Warns of Drug Interactions Computerized Physician Order Entry (CPOE) n n Provides Decision Support Warns of Drug Interactions – Drug-Drug – Drug-Allergy – Drug-Food n n n Checks Dosing Reduces Transcription Error Reduces number of lost orders Reduces duplicative diagnostic testing Recommends cost effective, therapeutic alternatives

CPOE Advantages Automate ordering process n Reduces Order Errors n – Standardized, legible complete CPOE Advantages Automate ordering process n Reduces Order Errors n – Standardized, legible complete orders – Alerts n Data collected on variances in practice

Improved Quality n n CPOE allows for physician reminders of best practice or evidence-based Improved Quality n n 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 prophylaxis 18. 9% 32%

CPOE Disadvantages n n Errors still possible Alerts Multiple steps Access CPOE Disadvantages n n Errors still possible Alerts Multiple steps Access

Dosage Calculations n n Recognized cause of medication errors Use patient-specific information – height Dosage Calculations n n 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 n n Avoid calculations Cross-checking Cohen MR. Medication Errors. Causes, Dosage Calculations: Error Prevention n n 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 n Avoid when possible Enunciate slowly and distinctly State numbers Verbal Orders: Error Prevention n Avoid when possible Enunciate slowly and distinctly State numbers like pilots (i. e. , “one-five mg” for 15 mg) n n Spell out difficult drug names Specify concentrations Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8. 1 -8. 23.

Conflict Resolution n n Communication is essential No one is right all the time Conflict Resolution n n 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 n Educate patients about their medications Purpose of each medication Name of Patient Education n Educate patients about their medications Purpose of each medication Name of drug, dose, how to take, etc. n Provide patients with understandable written instructions n Lack of involving patients in check systems Inform patients about potential for error with drugs known to be problematic n

PRESCRIBING REVIEW n n Right indication Right drug choice Correct dosage Absence of contraindications PRESCRIBING REVIEW n n Right indication Right drug choice Correct dosage Absence of contraindications – Allergies – Drug interactions (food, other drugs) – Pregnancy and lactation

HIGH ALERT MEDICATIONS n n n n Insulin Lidocaine Intravenous magnesium sulfate Opiate narcotics HIGH ALERT MEDICATIONS n n n n Insulin Lidocaine Intravenous magnesium sulfate Opiate narcotics Neuromuscular blocking agents Intravenous potassium Intravenous sodium chloride (high concentration)

PROBLEMS n n n n Lack of knowledge of proper dose Outdated information Illegible PROBLEMS n n n n 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 n n Ordering a total course of therapy instead of daily doses Lack PROBLEMS n n 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 n n n Clear handwriting (Print) Avoid abbreviations when errors could occur Prescriber SOLUTIONS n n n Clear handwriting (Print) Avoid abbreviations when errors could occur Prescriber order entry Avoid verbal orders Double check doses Review cases of polypharmacy

SUMMARY n n Prescribing inappropriately can result in serious medication errors. Major advances have SUMMARY n n 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 n n Medication procurement in an era of medication shortages Compounding pharmacies NEXT SESSION n n Medication procurement in an era of medication shortages Compounding pharmacies – friend or foe?