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WELCOME
GINA GAMBARODirector, Marketing &
Business Development
2020 MONTHLY WEBINAR SERIES
Asking a question is easy! About the topic being presented —
Click on the Q&A icon at the bottom of your screen Type your question & hit Enter Questions will be answered at the program’s end, or offline if time runs out
About technical issues or CE credit — Click on the Chat icon at the bottom of your screen Type your question & hit Enter Our team will reply to your question right away
▶ This webinar is being recorded for on-demand access later, after the series’ conclusion
▶ To earn CE, you must attend the entire session
▶ For those sharing a computer Complete a manual sign-in sheet before the program ends Go to Chat to access the link for the sign-in sheet Each participant must complete an evaluation to obtain CE credit Instructions will also be emailed to the program registrant
Housekeeping notes
INTRODUCTION
ModeratorPAMELA BRYAN KRAMERExecutive Vice President
2020 MONTHLY WEBINAR SERIES
Strategies to Prevent Medication Errors in Your FacilityDana Saffel, PharmDCPh, BCGP, FASCPPresident, CEO
▶Review strategies for conducting an efficient medication reconciliation on transitions of care to reduce medication errors.
▶Give examples of common errors discovered during a medication reconciliation.▶Describe root cause analysis and failure modes and effects analysis (FMEA) and their roles
in preventing medication errors.
▶ Identify error-prone situations and processes to improve patient outcomes.
Objectives
6
A Glimpse at the Magnitude of the Problem
1. Slone Epidemiology Center at Boston University. Patterns of medication use in the United States, 2006.2. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US emergency department visits for outpatient adverse drug events, 2013-2014. JAMA 2016;316:2115-253. Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006.
ADE – Adverse Drug Event
82% of American adults take at least one medication and 29 percent take five or more1
ADEs cause approximately 1.3 million emergency department visits and 350,000 hospitalizations each year2
1.5 million Americans are harmed by medication errors costing in excess of $3.5 billion and 7000 deaths annually3
More than 40% of costs related to ambulatory (non-hospital) ADEs might be preventable3
You are 100 times more likely to die from a healthcare error than from
railroad or airline accidents
▶Preventable event that may cause or lead to: Inappropriate medication use Patient harm
▶Occurs while the medication is in the control of the healthcare professional, patient, or consumer
▶Related to: Professional practice, health care products, procedures & systems including:
Medication Error
• Prescribing• Order communication• Labeling • Packaging• Nomenclature• Compounding
• Dispensing • Distribution• Administration• Education• Monitoring• Use
Types of Errors
▶Latent Error Hidden problems within health care
systems that contribute to adverse event
▶Active Error Errors occurring at the point of
interface between humans and a complex system
The Swiss Cheese Model
• Patient education
/COMMUNICATING
- labeling/packaging- storage
Medication Reconciliation
Where Medicare Errors Happen
▶Can occur anywhere in the medication use process but are most frequent during: Prescribing (39% - 49%) Administering (26% - 38%)
▶Errors include: Omission errors – failure to administer an ordered medication dose Improper dose/quantity errors – any medication dose, strength, or quantity that
differs from that prescribed Unauthorized drug errors – medication dispensed or administered was not authorized
by the prescriber (includes wrong-drug errors)
Medication Errors Occur Throughout the Medication Use Process
Institute of Medicine Report. 2006
16.2%
4.6%3.1% 2.7% 2.3% 2.2% 2.0% 1.7% 1.7% 1.4%
0.0%2.0%4.0%6.0%8.0%
10.0%12.0%14.0%16.0%18.0%
Medications Commonly Implicated in Medication Errors
© USP MedMarx Annual Report 2008 p. 393
“The movement of patient between healthcare locations, providers, or different levels of
care within the same location as their needs change…”
Transitions in Care
National Transitions in Care Coalition. www.ntocc.org. Accessed June 8, 2015
Errors in the Transition Process
▶On average, 3.9 medication discrepancies identified per outpatient discharge
▶ADRs implicated as the reason for readmission in 4.5% of patients.
Armor, Wight, and Carter. J Pharm Pract 2014; October epub.
Anderegg et al. Am J Health-Syst Pharm 2014; 71: 1469-79
At least one medication discrepancy was identified in over 70% of SNF admissions.
- PharMerica report
▶A process for obtaining and documenting a complete and accurate list of a patient’s current medicines upon admission and comparing this list to the prescriber’s admission, transfer and/or discharge orders to identify and resolve discrepancies. This is done to avoid medication errors such as omissions, duplications,
dosing errors, or drug interactions.
▶Should be conducted at every transition of care in which new medications are ordered or existing orders rewritten.
Medication Reconciliation
Joint Commission Sentinel Event Alert Issue 35, January 25, 2006
Medication Orders
Admission
Discharge
Transfer Within System
Medication ReconciliationVerify Medications Taken at
Home (Best Possible Medication History
[BPMH])
Reconcile Home Medications with Those Ordered on Admission
Reconcile Home Medications with Those Ordered on Discharge
Reconcile Home Medications with Those
Ordered on Transfer
51%
22%
21%4%
2%
Incorrect / Missing Dose
Drug Commission
Errors Commonly Found During Medication Reconciliation
Incorrect / MissingFrequency
Incorrect Drug Drug Omission
Hart C, et al. A program using pharmacy technicians to collect medication histories in the emergency department. P T. 2015;40(1):56-61
• Incorrect or Missing Doses -record lists a different dose than what the patient is being given, or does not list the dose
• Incorrect or Missing Frequency – records lists an incorrect administration time
• Drug Commission - the record lists a drug that the patient is not actually taking
• Drug Omission - error is related to an action not taken
Society of Hospital Medicine. https://www.hospitalmedicine.org/clinical-topics/medication-reconciliation/. Accessed April 2, 2019.
21Society of Hospital Medicine. https://www.hospitalmedicine.org/clinical-topics/medication-reconciliation/. Accessed April 2, 2019.
▶Medication reconciliation is often inconsistent – Even with mandates, medication reconciliation processes can vary widely by
hospital, post-acute care setting, and out-patient setting..▶Time constraints sometimes trump safety –
While patient safety is often a top priority in principle, this does not always carry through in reality. Clinicians sometimes spend less than 15 minutes with a patient during an appointment and can lack the time necessary to perform proper medication reconciliation.
▶Medication reconciliation creates an opportunity to discuss adherence – Patients fail to take their medications about 50% of the time. While reasons why
vary, clinicians should stress the risk factors associated with non-adherence with patients and help improve compliance with instructions.
Best Practices for Medication Reconciliation
Medication Reconciliation: The Key Patient Safety Issue for Healthcare Providershttps://www.cureatr.com/medication-reconciliation-the-key-patient-safety-issue-for-healthcare-providers. Accessed March 31, 2019.
"It probably takes about 25 minutes to take a good medication history, and the average provider probably gives it about 4 minutes. You get what you pay for."
Jeffrey Schnipper, MD Brigham and Women’s Hospital, Boston
▶EHRs aren’t solving the problem – The use electronic health records (EHRs) can make medication reconciliation
worse in some cases, such as when clinicians complete documentation requirements without giving a patient proper attention during a visit.
▶Data gaps are a major issue – If your EHR is not connected to other providers and facilities, your
documentation may be missing critical information on medication history. This increases the risk associated with making treatment decisions because providers are working off of an incomplete picture of a patient’s health.
▶Medication reconciliation is vital to preventing readmissions – When a new medication is prescribed but other medications that the
patient might be taking are unknown, there is an increased chance of a complication, potentially resulting in harm and a readmission.
Best Practices for Medication Reconciliation (Con’t)
Medication Reconciliation: The Key Patient Safety Issue for Healthcare Providershttps://www.cureatr.com/medication-reconciliation-the-key-patient-safety-issue-for-healthcare-providers. Accessed March 31, 2019.
Error-Reduction Strategy Power (leverage)
Fail-safes and constraints High
Low
Forcing functionsAutomation and computerizationsStandardizationRedundanciesReminders and checklistsRules and policiesEducation and informationSuggestions to be more careful or vigilant
Error Reduction Strategies
Institute for Safe Medication Practices. Selecting the Best Error-Prevention Tools for the Job. https://www.ismp.org. Accessed August 26, 2016.
▶Actively engage in reporting safety events If you have ideas for solutions share those
▶Encourage others to report▶Proactively identify potentially unsafe situations – don’t
wait for an error to occur to report▶Ask to attend committee meetings, involvement in process
improvement groups.▶Foster the culture of safety by supporting those around you
Celebrate great catches Encourage others to report
▶Regularly consult and use the resources mentioned today
How To Engage In Your Organization’s Safety Program
Root Cause Analysis vs Failure Mode and Effects Analysis
▶RCA – Root Cause Analysis Reactive – process initiated after
an error has already occurred Asks key questions:
What process failed? Human vs Technology? How can we change moving forward?
▶FMEA - Failure Mode and Effects Analysis Proactive – process initiated to
evaluate potential pitfalls and vulnerabilities of processes
Asks key questions: IF this process fails, what is the outcome? Is this outcome acceptable?
▶ Senders JW. Qual Saf Health Care 2004; 13: 248-9.
▶ The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp
▶Structured method used to analyze serious adverse events Focused on process, not individual human error Multidisciplinary Analysis of timeline and events Identifies latent errors that allowed occurrence of active error
▶Outcome of RCA is to identify and eliminate the latent errors that allow the active error to occur
Root Cause Analysis
https://www.psnet.ahrq.gov/primers/primer/10. Accessed April 3, 2019.
▶Criticisms of Traditional Root Cause Analyses Term implies “one” root cause Focuses on analysis, but action is as important as the analysis
NPSF proposes RCA2 – Root Cause Analysis + Action Effectiveness of RCA variable
▶Consensus recommendations from national patient safety leaders and organizations
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.
▶Recommended team size: 4 to 6 members Larger teams use more resources and may make scheduling
more difficult.▶Recommended to interview but not include those most
closely involved with the event in the RCA Guilt / trauma Insist on corrective measures beyond what is prudent May steer team away from their role in the event and
activities that contributed to event Makes it harder for other team members to ask difficult
questions and have frank discussions
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.
▶Analysis Steps and Tools Provides all steps that should be completed
Example: triggering questions “was communication between frontline team members adequate?”
▶Actions Teams should identify at least one stronger or intermediate strength
action for each RCA review Each action requires at least one measure / metric
▶Feedback RCA actions should be shared with the organization and those closely
involved including patients and families.
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
3National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.
Step 1 Step 2 Step 3 Step 4 Step 5
Failure Mode Effects Analysis (FEMA) Process
The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp
Determine how medication will be procured, packaged, dispensed,
delivered and used (from purchase to administration)
Step 1 Step 2 Step 3 Step 4 Step 5
Failure Mode Effects Analysis (FEMA) Process
Identify potential failure points throughout the entirety of the
defined process
The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp
Determine how medication will be procured,
packaged, dispensed, delivered and used (from
purchase to administration)
Step 1 Step 2 Step 3 Step 4 Step 5
Failure Mode Effects Analysis (FEMA) Process
The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp
Identify potential failure points throughout the entirety of the
defined process
Determine the likelihood of failure at any of the pre-
specified points
Determine how medication will be procured,
packaged, dispensed, delivered and used (from
purchase to administration)
Step 1 Step 2 Step 3 Step 4 Step 5
Failure Mode Effects Analysis (FEMA) Process
Examine preexisting processes to detect error prior to reaching the
patient
Identify potential failure points throughout the entirety of the
defined process
Determine the likelihood of failure at any of the pre-
specified points
The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp
Determine how medication will be procured,
packaged, dispensed, delivered and used (from
purchase to administration)
Step 1 Step 2 Step 3 Step 4 Step 5
Failure Mode Effects Analysis (FEMA) Process
Outline the severity of failure and whether current or
developed processes would minimize potential for failure
and/or harm
Determine the likelihood of failure at any of the pre-
specified points
Determine how medication will be procured,
packaged, dispensed, delivered and used (from
purchase to administration)
Identify potential failure points throughout the entirety of the
defined process
Examine preexisting processes to detect error prior to reaching the
patient
The Institute of Safe Medication Practices www.ismp.org/tools/FMEA.asp
About CE creditAdministrator credit
This program has been approved for Continuing Education for one total participant hour by NAB/NCERS.
Approval #20210820-1-A68432-DL
Q & A
Obtaining CE credit▶Complete the evaluation at the conclusion of this program:
In your web browser Also emailed immediately following this program
▶For those sharing a computer to view the webinar: Submit your sign-in sheet to the email address listed on the form Each participant will then be emailed a link to the evaluation Each person must complete an evaluation to receive CE credit
▶Certificates should be emailed in about 30 days
Want more CE after this?
Look for our upcoming webinars:
ForumPharmacy.com
January: COVID-19 Vaccine Update and Q&A
February: Rebuilding Census After COVID
March: Survey Support
April: Alcohol & Substance Abuse Treatment in Long-Term Care
THANK YOU!