Preventing Medication Errors in Practice - Preventing Medication Errors...Preventing Medication Errors in Practice ... Human error At risk behavior Reckless behavior ... medication

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Preventing

Medication Errors in

PracticeMargo Karriker, PharmD, FSVHP, DICVP

University of California, Davis

University of California Veterinary Medical Center – San Diego

5th Annual UCI Conti Symposium on Veterinary Continuing Education

August 6th, 2017

To make no mistakes is not in

the power of man; but from

their errors and mistakes the

wise and good learn wisdom

for the future.

Plutarch

Objectives

• Recognize errors happen

• Examine error prevention initiatives in veterinary medicine

• Compare initiatives in human medicine

• Identify error prevention opportunities for your practice

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How many of us have a

medication error reporting and

prevention/medication safety

program?

Healthcare in the United States is not as safe as it should be –

and can be… (Institute of Medicine. November 1999)

Healthcare in the United States is not as safe as it should be –

and can be… (Institute of Medicine. November 1999)

Four strategies for improvement:

• Establish a national focus to create leadership, research, tools,

and protocols to enhance the knowledge base about safety.

• Identify and learn from errors by developing a nationwide

public mandatory reporting system and encourage

organizations to participate in voluntary reporting.

• Raise performance standards and expectations for

improvement in safety through oversight organizations.

• Implement safety systems in organizations to ensure safe

practices at the delivery level.

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Institute of Safe Medication

Practices501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use

• Began in 1975, with a ongoing column in Hospital Pharmacy that increases understanding and educates healthcare professionals and others about medication error prevention

• Voluntary consumer and practitioner reporting program

• Med-ERRS (Medical Error Recognition and Revision Strategies) works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design.

• Newsletters, educational programs and patient-safety tools

Source: www.ismp.org


Practices

Source: https://www.ismp.org/newsletters/acutecare


Practices

Source: https://www.ismp.org/Tools/highalertmedications.pdf

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Safety-minded culture

Punitive culture

Blame-free culture

Just culture

Source: Acute Care. ISMP Medication

Safety Alert.

http://www.ismp.org/newsletters/acutec

are/articles/20060907.asp

Safety-minded culture: Just

culture

Human error

At risk behavior

Reckless behavior


culture

Human error

At risk behavior

Reckless behavior

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culture

Human error

At risk behavior

Reckless behavior


culture

Human error

At risk behavior

Reckless behavior

ACTION IN VETERINARY MEDICINE

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Action in Veterinary Medicine:

FDA CVM

Source:

https://www.fda.gov/AnimalVeterinary/SafetyHealth/ProductSafetyInformation/


FDA CVM• FDA CVM’s role in

error prevention

• Evaluation of drug

names

• Review of drug labels

and packaging design

• Review of adverse

drug event reports

• Educational outreach

Source: https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm325222.htm


FDA CVM

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AAHA

Source:

https://ams.aaha.org/eweb/images/AAHAnet/phoenix2009procee

dings


AAHA• Client disclosure

• T:

• Truth and Transparency

• E

• Empathizing

• A

• Apology and Accountability

• M

• Management


AAHA

• Standard - PC57

• The practice utilizes a written protocol that defines what

constitutes an adverse/sentinel event and how such events are

addressed.

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AVMA• FAQs

• Prescription writing

best practices

• Guidelines for

veterinary

prescription drugs

Source: https://www.avma.org/KB/Resources/Reference/Pages/Pharmacy

LESSONS FROM HUMAN MEDICINE

The challenge

• May 2000

• Results of the ISMP “Medication Safety Self Assessment”

• Specific medication safety objectives were included in the CEO’s

strategic plan in only twelve percent of hospitals.

• About 50% of respondents did not feel that their leadership:

• Demonstrated a commitment to patient safety

• Encouraged practitioner error reporting

• Supported the use of system enhancements, like technology, that

were likely to reduce errors

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How many of us include

medication safety objectives

and goals in our strategic plan?

Pathways for Medication Safety

Strategic Planning

• Medication safety should be a critical component of a

strategic plan for all hospitals.

• Why is this important?

• Why should every hospital devote significant resources to

medication safety?

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Why is strategic planning

important?• Moves focus to long term goals

• Balances immediate/short-term patient needs with long-term

goals of the organization

• Safe medication use requires careful planning. Cannot be

achieved if all resources are spent meeting immediate needs.

• Errors involving medications comprise the largest single cause of

medical errors in hospitals

Why should we devote significant

resources to medication safety?• Two serious errors

occurred for every 100 admissions

• Length of stay increased

• $1000s of extra costs

• Preventable errors cost $ millions

• Malpractice/liability

• Marketing/bad PR

• Higher employee turnover

• Decreased operational efficiency

The implementation process

Involve key people

Review Materials

Map a Strategy for the Future

Select Change Projects

Implement a Strategic

Plan

Monitor Performance

Source: www.medpathways.info. Pathways for

Medication Safety. AHA/HRET/ISMP. 2002

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Creating a Model Strategic Plan


Create, communicate, and demonstrate a leadership-driven

culture of safety.

• Professional organizations

• Regulatory agencies

• Hospital leadership

• Peer leadership

• Consider a dedicated staff position focused on medication

safety

• Revise mission statement to include an emphasis on safety

• Create continuous safety training and provide feedback


Improve error detection, reporting and use of the information

to improve medication safety

Evaluate where technology can help reduce the risk of errors

• Every member of the staff

• Create a method to capture error reports efficiently

• Establish a feedback mechanism to keep everyone informed

• When adopting new technologies, consider safety issues

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Creating a Model Strategic PlanImprove error detection, reporting and use of the information

to improve medication safety

Evaluate where technology can help reduce the risk of errors

Source: https://www.usatoday.com/story/tech/columnist/2017/07/28/doctors-using-

virtual-reality-breathe-new-life-into-technology. July 28th 2017


Reduce the risk of errors with high-alert medications

prescribed and administered.

• Create and maintain and list of medications

• Establish the procedures required when these drugs are used


Establish a blame-free environment for reporting errors.

“I just don’t want to get anyone in trouble…”

• Survey staff about anxiety and fear about making and

reporting errors

• Consider anonymous reporting

• Link safety competence tenets to employee evaluations, not

frequency/pattern of reported errors

• Focus on systematic solutions to frequent causes of error

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Involve the community in medication safety initiatives.

• Communicate safety initiatives to clients

• Host client education training


Involve the community in medication safety initiatives.

• Rate of errors increased

• Incorrect dose

• Wrong medication taken/given

• Took/gave medication twice

• Cardiovascular drugs

• Analgesics

• Hormones and hormone antagonists

• Sedative/hypnotics/antipsychotics

Source: Hodges, N. L., Spiller, H. A., Casavant, M. J., Chounthirath, T., & Smith, G. A. (2017). Non-health care facility medication errors resulting in serious medical outcomes. Clinical toxicology, , 1-8.

Our program

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Medication Error Statistics

• Data collected from September 15, 2011 – February 25, 2016

• 657 total entries

• 603 entries evaluated

Inpatient

Outpatient

Potential

By Service

0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

Pe

rce

nt

Service

Outpatient

Inpatient

Errors Reach Patient

68%

29%

3%

Inpatient

Reached

Patient

Did Not

Reach

Patient

Unknown 83%

16%

1%

Outpatient

Reached

Patient

Did Not

Reach

Patient

Unknown

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Cause Harm/ Change in

Treatment

• Inpatient

• 13% classified as

causing harm

• Of errors that reached

patients, 28% required

change in treatment

• Outpatient

• 11% classified as

causing harm

• Of errors that reached

patients, 9% required

change in treatment

Medication/Medication Class

0

20

40

60

80

100

120

140

High Alert Medications

• Inpatient

• 509 entries

• 42 unknown drug

involved

• 201 High Alert Meds

• Outpatient

• 81 entries

• 3 unknown drug

involved

• 9 High Alert Meds

39% - 48%

involving High

Alert

Medications

11% - 15%

involving High

Alert

Medications

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Inpatient Error Causes

Human

Communication

Labeling

Unknown

Other

Staff Education

• What is a medication error?

• 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.

How to report

• Easy to access

• Minimal time

investment

• Focuses on root

cause

• Non-punitive

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What should be reported

• Nothing is too trivial

• Near-misses should be reported

• Even if it didn’t reach the patient

• Anything that is unintended

• Even if no harm was caused

How we’re using the data

• Focus on improved

patient care

• Consistent,

constructive

feedback

• Need buy-in from

everyone

Summary

• Prioritize error reporting and prevention

• Include error prevention goals in your strategic plan

• Create a blame-free culture of medication safety

• Implement a continuous, sustainable error prevention

program

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Resources

• Institute of Safe Medication Practices

• www.ismp.org

• FDA Center for Veterinary Medicine: Consumer Updates

• https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm3252

22.htm

• Pathways for Medication Safety: Institute for Healthcare

Improvement

• http://www.ihi.org

QUESTIONS?

Documents

Preventing Medication Errors in Practice - Preventing Medication Errors...Preventing Medication Errors in Practice ... Human error At risk behavior Reckless behavior ... medication