Medication Error Reduction Plan(MERP)Program

Loriann De Martini, Pharm.D.Chief Pharmaceutical Consultant

Michael Alexander, M.Sc.Pharmaceutical Consultant II

MERP Program Mission

• Promote safe and effective medication use in hospitals through reduction of preventable medication-related errors and adverse events. Program's objectives will be achieved through:

The Department's survey activities whereby each hospital's MERP will be assessed for implementation and compliance with applicable laws and regulations and,

Ongoing collaborative efforts with stakeholders to advance medication safety strategies statewide to decrease identified system vulnerabilities.

MERP Survey Summary January 2009 – August 2011

• 374 – Hospitals to be surveyed

• 300 – Completed surveys (80%)

• 277 – Noted deficiencies (92%)

Average three deficiencies per survey

• 23 – In compliance (8%)

Data as of 8/29/11

MERP Survey Deficiencies

• Failure to develop policies and procedures for safe use of medications – 60% [Title 22 70263(c)]

• Failure to conduct an annual review to assess effectiveness of the implementation of MERP –59% [HSC 1339.63(e)(2)]

• Failure to identify weakness or deficiencies that could contribute to errors – 43% [HSC 1339.63(e)(1)]

• Failure to include a multidisciplinary process to regularly analyze all errors – 41% [HSC 1339.63(e)(6)]

HSC = Health and Safety Code

Next Steps…

• Survey refinement

Analysis of first triennial cycle

Input from stakeholders

• Continue participation in regional medication safety collaborative. Peer to Peer learning

• Collection and analysis of survey findings to identify medication safety system vulnerabilities

Med-SET = Medication System Event Tracking

Med-SET

• Collect, quantify, and analyze medication safety data reported from deficiencies written by Pharmaceutical Consultants

• Categorize data into one or more 12 error categories with 85 sub-categories

• Objective: to inform and educate internal and external stakeholders on medication safety issues/vulnerabilities

• Launch: Fall 2011

Michael Alexander, M.Sc.

Pharmaceutical Consultant II

MERP Program Lead

Center for Health Care Quality

Presentation Goals

1. Provide information which may help you to decrease medication errors

2. Relate some important findings during MERP surveys.

Health and Safety Code 1339.63 (e)(1)

• Evaluate, assess, and include a method to address each of the procedures and systems listed under subdivision (d) to identify weaknesses or deficiencies that could contribute to errors in the administration of medication.

HSC 1339.63 (d): Procedures and Systems

• Prescribing

• Prescription order communication

• Product labeling

• Packaging and nomenclature

• Compounding

• Dispensing

• Distribution

• Administration

• Education

• Monitoring

• Use

Points to remember about (e)(1)

1. Ensure that you address each of the 11 items in (d).

2. Be able to discuss how you addressed each of the items in (d).

3. Not required to include interventions in each of the 11 areas in (d).

4. Do not place items in your plan without thoughtful consideration of why they are there.

Points to remember about (e)(1) continued:

5. Ensure that you do not have medication error issues which were not addressed in your MERP.

6. Identify weaknesses or deficiencies which can contribute to medication errors.

7. Use external sources to identify weaknesses or deficiencies

HSC 1339.63 (e)(2)

• Include an annual review to assess the effectiveness of the implementation of each of the procedures and systems listed under subdivision (d).

Points to remember about (e)(2)

1. Annually review each intervention in your MERP.

2. Assess whether you were successful or not successful in each case.

3. It is not required that you always be successful.

4. Use your medication error data to determine success.

Points to remember about (e)(2) continued:

5. Aggregated data not very useful; need to zero in on each identified problem.

6. Do not carry successful interventions forever in your plan.

Other points to remember:

• Ensure process is multidisciplinary; analyze all med errors; determine what you are going to about them 1339.63 (e)(6)

• Modify your plan as warranted 1339.63 (e)(3)

• Proactively identify actual and potential medication errors (e.g., med pass) 1339.63 (e)(5)

Findings:

• Fentanyl patches

• Droperidol

• Insulin

• IV infusion devices

Smart pumps; PCAs

Findings:

• Automated Dispensing Cabinets Discrepancies, overrides, profiling

• Emergency medications (MH, carts, boxes) Sealed, list of meds, exp date

• Refrigerators (storage); warmers in OR

• Expired drugs (unit inspections)

Findings:

• Lack of policies and procedures

• Policies and procedures not followed

• Recent medication deaths: heparin, morphine, warfarin, dexmetomidine, thymoglobulin

Findings:

• Limit access to medications

• Preprinted orders – include parameters for dose changes

(e.g., norepinephrine, nitroprusside)

The END

Trust but verify

Audience Participation

What are your medication safety concerns?

Questions?