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Reducing the Risk of Medication Errors Related to
Electronic Medication Systems Update - July 18, 2014
Laura A. Finn, CGP, FASCP, RPh Finn Consultants
Adjunct Associate Professor of Pharmacy Practice
Philadelphia College of Pharmacy
l.finn@usciences.edu
Objectives: Identify ways prescribers can be alert to
systems-based sources of error in using electronic medication systems
Describe areas in medication reconciliation where electronic health records are prone to medication error risks
Develop an awareness for potential sources of medication errors in prescribing, processing and administering medication orders with electronic systems
Benefits and Expectations for Electronic Medication Systems
Standardization of electronic health record and transfer of information between care sites(allow for earlier treatment in emergency)
E-prescribing (elimination of pharmacists’ need to read illegible handwriting)
Prescribing alerts and warnings ◦ Decision support software (CDS – clinical decision support)
◦ CGPs at point of prescribing ◦ Allergy warnings ◦ Drug Interaction warnings
Quicker access to medication adherence data Reporting of adverse events Track infections, improve population health….
“Health IT and Patient Safety: Building Safer Systems for Better Care” IOM 2011
Greater oversight (government / private sector)
New technology learning curve = errors
Alert fatigue
Med Admin scanners vs “using eyes”
Software vendors:
Non-disclosure / Hold Harmless clauses
can’t share the screen with error-prone design
It will take more than technology to reduce medication errors.
Medication Safety
Expectation is that electronic prescribing, decision support software, medication order processing, administration, and monitoring will reduce medication errors.
Are we sure our Electronic systems do not contribute to medication errors and negative outcomes?
Incomplete use of “paperless systems”
Can mixed Paper / Electronic systems create gaps in information resulting in negative patient outcomes?
Scenario 1: Focus on Heart Failure-
Patient admitted to nursing home for Post-Acute Care
Post-Acute – Physician’s Orders reviewed and signed q 2 months
Electronic Medication list printed for MD review 5/18/14 and signed by MD 5/22/14.
Cardiology Apt 5/20/14 (discontinuation of furosemide)
Attending asked to see patient at request of nurse and family for “progressive edema” 6/2
Progress Note written 6/2 “No new orders; continue furosemide…”
But resident had not received diuretic in 2 weeks…
If this patient were to be transferred to acute care hospital, would the admitting physician have accurate current medication list?
Decisions are made on inaccurate medication history and prescribing occurs based on misperceptions.
Medication Safety with Electronic Technology
Will our electronic systems and technology improve medication safety and decrease potential for medication errors? Prescribing - medication choice errors, order entry
Warning fatigue , excessive warnings
Medication reconciliation discrepancies, duplication
Role of electronic records in unnecessary medication use
Decisions based on inaccurate, incomplete, outdated electronic health information
New technology “learning curve” and alterations to workflow
Medication Safety with Electronic Technology
Health IT Patient Safety Action & Surveillance Plan - July 2013
Available at:
http://www.healthit.gov/sites/default/files/safety_plan_master.pdf
Medication Safety with Electronic Technology
System-based sources of Medication Errors may contribute to negative patient outcomes:
Prescribing
Medication Reconciliation at Care Transitions
Administration
Monitoring
Medication Safety with Electronic Technology
E-Prescribing – reduces problems with handwriting, ambiguous orders, and incomplete orders; but we must
recognize technology may also contribute to medication errors.
Abbreviation U is NOT Acceptable either in paper order or electronic records or medication labeling.
CPOE
Computerized Physician Order Entry became Computerized Prescriber Order Entry became Computerized Provider Order Entry.
Who is entering the orders?
Before 2009 – Estimate 6% hospitals had CPOE
ARRA -American Recovery & Reinvestment Act
provided $20 billion (incentive payments/ also financial penalties) to both outpatient physician offices and hospitals with CPOE as a core requirement
2011 – Estimated 30%+
Scenario 2: Focus on Order Entry and Care Transitions Acute to Post-Acute
Patient with pneumonia, HTN, dry eyes
Hospital Discharge medication list included:
Cyclosporine ophthalmic bid
--------------------------------------------------------
Computerized signed physician orders state:
Cyclopentalate ophthalmic bid dx: dry eyes
Received cyclopentalate eye drops for 3 weeks
What went wrong?
Medication Safety with Electronic Technology
Root Cause Analysis - RCA
Admission medication list (generic name)
Discharge medication list (generic name)
Telephone approval of medication list included generic name
Order entry by nurse –
System did not cross match generic with brand; no choice for generic product thus error in product choice
Pharmacy filled product (dx: dry eyes)
Attending physician approved/ signed computerized list of medications with incorrect eye medication
Medication Safety with Electronic Technology
Comparison to old “paper system” where order would have been faxed to pharmacy to enter drug into profile and pharmacist would choose medication, complete labeling directions.
Nurse would transcribe order directly from hospital discharge list onto MAR.
MAR would be checked at time of each dose administration with label of drug product.
Electronic System – Pharmacist did not view cyclosporine order.
Analysis leads to Process Improvement with goal to prevent future medication errors
Medication list upon hospitalization (include brand name?)
Medication Choices – Remove potential medications which would not be used in this setting
Cross-match brand with generic
Review indication with each medication order
Read medication list and be aware of all medications being signed/approved
Do not administer unfamiliar medications without check of drug information
Definition of Medication Error
The National Coordinating Council for Medication Error Reporting and Prevention (NCCMRP) uses this definition:
“any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer.”
Medication Error – “May be related to:
Professional practice,
Health care products,
Procedures,
Systems,
Includes:
prescribing, order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use”. (NCCMERP)
Medication Safety- Organization and Individuals
Organizational and Individual Commitment:
Need for leaders of health care organization to make medication safety a high priority
Regardless of the organization, individuals still have the obligation to promote medication safety
ISMP: “For prevention efforts to be effective, they must become a priority.”
What about you?
Medication Safety – Multidisciplinary Approach
What can we do as part of the health care team engaged in actions to improve medication safety:
• Encourage error reporting and analysis of near misses – Just Culture
• Improve degree of reporting and system analysis of near misses
• Educate other practitioners on error prevention and error causes
• Overall medication management is only as good as the “weakest link” in your practice.
• Who takes the evening, weekend call??
Medication Safety – Multidisciplinary Approach
Utilize standard methods for medication error and near miss analysis: ◦ Root Cause Analysis - RCA ◦ Failure Mode and Effects Analysis – FMEA
Need to improve the system not just the performance of individuals
Learn from other errors reported through PSOs (public safety organizations) like ISMP and published accounts of errors
Proactively review your systems and make changes to decrease potential for medication errors
Scenario 3: Focus on Care Transitions Acute to Post-Acute
Patient 94 yr old with immobility post-op ankle fracture
Enoxaparin 100mg/mL SQ daily x 14 days
Patient received 100mg daily…. til RPh review on day 9
Orthopedic Rx and hospital records indicated dose = 40mg daily
What went wrong?
Misinterpretation of Drug or Dose
Interpretation of concentration as the dose
Due to incomplete medication order upon discharge med list (signed by prescriber)
Lack of dosage in medication order
Focus on High Risk Medications
Anticoagulants
Insulin and Oral diabetes medications
Antibiotics
Cardiovascular medications
Anti-seizure medications
Liquids with a concentration
Unusual Dose/Dosing- 2 capsules, 1 ½ tabs, 0.5 tab or ¼ tab, variable dose
Narcotics
Narrow therapeutic window
Combination Medication Products
Potential Sources of Medication Errors
Prescribers can impact safe medication orders:
Review post-acute discharge medications before signing
Recognize incomplete orders, concentration but no dose– Keppra ® 100mg/mL, Lantus ® 100 units/mL
Recognize pitfalls such as prescribing in mg but provider order entry in mL. Who makes dose conversion?
Be aware of look alike / sound alike medications. (LASA meds)
Potential Sources of Medication Errors
Slow down, speak clearly when giving verbal order. Spell drug names if not being understood. ◦ F and S sound alike; B and D sound alike
Pronounce digits separately: ◦ Ex. “Forty milligrams – four zero mg”
Provide complete information – drug concentration, dosage units mcg, mg, meq
Include units – Dose is not just 25 or 20 or .125 Full drug name - Misinterpretation of computerized drug
names on drop down menu Ex. Order by prescriber to discontinue potassium Patient actually was prescribed NSAID - Diclofenac
Potassium
Potential Sources of Medication Errors
Prescribing System improvements include:
Removal of problem creating menu choices from order entry drop down menu.
Use of Tall Man lettering to reduce risks of improper choice for look alike medications.
Review of default times/ dates on order entry
Review templates for accuracy
ex. Error in Zpak ® template = 6 days of azithromycin
Potential Sources of Medication Errors
Name Confusion
Look Alike Sound Alike
◦ Lillian Williams – William Gillian
◦ James Franklin – Franklin Jones
◦ Gylburide – Glipizide
◦ Serzone ® – Seroquel ®
◦ Fosamax ® – Flomax ®
◦ Zytec ® – Zyprexa ®
◦ Wellbutrin SR ® – Wellbutrin XL ®
Potential Sources of Medication Errors
E-Prescribing
Do not keep multiple EMR open.
Identify patient with multiple identifiers.
Ex. levothyroxine started on the wrong spouse
Dose was increased when no change in TSH on spouse not receiving the medication for 6 weeks.
Potential Sources of Medication Errors E-Prescribing Focus: Correct choice off drop down menu – patient
name, drug name, drug salt, dose, ½ or 0.5 tablet dose (ex. lisinopril ½ tab in special instructions led to medication doubling)
Multiple EHR open at the same time
Beware of abbreviations for drug names
Short-cut abbreviations, default dose
Bypassing or “turning off” safety alerts
Use of “codes”
Potential Sources of Medication Errors
E-Prescribing Concerns–
Who has access to your prescribing system?
Need to keep updated with guidelines, FDA warnings, software
Height / Weight software alerts may be missed resulting in dosing errors (mix up ht in cm instead of wt in kg)
Transposing numerals in height or weight
Duplication if errors in transmission occur
Potential Sources of Medication Errors Warnings and Alerts
If interpreted at point of care by provider entering order, can be helpful if acted upon properly.
System needs review for threshold and specificity to reduce those not clinically significant.
Create “hard stops” to prevent the most outstanding patient safety errors.
When bypassed, expectation is that pharmacist will interpret
Advise safety team to review reasons for bypassed warnings frequently.
Transfer of Medication Errors
Error with human / software interface If wrong medication / drug class
chosen from drop down menu will the error can be transferred to other electronic health records?
Risk: How much HIT is “cut and pasted”?
Thorton JD, et al. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013 Feb;41(2):382-8 http://www.ncbi.nlm.nih.gov/pubmed/23263617/
Potential Sources of Medication Errors Administering
Do not assume patient has clear understanding of medication directions for administration.
Are labels of sufficient font, lettering, size and clarity?
Does patient understand the dose, administration route, frequency, and duration of administration?
Can the patient appropriately administer the dose?
Ex. cutting tablets in half, swallowing whole…
Are PRN medications labeled appropriately?
◦ Ex. Klonopin PRN
Potential Sources of Medication Errors Administering
Patient may be confused about how much medication to take.
Example: “Take 0.5 tablet….”
Data entered for medication order may be user friendly to prescriber and pharmacy but is it user friendly for the outpatient to understand?
National Patient Safety Goal 2014
Maintain and communicate accurate patient medication information.
NPSG.03.06.01
“evidence that medication discrepancies can affect patient outcomes”
What is the role of electronic systems in improving patient outcomes? vs reducing patient outcomes through medication errors and adverse events?
Perils and Opportunities at Medication Reconciliation
Potential source of medication errors
Transfer from one point of care to another, often involves medication changes.
Institute for Healthcare Improvement estimates:
Up to 50% of all medication errors and 29% adverse
drug events in the hospitals may be associated with
communication gaps at care transitions.
Care Transitions
Office of Inspector General Feb 2014 report:
“Adverse Events in Skilled Nursing Facilities” 653 Medicare beneficiaries discharged from
hospital to SNFs for max 35 days post-acute care
22% experienced an adverse event
additional 11% harmed during SNF stay
59% events identified as preventable by MD review
Half who experienced harm returned to hospital for treatment
At a cost to Medicare Aug 2011 = $208 million
Extrapolated to over $2 Billion in yr 2011
Care Transitions
“up to 70% care transitions resulted in discrepancies” - 1/3 having potential to harm
Archives of Internal Medicine June 2012
30% of elderly patients’ medication information that was available to the ER staff at the time of initial diagnosis differed from that obtained from outside caregivers.
A review of 577 discharge drug summaries found 66% contained at least one inconsistency.
Institute for Healthcare Improvement
Care - Transitions
Engage the patient (family/caregivers)
Study by Mayo Clinic found lack of knowledge in patients prescribed a new medication on hospital discharge:
15% unaware of Rx for new medication
33% could not name the new medication
1/3 could not describe how to take the new medication or what is was for
Focus on High Risk Medications
Anticoagulants
Insulin and Oral diabetes medications
Antibiotics
Cardiovascular medications
Anti-seizure medications
Liquids with a concentration
Unusual Dose/Dosing- 2 capsules, 1 ½ tabs, 0.5 tab or ¼ tab, variable dose
Narcotics
Combination Medication Products
Medication Reconciliation - Care Transitions
To improve medication outcomes:
reconciliation systems and procedures need to be reviewed
Not just educating an individual deemed “responsible for a discrepancy”
Increase team awareness of potential for medication discrepancies
Medication Reconciliation - Transitions
Problem: Missing information concerning dose particularly with liquids, injections
◦ Enoxaparin 100 mg/mL = concentration, missing actual dose
◦ Lantus ® 100units/mL = concentration
◦ Leviteracetam (Keppra ® ) suspension 100mg/mL - is the concentration not dose
Verifying Post Acute Discharge Medication Orders
Inability to determine if stopped medications were “purposely discontinued for a reason” or “inadvertently missed”
Solution: physicians review (print out) discharge summary and medication reconciliation at same time for final review and corrections
(with all the patient’s information in one place)
Post-Acute Discharge Orders
Lack of defined duration / stop date – Difficult to determine start dates/stop dates ◦ Variable stop dates based on next cardiology
visit, orthopedic visit, etc. Ex. amiodarone 200mg bid until cardiology
appointment
Inappropriate abbreviations ◦ “levofloxacin 500mg q 48 hours x 3 d”
Does d refer to doses or days?
Missed or inaccurate information input upon hospital admission
May result in incorrect information upon discharge:
Clinical decisions may be based on inaccurate information.
Hospital treatment may reflect inaccurate dose from point of admission.
Untreated medical conditions upon discharge (These can be unintentional discontinuation, - errors of omission)
Source: Bell, et al, Association of Hospital Admission with Unintentional Discontinuation of Medications for Chronic Diseases. JAMA, 2011: 306 (8):840
Missed or inaccurate information input upon hospital admission
Use of most recent hospitalization discharge
meds as admission meds for newest hospital admission resulting in restart or documentation as “home meds” those that were discontinued or altered during outpatient time ◦ Old dose of levothyroxine, metoprolol, lisinopril, which were
changed months prior to admission but restarted as “home meds” upon entering hospital
Consultant Practices may also be using outdated lists by consulting practices
Medication Safety with Electronic Technology
The Joint Commission 2014 Patient Safety Goals - Use Medicines Safely
IOM – “Electronic Prescribing and Monitoring for Errors in All Care Settings is Essential”
Target high risk medications
Medication Safety with Electronic Technology
Adverse Event and Error Reporting:
FDA MedWatch Form is available at:
www.fda.gov/medwatch/how.htm
- USP-ISMP MERP (Medication Error Reporting Program)
www.ismp.org/orderforms/reporterrortoismp.asp
-It is essential that we report incidents related to Health Information Technology.*
Medication Safety with Electronic Technology
Increase awareness among your colleagues with examples of the potential errors that may occur and how to screen for them
Team Focus on multi-factorial causes when identifying potential errors and the necessary changes to prevent recurrence.
Use technology to reduce medication errors but beware of how technology may contribute to errors.
Engage the patient, family, caregiver when gathering information about medication use.
“I didn’t receive any eye drops that I used to take….
”I
References Institute of Medicine (IOM), Health IT and Patient Safety: Building
Safer Systems for Better Care (National Academy Press, 2012) available at http://www.iom.edu/Reports/2011/Health-IT-and-Patient-SafetyBuilding-Safer-Systems-for-Better-Care.aspx (last accessed July 9, 2014).
IOM, To Err Is Human: Building a Safer Health System (National Academy Press, 2000), available at http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx (last accessed July 9,2014).
Bell, et al, Association of Hospital Admission with Unintentional Discontinuation of Medications for Chronic Diseases. JAMA, 2011: 306 (8):840
Adverse Events in Skilled Nursing Facilities – National Incidence among Medicare Beneficiaries – Office of Inspector General – Feb 2014 available at: http://oig.hhs.gov/oei-06-11-00370.pdf
References Radley DC, Wasserman MR, Olsho LE, Shoemaker SJ, Spranca MD,
Bradshaw B. Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. J Am Med Inform Assoc. 2013;20(3):470-6. doi:10.1136/amiajnl-2012-001241. http://jamia.bmj.com/content/early/2013/01/27/amiajnl-2012-001241.full
How to Guide: Prevent /Adverse Drug Events by Implementing Medication Reconciliation. Cambridge,MA: Institute of Healthcare Improvement; 2011
National Coordinating Council for Medication Error Reporting and Prevention. “What is a Medication Error?”
http://www.nccmerp.org/aboutMedErrors.html Accessed 4/3/14
Thorton JD, et al. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013 Feb;41(2):382-8 http://www.ncbi.nlm.nih.gov/pubmed/23263617
Resource
Website of resources: www.ismp.org
Institute for Safe Medication Practices
“The great aim of education is not knowledge but action.”
H. Spencer
Thank You !
l.finn@usciences.edu
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