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Reduction
of harm ffrom high
risk mediications
Apollo Medicine 2012 JuneVolume 9 Number 2 pp 160e165 Article on Quality
Reduction of harm from high risk medications
Gaurav Loriaa
Coorda The presultsReceivCopyridoi10
ABSTRACT
High risk medications High risk medications are medicines that are most likely to cause significant harm to thepatient even when used as intended The Institute for Safe Medication Practices (ISMP) reports that the incidentrates of this group of medicines may not necessarily be higher than the other medicines but when incidents occur theimpact on the patients would be serious (significant)In seeking to improve patient safety the primary focus should be on preventing errors with the greatest potential forharm Many of the highest risk medications e eg heparin insulin morphine and propofol e are delivered by IVinfusion 61 of the most serious and life threatening potential adverse drug events (ADEs) are IV drug relatedIV administration often results in the most serious outcomes of medication errors
Copyright copy 2012 Indraprastha Medical Corporation Ltd All rights reserved
Keywords High risk medication ISMP High alert medications
INTRODUCTION
ISMP defines High Alert Medications as ldquodrugs that beara heightened risk of causing significant patient harm whenthey are used wrongly Although mistakes may or may notbe more common with these drugs the consequences of anerror are clearly more devastating to patientsrdquo
inator Quality e Apollo Group Consultant Quality e Apollo Clinics 108roject was done at the time when we had only concentrated electrolytwe added other drugs (high risk) in our list as welled 3042012 Accepted 152012 Available online 852012ght 2012 Indraprastha Medical Corporation Ltd All rights reserved1016japme201205001
HIGH RISK MEDICATIONS (ACCEPTEDWORLDWIDE)
1) Concentrated electrolytes gt09 sodium chloridemagnesium sulphate and potassium chloride
2) Anticoagulants heparin
3) Human insulin human actrapid human insulatardand other insulins (all short long and intermediateacting)
4) Narcotics morphine fentanyl pethidine
5) Chemotherapeutic agents
6) Look alike and sound alike drugs (LASA)The risks caused due to the high risk medications are
given in the table below
Nehal Chambers Apollo Hospitals Jubilee Hills Hyderabad Indiaes as our high alert medications This project was done and after the
Medicine group Risks to the patient
Anticoagulants Narrow therapeutic indexpotential for clot or bleedinteractions with othermedications even herbalmedicines over the counterdrugs and food
Opiates Sedation respiratory depressionconfusion lethargy nauseavomiting constipation
Insulin Loss of blood sugar control inpost-operative patients achievingblood sugar control withoutcausing hypoglycaemia
Concentratedelectrolytes
Increase in the level of theelectrolytes leading to lethal effects
LASA Risk of administration of theincorrect medications and theconsequent adverse effects
Reduction of harm from high risk medications Article on Quality 161
OBJECTIVES OF THE STUDY
d To know the current status of the care in the delivery ofhigh risk medications to the patients
d To intervene if any care in the delivery of the high riskmedications is still required
METHODOLOGY OF STUDY
d A random study was conducted in the hospital in allICUs 1st and 2nd floors
d The study had been carried out for 6 weeksd Over 100 patients were studied with regard to the care in
administration of high risk medicationsd Over 100 samples were studied with regard to the
dispensing of the high risk medications to the patientsfrom the pharmacy and storage in the pharmacy
Graph Analyzed results- errors in high risk medicationadministration
INCLUSIONS OF THE STUDY
d All the patients in the ICUs 1st and 2nd floors wereincluded in the study
d The case files of all the patients were referred for therequired information
d Thesepatientswereobserved for theproper administrationofthe high risk medications in the respective departments
d The dispensing of the high risk medicines was observedduring morning and the evening time
EXCLUSIONS OF THE STUDY
d LASA drugs were excludedd Dispensing during the night time was excludedd Chemo drugs were excluded for the three quarters of the
study
INTERPRETATIONS
The errors observed in the administration and transcrip-tions wered Drugs indented but not administeredd Drugs not written in the high alert chart by the physiciansd No double signatures in the drug chart after adminis-
tering the narcoticsd Hypoglycaemia not monitored and documentedd Magnesium levels were not monitored after the adminis-
tration of the electrolyte magnesium sulphated Blood pressure when improper after the administration
of fentanyl not correctedd Indications for the drugs not written in the drug chart
especially in case of chemo drugsd Correct date is not written in the drug chartd Wrong drugs are written in the high alert chartd Stop orders not written in the high alert chart
DETAILED DESCRIPTION OF THE INTERPRE-TATIONS OF THE STUDY
d Among 110 patients observed for the administration ofthe high risk medications 50 errors were found to occurie at the rate of 455 (Fig 1)
MEDICATION
ERROR
MAN MACHINE
METHOD ENVIRONMENT
Floor wise dispensing counters not available
Wrong selection of drugs
Wrong verbal order taken by staff
Staff not complying with two identifier while labeling and administering drugs
Pharmacy staff not trained in drug selection and packaging
Ward pharmacist not trained to check prescriptions
Staff not motivated to report errors
Complicated indenting system time consuming
No training for prescription writing
Nurse not trained to take verbal orders
INVENTORY
Out of stock
Delay in bringing medicines from storesINTERPRETATION
Wrong interpretation of medicine
Illegible
Manual work
Look alike sound alike drugs
Incorrect prescription written by doctor
Junior doctors reluctant to take verbal order Staff not following 7R check before administration
Procedure for drug selection and packaging not in place
Unorganized drug in IP pharmacy
Verbal order taken
Improper procedure for medicine administration
Inappropriate organization of drugs in IP pharmacy
Unorganized Imprest stock in ward
Noising factors in IP pharmacy
Time for 7R check not available
Computer system fails to operate
Fig 1 Fish bone analysis - medication errors
162 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Among all the errors which were observedB 20 of the errors happened to be the absence of
double signature during the administration of thehigh risk medications mostly concentratedelectrolytes
B 10 of the errors e high risk medications not writtenin high alert chart of the drug chart by the physician
d Among the errors observed the areas of errorsB Absence of double signatured70 of was observed
in CT postB The other areas were the errors were observeddPICU
regency III floor II floor cancer blockd The reasons for the errors found areB Lack of proper training to the staff with regard to the
specific drugsB Lack of timeB Ignorance of the staff with respect to continuous
implementation of the policy guidelinesB Lack of monitoring by the accountable authority
d The interventions ought to be carried out to minimisethe errors were
First and foremost is the proper training of the staffin terms of the policy which includes the list of thehigh risk medicines and all its required guidelinesMonitoring the staff for the follow up of the policyPutting up display charts depicting the policy ofadministration of the high risk medications so thatthe staff will be reminded of the policyMake the senior staff accountable for the regularimplementation of the policySet up a deadline (time period) for the review of theperformance of the staff after the interventionReview the performance of the hospital staff afterthe intervention for the knowledge of the improve-ment in the policy implementationReward the department or the staff who succeed infollowing the policy and responsible for the change inthe implementation of the policyMotivate the staff with regard to the policyimplementationPeriodical review (monthly) of the follow up of thepolicy by the medication safety committee
Reduction of harm from high risk medications Article on Quality 163
Make antidotes or rescue drugs available at the pointof care for immediate administration and establishingprotocols that allow for nurses to administer antidotesor reversal agents per protocol without having tocontact a physician
DISPENSING AND STORAGE OF THE HIGHRISK MEDICATIONS
d The high risk medications must be stored in the hospitalpharmacy with special care
Electrolytes
The concentrated electrolytes (sodium chloride potas-sium chloride magnesium sulphate) must be stored onlyin the pharmacy Theymust not be in the patient care areasThe concentrated electrolytes must be diluted under thelaminar hood of the pharmacy only by the personresponsible for dilutionWhile dispensing they must be sent with the HIGHRISK MEDICATION sticker
Narcotics
Narcotic drugs (morphine fentanyl pethidine) must bestored under the double lock chamber in the pharmacyThe two keys must be with two separate persons amongthe pharmacy staff nurses (in patient care areas)After the reception of the indent by the pharmacy theindent must undergo double check by the pharmacy staffand the staff responsible must unlock and take out thedrug and fill the details in the narcotic drug receiptThe drug must be sent with HIGH RISK MEDICA-TION stickerAll the narcotics issued by the pharmacy will be docu-mented in the NARCOTICS BOOK by the concernedpharmacist
Insulin
All the insulin injections must be stored in a separaterefrigerator in the pharmacyThe insulin drugs must be sent with the HIGH RISKMEDICATION sticker along with the ice pack
Heparin
Heparin must be stored in the lock and keyHeparin must be sent with HIGH RISK MEDICA-TION sticker
Chemotherapeutic drugs
These drugs are stored in the refrigerator in the phar-macy (usually chemo unit pharmacy)They are sent with HIGH RISK MEDICATION stickerThe pharmacist who dispenses the drug takes the signa-ture of the user department staff who received the drugas it is costly and must not be misused
ERRORS IN DISPENSING
The errors encountered in dispensing of the high risk medi-cations wered Drugs sent without HIGH RISK MEDICATION stickerd The concentrated electrolytes after dilution were handed
over directly to the nurse and confusion observed in thedispensing staff whether the medicine has been dispensed
d The staffs which assemble the indented medicines andsend them to the concerned staff for verification forgetsto attach the HIGH RISK MEDICATION sticker andhave to be alerted by the verification staff The chanceof medicine been dispensed without the HIGH RISKMEDICATION sticker increases the chance of errors
INTERPRETATION OF THE ERRORS INDISPENSING HIGH RISK MEDICATION
d Out of the 100 observations of dispensing of high riskmedication 10 of errors were observed
d The dispensing process was taking place quite accordingto the policy guidelines
d Out of all the errors 50 were the error of sending themedicationwithoutHIGHRISKMEDICATIONsticker
164 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Most of the errors were bound to be occurring at thelevel of the staff which is assembling the medicationsand sending for the verification
REASONS FOR THE ERRORS DURINGDISPENSING
Pharmacy was overcrowded with staff during the peaktime of morning (11 ame2 pm)Chaos between the staff assembling verifying packingand dispensing the medicines (leads to confusion amongthe staff)Staff unable to handle all the indents which resulted indelay in dispensing and piling up of the indentsSlow connectivity of the intranet in the hospital due towhich there was a delay in the reception of the indent
INTERVENTIONS FOR PROPER IMPLE-MENTATION OF THE POLICY GUIDELINES INDISPENSING THE HIGH RISK MEDICATIONS
U Pharmacy staff to be educated about the list of thehigh risk medications
U Display charts made available for the policy guidelinesatd Assembling counters e staff can identify the highrisk drugs and take steps to prevent the error of mixingthem with other drugs while replacing and error of notplacing the high risk sticker
d Verifying counterse staff can easily identify themedi-cines if they are without sticker identify the correctmedicine (in case of LASA) easy to alert the dispensingstaff not to mix with other drugs
d Packing and dispensing counters e staff can easilyseparate them and dispense them mostly if it is animmediate requirement because of the sticker placed
U Assignment of a separate dispensing staff for the highrisk medication to avoid the chaos
U Staff to be motivated to follow the policy guidelinesconstantly (by reward etc)
U Review of the performance after the interventionU Periodical review of the policy and the performance
standardsU Adequate staff to be maintained in the pharmacy to
avoid chaos in the departmentU Keep the staff educated about the updated policyU Keep the intranet always active to prevent the delay in
the dispensing of the medicationsU All the high risk medications to be kept at the separate
corner of the pharmacy for easy differentiation (exceptnarcotics which are in double lock)
U Keep all the high risk medicines at the place where theinsulin refrigerator is placed rather than at the othercorner which is not easily accessible No chaos willbe observed in this situation after the changed The areas to be concentrated to greater extent wereSICU PICU CT post chemo unit floors (II and III)
d A periodical review is carried out in the hospital afterthe intervention to have a broader and comprehensivestudy of the implementation intensity of the policyguidelines with respect to the high risk medications
d A near to 100 compliance would suggest that thepolicy guidelines are been followed in the hospital ina sustained manner and safe high risk medication prac-tise can be delivered to the patients of the hospital
On the whole the compliance of the hospital needed tobe improved with respect to the current status
MODIFIED POLICY FOR HIGH ALERTMEDICATIONS
d The high alert (concentrated electrolytes) must be prescribedin a separate high alert medications chart in the drug chart
d All concentrated electrolytes must be stored in the phar-macy only They must not be in the patient care areas
d All the narcotic drugs must be stored in a double locksystem and two keys with two different nurses
d The narcotic drugs should be discarded in the presenceof two witnesses in the sink and the empty ampouleshould be sent to the pharmacy in a black cover forfurther discarding from the hospital
d The high risk medications must be administered in thepresence of a witness
d After the administration of the high risk medicationsmonitoring must be done to check for any adverse events
d All the high risk medications must be dispensed withHIGH RISK MEDICATION sticker
Action taken
After understanding the lacunae in the system high alert policywasmodified and separate stickers were designed to ensure thatall high alert medications are labelled with instructions Evenfew more drugs like insulin LASA etc were added into thelist to ensure that we have covered all high risk drugs as well
The same was implemented effectively from October2011
Reduction of harm from high risk medications Article on Quality 165
Post implementation
A similar study was conducted on the same number ofpatients during February 2012eMarch 2012
The number of errors related to high alert drugs reducedto 12 with respect to focused trainings labelling posterscharts etc and none of the errors actually reached thepatient
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
Apollo Medicine 2012 JuneVolume 9 Number 2 pp 160e165 Article on Quality
Reduction of harm from high risk medications
Gaurav Loriaa
Coorda The presultsReceivCopyridoi10
ABSTRACT
High risk medications High risk medications are medicines that are most likely to cause significant harm to thepatient even when used as intended The Institute for Safe Medication Practices (ISMP) reports that the incidentrates of this group of medicines may not necessarily be higher than the other medicines but when incidents occur theimpact on the patients would be serious (significant)In seeking to improve patient safety the primary focus should be on preventing errors with the greatest potential forharm Many of the highest risk medications e eg heparin insulin morphine and propofol e are delivered by IVinfusion 61 of the most serious and life threatening potential adverse drug events (ADEs) are IV drug relatedIV administration often results in the most serious outcomes of medication errors
Copyright copy 2012 Indraprastha Medical Corporation Ltd All rights reserved
Keywords High risk medication ISMP High alert medications
INTRODUCTION
ISMP defines High Alert Medications as ldquodrugs that beara heightened risk of causing significant patient harm whenthey are used wrongly Although mistakes may or may notbe more common with these drugs the consequences of anerror are clearly more devastating to patientsrdquo
inator Quality e Apollo Group Consultant Quality e Apollo Clinics 108roject was done at the time when we had only concentrated electrolytwe added other drugs (high risk) in our list as welled 3042012 Accepted 152012 Available online 852012ght 2012 Indraprastha Medical Corporation Ltd All rights reserved1016japme201205001
HIGH RISK MEDICATIONS (ACCEPTEDWORLDWIDE)
1) Concentrated electrolytes gt09 sodium chloridemagnesium sulphate and potassium chloride
2) Anticoagulants heparin
3) Human insulin human actrapid human insulatardand other insulins (all short long and intermediateacting)
4) Narcotics morphine fentanyl pethidine
5) Chemotherapeutic agents
6) Look alike and sound alike drugs (LASA)The risks caused due to the high risk medications are
given in the table below
Nehal Chambers Apollo Hospitals Jubilee Hills Hyderabad Indiaes as our high alert medications This project was done and after the
Medicine group Risks to the patient
Anticoagulants Narrow therapeutic indexpotential for clot or bleedinteractions with othermedications even herbalmedicines over the counterdrugs and food
Opiates Sedation respiratory depressionconfusion lethargy nauseavomiting constipation
Insulin Loss of blood sugar control inpost-operative patients achievingblood sugar control withoutcausing hypoglycaemia
Concentratedelectrolytes
Increase in the level of theelectrolytes leading to lethal effects
LASA Risk of administration of theincorrect medications and theconsequent adverse effects
Reduction of harm from high risk medications Article on Quality 161
OBJECTIVES OF THE STUDY
d To know the current status of the care in the delivery ofhigh risk medications to the patients
d To intervene if any care in the delivery of the high riskmedications is still required
METHODOLOGY OF STUDY
d A random study was conducted in the hospital in allICUs 1st and 2nd floors
d The study had been carried out for 6 weeksd Over 100 patients were studied with regard to the care in
administration of high risk medicationsd Over 100 samples were studied with regard to the
dispensing of the high risk medications to the patientsfrom the pharmacy and storage in the pharmacy
Graph Analyzed results- errors in high risk medicationadministration
INCLUSIONS OF THE STUDY
d All the patients in the ICUs 1st and 2nd floors wereincluded in the study
d The case files of all the patients were referred for therequired information
d Thesepatientswereobserved for theproper administrationofthe high risk medications in the respective departments
d The dispensing of the high risk medicines was observedduring morning and the evening time
EXCLUSIONS OF THE STUDY
d LASA drugs were excludedd Dispensing during the night time was excludedd Chemo drugs were excluded for the three quarters of the
study
INTERPRETATIONS
The errors observed in the administration and transcrip-tions wered Drugs indented but not administeredd Drugs not written in the high alert chart by the physiciansd No double signatures in the drug chart after adminis-
tering the narcoticsd Hypoglycaemia not monitored and documentedd Magnesium levels were not monitored after the adminis-
tration of the electrolyte magnesium sulphated Blood pressure when improper after the administration
of fentanyl not correctedd Indications for the drugs not written in the drug chart
especially in case of chemo drugsd Correct date is not written in the drug chartd Wrong drugs are written in the high alert chartd Stop orders not written in the high alert chart
DETAILED DESCRIPTION OF THE INTERPRE-TATIONS OF THE STUDY
d Among 110 patients observed for the administration ofthe high risk medications 50 errors were found to occurie at the rate of 455 (Fig 1)
MEDICATION
ERROR
MAN MACHINE
METHOD ENVIRONMENT
Floor wise dispensing counters not available
Wrong selection of drugs
Wrong verbal order taken by staff
Staff not complying with two identifier while labeling and administering drugs
Pharmacy staff not trained in drug selection and packaging
Ward pharmacist not trained to check prescriptions
Staff not motivated to report errors
Complicated indenting system time consuming
No training for prescription writing
Nurse not trained to take verbal orders
INVENTORY
Out of stock
Delay in bringing medicines from storesINTERPRETATION
Wrong interpretation of medicine
Illegible
Manual work
Look alike sound alike drugs
Incorrect prescription written by doctor
Junior doctors reluctant to take verbal order Staff not following 7R check before administration
Procedure for drug selection and packaging not in place
Unorganized drug in IP pharmacy
Verbal order taken
Improper procedure for medicine administration
Inappropriate organization of drugs in IP pharmacy
Unorganized Imprest stock in ward
Noising factors in IP pharmacy
Time for 7R check not available
Computer system fails to operate
Fig 1 Fish bone analysis - medication errors
162 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Among all the errors which were observedB 20 of the errors happened to be the absence of
double signature during the administration of thehigh risk medications mostly concentratedelectrolytes
B 10 of the errors e high risk medications not writtenin high alert chart of the drug chart by the physician
d Among the errors observed the areas of errorsB Absence of double signatured70 of was observed
in CT postB The other areas were the errors were observeddPICU
regency III floor II floor cancer blockd The reasons for the errors found areB Lack of proper training to the staff with regard to the
specific drugsB Lack of timeB Ignorance of the staff with respect to continuous
implementation of the policy guidelinesB Lack of monitoring by the accountable authority
d The interventions ought to be carried out to minimisethe errors were
First and foremost is the proper training of the staffin terms of the policy which includes the list of thehigh risk medicines and all its required guidelinesMonitoring the staff for the follow up of the policyPutting up display charts depicting the policy ofadministration of the high risk medications so thatthe staff will be reminded of the policyMake the senior staff accountable for the regularimplementation of the policySet up a deadline (time period) for the review of theperformance of the staff after the interventionReview the performance of the hospital staff afterthe intervention for the knowledge of the improve-ment in the policy implementationReward the department or the staff who succeed infollowing the policy and responsible for the change inthe implementation of the policyMotivate the staff with regard to the policyimplementationPeriodical review (monthly) of the follow up of thepolicy by the medication safety committee
Reduction of harm from high risk medications Article on Quality 163
Make antidotes or rescue drugs available at the pointof care for immediate administration and establishingprotocols that allow for nurses to administer antidotesor reversal agents per protocol without having tocontact a physician
DISPENSING AND STORAGE OF THE HIGHRISK MEDICATIONS
d The high risk medications must be stored in the hospitalpharmacy with special care
Electrolytes
The concentrated electrolytes (sodium chloride potas-sium chloride magnesium sulphate) must be stored onlyin the pharmacy Theymust not be in the patient care areasThe concentrated electrolytes must be diluted under thelaminar hood of the pharmacy only by the personresponsible for dilutionWhile dispensing they must be sent with the HIGHRISK MEDICATION sticker
Narcotics
Narcotic drugs (morphine fentanyl pethidine) must bestored under the double lock chamber in the pharmacyThe two keys must be with two separate persons amongthe pharmacy staff nurses (in patient care areas)After the reception of the indent by the pharmacy theindent must undergo double check by the pharmacy staffand the staff responsible must unlock and take out thedrug and fill the details in the narcotic drug receiptThe drug must be sent with HIGH RISK MEDICA-TION stickerAll the narcotics issued by the pharmacy will be docu-mented in the NARCOTICS BOOK by the concernedpharmacist
Insulin
All the insulin injections must be stored in a separaterefrigerator in the pharmacyThe insulin drugs must be sent with the HIGH RISKMEDICATION sticker along with the ice pack
Heparin
Heparin must be stored in the lock and keyHeparin must be sent with HIGH RISK MEDICA-TION sticker
Chemotherapeutic drugs
These drugs are stored in the refrigerator in the phar-macy (usually chemo unit pharmacy)They are sent with HIGH RISK MEDICATION stickerThe pharmacist who dispenses the drug takes the signa-ture of the user department staff who received the drugas it is costly and must not be misused
ERRORS IN DISPENSING
The errors encountered in dispensing of the high risk medi-cations wered Drugs sent without HIGH RISK MEDICATION stickerd The concentrated electrolytes after dilution were handed
over directly to the nurse and confusion observed in thedispensing staff whether the medicine has been dispensed
d The staffs which assemble the indented medicines andsend them to the concerned staff for verification forgetsto attach the HIGH RISK MEDICATION sticker andhave to be alerted by the verification staff The chanceof medicine been dispensed without the HIGH RISKMEDICATION sticker increases the chance of errors
INTERPRETATION OF THE ERRORS INDISPENSING HIGH RISK MEDICATION
d Out of the 100 observations of dispensing of high riskmedication 10 of errors were observed
d The dispensing process was taking place quite accordingto the policy guidelines
d Out of all the errors 50 were the error of sending themedicationwithoutHIGHRISKMEDICATIONsticker
164 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Most of the errors were bound to be occurring at thelevel of the staff which is assembling the medicationsand sending for the verification
REASONS FOR THE ERRORS DURINGDISPENSING
Pharmacy was overcrowded with staff during the peaktime of morning (11 ame2 pm)Chaos between the staff assembling verifying packingand dispensing the medicines (leads to confusion amongthe staff)Staff unable to handle all the indents which resulted indelay in dispensing and piling up of the indentsSlow connectivity of the intranet in the hospital due towhich there was a delay in the reception of the indent
INTERVENTIONS FOR PROPER IMPLE-MENTATION OF THE POLICY GUIDELINES INDISPENSING THE HIGH RISK MEDICATIONS
U Pharmacy staff to be educated about the list of thehigh risk medications
U Display charts made available for the policy guidelinesatd Assembling counters e staff can identify the highrisk drugs and take steps to prevent the error of mixingthem with other drugs while replacing and error of notplacing the high risk sticker
d Verifying counterse staff can easily identify themedi-cines if they are without sticker identify the correctmedicine (in case of LASA) easy to alert the dispensingstaff not to mix with other drugs
d Packing and dispensing counters e staff can easilyseparate them and dispense them mostly if it is animmediate requirement because of the sticker placed
U Assignment of a separate dispensing staff for the highrisk medication to avoid the chaos
U Staff to be motivated to follow the policy guidelinesconstantly (by reward etc)
U Review of the performance after the interventionU Periodical review of the policy and the performance
standardsU Adequate staff to be maintained in the pharmacy to
avoid chaos in the departmentU Keep the staff educated about the updated policyU Keep the intranet always active to prevent the delay in
the dispensing of the medicationsU All the high risk medications to be kept at the separate
corner of the pharmacy for easy differentiation (exceptnarcotics which are in double lock)
U Keep all the high risk medicines at the place where theinsulin refrigerator is placed rather than at the othercorner which is not easily accessible No chaos willbe observed in this situation after the changed The areas to be concentrated to greater extent wereSICU PICU CT post chemo unit floors (II and III)
d A periodical review is carried out in the hospital afterthe intervention to have a broader and comprehensivestudy of the implementation intensity of the policyguidelines with respect to the high risk medications
d A near to 100 compliance would suggest that thepolicy guidelines are been followed in the hospital ina sustained manner and safe high risk medication prac-tise can be delivered to the patients of the hospital
On the whole the compliance of the hospital needed tobe improved with respect to the current status
MODIFIED POLICY FOR HIGH ALERTMEDICATIONS
d The high alert (concentrated electrolytes) must be prescribedin a separate high alert medications chart in the drug chart
d All concentrated electrolytes must be stored in the phar-macy only They must not be in the patient care areas
d All the narcotic drugs must be stored in a double locksystem and two keys with two different nurses
d The narcotic drugs should be discarded in the presenceof two witnesses in the sink and the empty ampouleshould be sent to the pharmacy in a black cover forfurther discarding from the hospital
d The high risk medications must be administered in thepresence of a witness
d After the administration of the high risk medicationsmonitoring must be done to check for any adverse events
d All the high risk medications must be dispensed withHIGH RISK MEDICATION sticker
Action taken
After understanding the lacunae in the system high alert policywasmodified and separate stickers were designed to ensure thatall high alert medications are labelled with instructions Evenfew more drugs like insulin LASA etc were added into thelist to ensure that we have covered all high risk drugs as well
The same was implemented effectively from October2011
Reduction of harm from high risk medications Article on Quality 165
Post implementation
A similar study was conducted on the same number ofpatients during February 2012eMarch 2012
The number of errors related to high alert drugs reducedto 12 with respect to focused trainings labelling posterscharts etc and none of the errors actually reached thepatient
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
Medicine group Risks to the patient
Anticoagulants Narrow therapeutic indexpotential for clot or bleedinteractions with othermedications even herbalmedicines over the counterdrugs and food
Opiates Sedation respiratory depressionconfusion lethargy nauseavomiting constipation
Insulin Loss of blood sugar control inpost-operative patients achievingblood sugar control withoutcausing hypoglycaemia
Concentratedelectrolytes
Increase in the level of theelectrolytes leading to lethal effects
LASA Risk of administration of theincorrect medications and theconsequent adverse effects
Reduction of harm from high risk medications Article on Quality 161
OBJECTIVES OF THE STUDY
d To know the current status of the care in the delivery ofhigh risk medications to the patients
d To intervene if any care in the delivery of the high riskmedications is still required
METHODOLOGY OF STUDY
d A random study was conducted in the hospital in allICUs 1st and 2nd floors
d The study had been carried out for 6 weeksd Over 100 patients were studied with regard to the care in
administration of high risk medicationsd Over 100 samples were studied with regard to the
dispensing of the high risk medications to the patientsfrom the pharmacy and storage in the pharmacy
Graph Analyzed results- errors in high risk medicationadministration
INCLUSIONS OF THE STUDY
d All the patients in the ICUs 1st and 2nd floors wereincluded in the study
d The case files of all the patients were referred for therequired information
d Thesepatientswereobserved for theproper administrationofthe high risk medications in the respective departments
d The dispensing of the high risk medicines was observedduring morning and the evening time
EXCLUSIONS OF THE STUDY
d LASA drugs were excludedd Dispensing during the night time was excludedd Chemo drugs were excluded for the three quarters of the
study
INTERPRETATIONS
The errors observed in the administration and transcrip-tions wered Drugs indented but not administeredd Drugs not written in the high alert chart by the physiciansd No double signatures in the drug chart after adminis-
tering the narcoticsd Hypoglycaemia not monitored and documentedd Magnesium levels were not monitored after the adminis-
tration of the electrolyte magnesium sulphated Blood pressure when improper after the administration
of fentanyl not correctedd Indications for the drugs not written in the drug chart
especially in case of chemo drugsd Correct date is not written in the drug chartd Wrong drugs are written in the high alert chartd Stop orders not written in the high alert chart
DETAILED DESCRIPTION OF THE INTERPRE-TATIONS OF THE STUDY
d Among 110 patients observed for the administration ofthe high risk medications 50 errors were found to occurie at the rate of 455 (Fig 1)
MEDICATION
ERROR
MAN MACHINE
METHOD ENVIRONMENT
Floor wise dispensing counters not available
Wrong selection of drugs
Wrong verbal order taken by staff
Staff not complying with two identifier while labeling and administering drugs
Pharmacy staff not trained in drug selection and packaging
Ward pharmacist not trained to check prescriptions
Staff not motivated to report errors
Complicated indenting system time consuming
No training for prescription writing
Nurse not trained to take verbal orders
INVENTORY
Out of stock
Delay in bringing medicines from storesINTERPRETATION
Wrong interpretation of medicine
Illegible
Manual work
Look alike sound alike drugs
Incorrect prescription written by doctor
Junior doctors reluctant to take verbal order Staff not following 7R check before administration
Procedure for drug selection and packaging not in place
Unorganized drug in IP pharmacy
Verbal order taken
Improper procedure for medicine administration
Inappropriate organization of drugs in IP pharmacy
Unorganized Imprest stock in ward
Noising factors in IP pharmacy
Time for 7R check not available
Computer system fails to operate
Fig 1 Fish bone analysis - medication errors
162 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Among all the errors which were observedB 20 of the errors happened to be the absence of
double signature during the administration of thehigh risk medications mostly concentratedelectrolytes
B 10 of the errors e high risk medications not writtenin high alert chart of the drug chart by the physician
d Among the errors observed the areas of errorsB Absence of double signatured70 of was observed
in CT postB The other areas were the errors were observeddPICU
regency III floor II floor cancer blockd The reasons for the errors found areB Lack of proper training to the staff with regard to the
specific drugsB Lack of timeB Ignorance of the staff with respect to continuous
implementation of the policy guidelinesB Lack of monitoring by the accountable authority
d The interventions ought to be carried out to minimisethe errors were
First and foremost is the proper training of the staffin terms of the policy which includes the list of thehigh risk medicines and all its required guidelinesMonitoring the staff for the follow up of the policyPutting up display charts depicting the policy ofadministration of the high risk medications so thatthe staff will be reminded of the policyMake the senior staff accountable for the regularimplementation of the policySet up a deadline (time period) for the review of theperformance of the staff after the interventionReview the performance of the hospital staff afterthe intervention for the knowledge of the improve-ment in the policy implementationReward the department or the staff who succeed infollowing the policy and responsible for the change inthe implementation of the policyMotivate the staff with regard to the policyimplementationPeriodical review (monthly) of the follow up of thepolicy by the medication safety committee
Reduction of harm from high risk medications Article on Quality 163
Make antidotes or rescue drugs available at the pointof care for immediate administration and establishingprotocols that allow for nurses to administer antidotesor reversal agents per protocol without having tocontact a physician
DISPENSING AND STORAGE OF THE HIGHRISK MEDICATIONS
d The high risk medications must be stored in the hospitalpharmacy with special care
Electrolytes
The concentrated electrolytes (sodium chloride potas-sium chloride magnesium sulphate) must be stored onlyin the pharmacy Theymust not be in the patient care areasThe concentrated electrolytes must be diluted under thelaminar hood of the pharmacy only by the personresponsible for dilutionWhile dispensing they must be sent with the HIGHRISK MEDICATION sticker
Narcotics
Narcotic drugs (morphine fentanyl pethidine) must bestored under the double lock chamber in the pharmacyThe two keys must be with two separate persons amongthe pharmacy staff nurses (in patient care areas)After the reception of the indent by the pharmacy theindent must undergo double check by the pharmacy staffand the staff responsible must unlock and take out thedrug and fill the details in the narcotic drug receiptThe drug must be sent with HIGH RISK MEDICA-TION stickerAll the narcotics issued by the pharmacy will be docu-mented in the NARCOTICS BOOK by the concernedpharmacist
Insulin
All the insulin injections must be stored in a separaterefrigerator in the pharmacyThe insulin drugs must be sent with the HIGH RISKMEDICATION sticker along with the ice pack
Heparin
Heparin must be stored in the lock and keyHeparin must be sent with HIGH RISK MEDICA-TION sticker
Chemotherapeutic drugs
These drugs are stored in the refrigerator in the phar-macy (usually chemo unit pharmacy)They are sent with HIGH RISK MEDICATION stickerThe pharmacist who dispenses the drug takes the signa-ture of the user department staff who received the drugas it is costly and must not be misused
ERRORS IN DISPENSING
The errors encountered in dispensing of the high risk medi-cations wered Drugs sent without HIGH RISK MEDICATION stickerd The concentrated electrolytes after dilution were handed
over directly to the nurse and confusion observed in thedispensing staff whether the medicine has been dispensed
d The staffs which assemble the indented medicines andsend them to the concerned staff for verification forgetsto attach the HIGH RISK MEDICATION sticker andhave to be alerted by the verification staff The chanceof medicine been dispensed without the HIGH RISKMEDICATION sticker increases the chance of errors
INTERPRETATION OF THE ERRORS INDISPENSING HIGH RISK MEDICATION
d Out of the 100 observations of dispensing of high riskmedication 10 of errors were observed
d The dispensing process was taking place quite accordingto the policy guidelines
d Out of all the errors 50 were the error of sending themedicationwithoutHIGHRISKMEDICATIONsticker
164 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Most of the errors were bound to be occurring at thelevel of the staff which is assembling the medicationsand sending for the verification
REASONS FOR THE ERRORS DURINGDISPENSING
Pharmacy was overcrowded with staff during the peaktime of morning (11 ame2 pm)Chaos between the staff assembling verifying packingand dispensing the medicines (leads to confusion amongthe staff)Staff unable to handle all the indents which resulted indelay in dispensing and piling up of the indentsSlow connectivity of the intranet in the hospital due towhich there was a delay in the reception of the indent
INTERVENTIONS FOR PROPER IMPLE-MENTATION OF THE POLICY GUIDELINES INDISPENSING THE HIGH RISK MEDICATIONS
U Pharmacy staff to be educated about the list of thehigh risk medications
U Display charts made available for the policy guidelinesatd Assembling counters e staff can identify the highrisk drugs and take steps to prevent the error of mixingthem with other drugs while replacing and error of notplacing the high risk sticker
d Verifying counterse staff can easily identify themedi-cines if they are without sticker identify the correctmedicine (in case of LASA) easy to alert the dispensingstaff not to mix with other drugs
d Packing and dispensing counters e staff can easilyseparate them and dispense them mostly if it is animmediate requirement because of the sticker placed
U Assignment of a separate dispensing staff for the highrisk medication to avoid the chaos
U Staff to be motivated to follow the policy guidelinesconstantly (by reward etc)
U Review of the performance after the interventionU Periodical review of the policy and the performance
standardsU Adequate staff to be maintained in the pharmacy to
avoid chaos in the departmentU Keep the staff educated about the updated policyU Keep the intranet always active to prevent the delay in
the dispensing of the medicationsU All the high risk medications to be kept at the separate
corner of the pharmacy for easy differentiation (exceptnarcotics which are in double lock)
U Keep all the high risk medicines at the place where theinsulin refrigerator is placed rather than at the othercorner which is not easily accessible No chaos willbe observed in this situation after the changed The areas to be concentrated to greater extent wereSICU PICU CT post chemo unit floors (II and III)
d A periodical review is carried out in the hospital afterthe intervention to have a broader and comprehensivestudy of the implementation intensity of the policyguidelines with respect to the high risk medications
d A near to 100 compliance would suggest that thepolicy guidelines are been followed in the hospital ina sustained manner and safe high risk medication prac-tise can be delivered to the patients of the hospital
On the whole the compliance of the hospital needed tobe improved with respect to the current status
MODIFIED POLICY FOR HIGH ALERTMEDICATIONS
d The high alert (concentrated electrolytes) must be prescribedin a separate high alert medications chart in the drug chart
d All concentrated electrolytes must be stored in the phar-macy only They must not be in the patient care areas
d All the narcotic drugs must be stored in a double locksystem and two keys with two different nurses
d The narcotic drugs should be discarded in the presenceof two witnesses in the sink and the empty ampouleshould be sent to the pharmacy in a black cover forfurther discarding from the hospital
d The high risk medications must be administered in thepresence of a witness
d After the administration of the high risk medicationsmonitoring must be done to check for any adverse events
d All the high risk medications must be dispensed withHIGH RISK MEDICATION sticker
Action taken
After understanding the lacunae in the system high alert policywasmodified and separate stickers were designed to ensure thatall high alert medications are labelled with instructions Evenfew more drugs like insulin LASA etc were added into thelist to ensure that we have covered all high risk drugs as well
The same was implemented effectively from October2011
Reduction of harm from high risk medications Article on Quality 165
Post implementation
A similar study was conducted on the same number ofpatients during February 2012eMarch 2012
The number of errors related to high alert drugs reducedto 12 with respect to focused trainings labelling posterscharts etc and none of the errors actually reached thepatient
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
MEDICATION
ERROR
MAN MACHINE
METHOD ENVIRONMENT
Floor wise dispensing counters not available
Wrong selection of drugs
Wrong verbal order taken by staff
Staff not complying with two identifier while labeling and administering drugs
Pharmacy staff not trained in drug selection and packaging
Ward pharmacist not trained to check prescriptions
Staff not motivated to report errors
Complicated indenting system time consuming
No training for prescription writing
Nurse not trained to take verbal orders
INVENTORY
Out of stock
Delay in bringing medicines from storesINTERPRETATION
Wrong interpretation of medicine
Illegible
Manual work
Look alike sound alike drugs
Incorrect prescription written by doctor
Junior doctors reluctant to take verbal order Staff not following 7R check before administration
Procedure for drug selection and packaging not in place
Unorganized drug in IP pharmacy
Verbal order taken
Improper procedure for medicine administration
Inappropriate organization of drugs in IP pharmacy
Unorganized Imprest stock in ward
Noising factors in IP pharmacy
Time for 7R check not available
Computer system fails to operate
Fig 1 Fish bone analysis - medication errors
162 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Among all the errors which were observedB 20 of the errors happened to be the absence of
double signature during the administration of thehigh risk medications mostly concentratedelectrolytes
B 10 of the errors e high risk medications not writtenin high alert chart of the drug chart by the physician
d Among the errors observed the areas of errorsB Absence of double signatured70 of was observed
in CT postB The other areas were the errors were observeddPICU
regency III floor II floor cancer blockd The reasons for the errors found areB Lack of proper training to the staff with regard to the
specific drugsB Lack of timeB Ignorance of the staff with respect to continuous
implementation of the policy guidelinesB Lack of monitoring by the accountable authority
d The interventions ought to be carried out to minimisethe errors were
First and foremost is the proper training of the staffin terms of the policy which includes the list of thehigh risk medicines and all its required guidelinesMonitoring the staff for the follow up of the policyPutting up display charts depicting the policy ofadministration of the high risk medications so thatthe staff will be reminded of the policyMake the senior staff accountable for the regularimplementation of the policySet up a deadline (time period) for the review of theperformance of the staff after the interventionReview the performance of the hospital staff afterthe intervention for the knowledge of the improve-ment in the policy implementationReward the department or the staff who succeed infollowing the policy and responsible for the change inthe implementation of the policyMotivate the staff with regard to the policyimplementationPeriodical review (monthly) of the follow up of thepolicy by the medication safety committee
Reduction of harm from high risk medications Article on Quality 163
Make antidotes or rescue drugs available at the pointof care for immediate administration and establishingprotocols that allow for nurses to administer antidotesor reversal agents per protocol without having tocontact a physician
DISPENSING AND STORAGE OF THE HIGHRISK MEDICATIONS
d The high risk medications must be stored in the hospitalpharmacy with special care
Electrolytes
The concentrated electrolytes (sodium chloride potas-sium chloride magnesium sulphate) must be stored onlyin the pharmacy Theymust not be in the patient care areasThe concentrated electrolytes must be diluted under thelaminar hood of the pharmacy only by the personresponsible for dilutionWhile dispensing they must be sent with the HIGHRISK MEDICATION sticker
Narcotics
Narcotic drugs (morphine fentanyl pethidine) must bestored under the double lock chamber in the pharmacyThe two keys must be with two separate persons amongthe pharmacy staff nurses (in patient care areas)After the reception of the indent by the pharmacy theindent must undergo double check by the pharmacy staffand the staff responsible must unlock and take out thedrug and fill the details in the narcotic drug receiptThe drug must be sent with HIGH RISK MEDICA-TION stickerAll the narcotics issued by the pharmacy will be docu-mented in the NARCOTICS BOOK by the concernedpharmacist
Insulin
All the insulin injections must be stored in a separaterefrigerator in the pharmacyThe insulin drugs must be sent with the HIGH RISKMEDICATION sticker along with the ice pack
Heparin
Heparin must be stored in the lock and keyHeparin must be sent with HIGH RISK MEDICA-TION sticker
Chemotherapeutic drugs
These drugs are stored in the refrigerator in the phar-macy (usually chemo unit pharmacy)They are sent with HIGH RISK MEDICATION stickerThe pharmacist who dispenses the drug takes the signa-ture of the user department staff who received the drugas it is costly and must not be misused
ERRORS IN DISPENSING
The errors encountered in dispensing of the high risk medi-cations wered Drugs sent without HIGH RISK MEDICATION stickerd The concentrated electrolytes after dilution were handed
over directly to the nurse and confusion observed in thedispensing staff whether the medicine has been dispensed
d The staffs which assemble the indented medicines andsend them to the concerned staff for verification forgetsto attach the HIGH RISK MEDICATION sticker andhave to be alerted by the verification staff The chanceof medicine been dispensed without the HIGH RISKMEDICATION sticker increases the chance of errors
INTERPRETATION OF THE ERRORS INDISPENSING HIGH RISK MEDICATION
d Out of the 100 observations of dispensing of high riskmedication 10 of errors were observed
d The dispensing process was taking place quite accordingto the policy guidelines
d Out of all the errors 50 were the error of sending themedicationwithoutHIGHRISKMEDICATIONsticker
164 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Most of the errors were bound to be occurring at thelevel of the staff which is assembling the medicationsand sending for the verification
REASONS FOR THE ERRORS DURINGDISPENSING
Pharmacy was overcrowded with staff during the peaktime of morning (11 ame2 pm)Chaos between the staff assembling verifying packingand dispensing the medicines (leads to confusion amongthe staff)Staff unable to handle all the indents which resulted indelay in dispensing and piling up of the indentsSlow connectivity of the intranet in the hospital due towhich there was a delay in the reception of the indent
INTERVENTIONS FOR PROPER IMPLE-MENTATION OF THE POLICY GUIDELINES INDISPENSING THE HIGH RISK MEDICATIONS
U Pharmacy staff to be educated about the list of thehigh risk medications
U Display charts made available for the policy guidelinesatd Assembling counters e staff can identify the highrisk drugs and take steps to prevent the error of mixingthem with other drugs while replacing and error of notplacing the high risk sticker
d Verifying counterse staff can easily identify themedi-cines if they are without sticker identify the correctmedicine (in case of LASA) easy to alert the dispensingstaff not to mix with other drugs
d Packing and dispensing counters e staff can easilyseparate them and dispense them mostly if it is animmediate requirement because of the sticker placed
U Assignment of a separate dispensing staff for the highrisk medication to avoid the chaos
U Staff to be motivated to follow the policy guidelinesconstantly (by reward etc)
U Review of the performance after the interventionU Periodical review of the policy and the performance
standardsU Adequate staff to be maintained in the pharmacy to
avoid chaos in the departmentU Keep the staff educated about the updated policyU Keep the intranet always active to prevent the delay in
the dispensing of the medicationsU All the high risk medications to be kept at the separate
corner of the pharmacy for easy differentiation (exceptnarcotics which are in double lock)
U Keep all the high risk medicines at the place where theinsulin refrigerator is placed rather than at the othercorner which is not easily accessible No chaos willbe observed in this situation after the changed The areas to be concentrated to greater extent wereSICU PICU CT post chemo unit floors (II and III)
d A periodical review is carried out in the hospital afterthe intervention to have a broader and comprehensivestudy of the implementation intensity of the policyguidelines with respect to the high risk medications
d A near to 100 compliance would suggest that thepolicy guidelines are been followed in the hospital ina sustained manner and safe high risk medication prac-tise can be delivered to the patients of the hospital
On the whole the compliance of the hospital needed tobe improved with respect to the current status
MODIFIED POLICY FOR HIGH ALERTMEDICATIONS
d The high alert (concentrated electrolytes) must be prescribedin a separate high alert medications chart in the drug chart
d All concentrated electrolytes must be stored in the phar-macy only They must not be in the patient care areas
d All the narcotic drugs must be stored in a double locksystem and two keys with two different nurses
d The narcotic drugs should be discarded in the presenceof two witnesses in the sink and the empty ampouleshould be sent to the pharmacy in a black cover forfurther discarding from the hospital
d The high risk medications must be administered in thepresence of a witness
d After the administration of the high risk medicationsmonitoring must be done to check for any adverse events
d All the high risk medications must be dispensed withHIGH RISK MEDICATION sticker
Action taken
After understanding the lacunae in the system high alert policywasmodified and separate stickers were designed to ensure thatall high alert medications are labelled with instructions Evenfew more drugs like insulin LASA etc were added into thelist to ensure that we have covered all high risk drugs as well
The same was implemented effectively from October2011
Reduction of harm from high risk medications Article on Quality 165
Post implementation
A similar study was conducted on the same number ofpatients during February 2012eMarch 2012
The number of errors related to high alert drugs reducedto 12 with respect to focused trainings labelling posterscharts etc and none of the errors actually reached thepatient
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
Reduction of harm from high risk medications Article on Quality 163
Make antidotes or rescue drugs available at the pointof care for immediate administration and establishingprotocols that allow for nurses to administer antidotesor reversal agents per protocol without having tocontact a physician
DISPENSING AND STORAGE OF THE HIGHRISK MEDICATIONS
d The high risk medications must be stored in the hospitalpharmacy with special care
Electrolytes
The concentrated electrolytes (sodium chloride potas-sium chloride magnesium sulphate) must be stored onlyin the pharmacy Theymust not be in the patient care areasThe concentrated electrolytes must be diluted under thelaminar hood of the pharmacy only by the personresponsible for dilutionWhile dispensing they must be sent with the HIGHRISK MEDICATION sticker
Narcotics
Narcotic drugs (morphine fentanyl pethidine) must bestored under the double lock chamber in the pharmacyThe two keys must be with two separate persons amongthe pharmacy staff nurses (in patient care areas)After the reception of the indent by the pharmacy theindent must undergo double check by the pharmacy staffand the staff responsible must unlock and take out thedrug and fill the details in the narcotic drug receiptThe drug must be sent with HIGH RISK MEDICA-TION stickerAll the narcotics issued by the pharmacy will be docu-mented in the NARCOTICS BOOK by the concernedpharmacist
Insulin
All the insulin injections must be stored in a separaterefrigerator in the pharmacyThe insulin drugs must be sent with the HIGH RISKMEDICATION sticker along with the ice pack
Heparin
Heparin must be stored in the lock and keyHeparin must be sent with HIGH RISK MEDICA-TION sticker
Chemotherapeutic drugs
These drugs are stored in the refrigerator in the phar-macy (usually chemo unit pharmacy)They are sent with HIGH RISK MEDICATION stickerThe pharmacist who dispenses the drug takes the signa-ture of the user department staff who received the drugas it is costly and must not be misused
ERRORS IN DISPENSING
The errors encountered in dispensing of the high risk medi-cations wered Drugs sent without HIGH RISK MEDICATION stickerd The concentrated electrolytes after dilution were handed
over directly to the nurse and confusion observed in thedispensing staff whether the medicine has been dispensed
d The staffs which assemble the indented medicines andsend them to the concerned staff for verification forgetsto attach the HIGH RISK MEDICATION sticker andhave to be alerted by the verification staff The chanceof medicine been dispensed without the HIGH RISKMEDICATION sticker increases the chance of errors
INTERPRETATION OF THE ERRORS INDISPENSING HIGH RISK MEDICATION
d Out of the 100 observations of dispensing of high riskmedication 10 of errors were observed
d The dispensing process was taking place quite accordingto the policy guidelines
d Out of all the errors 50 were the error of sending themedicationwithoutHIGHRISKMEDICATIONsticker
164 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Most of the errors were bound to be occurring at thelevel of the staff which is assembling the medicationsand sending for the verification
REASONS FOR THE ERRORS DURINGDISPENSING
Pharmacy was overcrowded with staff during the peaktime of morning (11 ame2 pm)Chaos between the staff assembling verifying packingand dispensing the medicines (leads to confusion amongthe staff)Staff unable to handle all the indents which resulted indelay in dispensing and piling up of the indentsSlow connectivity of the intranet in the hospital due towhich there was a delay in the reception of the indent
INTERVENTIONS FOR PROPER IMPLE-MENTATION OF THE POLICY GUIDELINES INDISPENSING THE HIGH RISK MEDICATIONS
U Pharmacy staff to be educated about the list of thehigh risk medications
U Display charts made available for the policy guidelinesatd Assembling counters e staff can identify the highrisk drugs and take steps to prevent the error of mixingthem with other drugs while replacing and error of notplacing the high risk sticker
d Verifying counterse staff can easily identify themedi-cines if they are without sticker identify the correctmedicine (in case of LASA) easy to alert the dispensingstaff not to mix with other drugs
d Packing and dispensing counters e staff can easilyseparate them and dispense them mostly if it is animmediate requirement because of the sticker placed
U Assignment of a separate dispensing staff for the highrisk medication to avoid the chaos
U Staff to be motivated to follow the policy guidelinesconstantly (by reward etc)
U Review of the performance after the interventionU Periodical review of the policy and the performance
standardsU Adequate staff to be maintained in the pharmacy to
avoid chaos in the departmentU Keep the staff educated about the updated policyU Keep the intranet always active to prevent the delay in
the dispensing of the medicationsU All the high risk medications to be kept at the separate
corner of the pharmacy for easy differentiation (exceptnarcotics which are in double lock)
U Keep all the high risk medicines at the place where theinsulin refrigerator is placed rather than at the othercorner which is not easily accessible No chaos willbe observed in this situation after the changed The areas to be concentrated to greater extent wereSICU PICU CT post chemo unit floors (II and III)
d A periodical review is carried out in the hospital afterthe intervention to have a broader and comprehensivestudy of the implementation intensity of the policyguidelines with respect to the high risk medications
d A near to 100 compliance would suggest that thepolicy guidelines are been followed in the hospital ina sustained manner and safe high risk medication prac-tise can be delivered to the patients of the hospital
On the whole the compliance of the hospital needed tobe improved with respect to the current status
MODIFIED POLICY FOR HIGH ALERTMEDICATIONS
d The high alert (concentrated electrolytes) must be prescribedin a separate high alert medications chart in the drug chart
d All concentrated electrolytes must be stored in the phar-macy only They must not be in the patient care areas
d All the narcotic drugs must be stored in a double locksystem and two keys with two different nurses
d The narcotic drugs should be discarded in the presenceof two witnesses in the sink and the empty ampouleshould be sent to the pharmacy in a black cover forfurther discarding from the hospital
d The high risk medications must be administered in thepresence of a witness
d After the administration of the high risk medicationsmonitoring must be done to check for any adverse events
d All the high risk medications must be dispensed withHIGH RISK MEDICATION sticker
Action taken
After understanding the lacunae in the system high alert policywasmodified and separate stickers were designed to ensure thatall high alert medications are labelled with instructions Evenfew more drugs like insulin LASA etc were added into thelist to ensure that we have covered all high risk drugs as well
The same was implemented effectively from October2011
Reduction of harm from high risk medications Article on Quality 165
Post implementation
A similar study was conducted on the same number ofpatients during February 2012eMarch 2012
The number of errors related to high alert drugs reducedto 12 with respect to focused trainings labelling posterscharts etc and none of the errors actually reached thepatient
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
164 Apollo Medicine 2012 June Vol 9 No 2 Loria
d Most of the errors were bound to be occurring at thelevel of the staff which is assembling the medicationsand sending for the verification
REASONS FOR THE ERRORS DURINGDISPENSING
Pharmacy was overcrowded with staff during the peaktime of morning (11 ame2 pm)Chaos between the staff assembling verifying packingand dispensing the medicines (leads to confusion amongthe staff)Staff unable to handle all the indents which resulted indelay in dispensing and piling up of the indentsSlow connectivity of the intranet in the hospital due towhich there was a delay in the reception of the indent
INTERVENTIONS FOR PROPER IMPLE-MENTATION OF THE POLICY GUIDELINES INDISPENSING THE HIGH RISK MEDICATIONS
U Pharmacy staff to be educated about the list of thehigh risk medications
U Display charts made available for the policy guidelinesatd Assembling counters e staff can identify the highrisk drugs and take steps to prevent the error of mixingthem with other drugs while replacing and error of notplacing the high risk sticker
d Verifying counterse staff can easily identify themedi-cines if they are without sticker identify the correctmedicine (in case of LASA) easy to alert the dispensingstaff not to mix with other drugs
d Packing and dispensing counters e staff can easilyseparate them and dispense them mostly if it is animmediate requirement because of the sticker placed
U Assignment of a separate dispensing staff for the highrisk medication to avoid the chaos
U Staff to be motivated to follow the policy guidelinesconstantly (by reward etc)
U Review of the performance after the interventionU Periodical review of the policy and the performance
standardsU Adequate staff to be maintained in the pharmacy to
avoid chaos in the departmentU Keep the staff educated about the updated policyU Keep the intranet always active to prevent the delay in
the dispensing of the medicationsU All the high risk medications to be kept at the separate
corner of the pharmacy for easy differentiation (exceptnarcotics which are in double lock)
U Keep all the high risk medicines at the place where theinsulin refrigerator is placed rather than at the othercorner which is not easily accessible No chaos willbe observed in this situation after the changed The areas to be concentrated to greater extent wereSICU PICU CT post chemo unit floors (II and III)
d A periodical review is carried out in the hospital afterthe intervention to have a broader and comprehensivestudy of the implementation intensity of the policyguidelines with respect to the high risk medications
d A near to 100 compliance would suggest that thepolicy guidelines are been followed in the hospital ina sustained manner and safe high risk medication prac-tise can be delivered to the patients of the hospital
On the whole the compliance of the hospital needed tobe improved with respect to the current status
MODIFIED POLICY FOR HIGH ALERTMEDICATIONS
d The high alert (concentrated electrolytes) must be prescribedin a separate high alert medications chart in the drug chart
d All concentrated electrolytes must be stored in the phar-macy only They must not be in the patient care areas
d All the narcotic drugs must be stored in a double locksystem and two keys with two different nurses
d The narcotic drugs should be discarded in the presenceof two witnesses in the sink and the empty ampouleshould be sent to the pharmacy in a black cover forfurther discarding from the hospital
d The high risk medications must be administered in thepresence of a witness
d After the administration of the high risk medicationsmonitoring must be done to check for any adverse events
d All the high risk medications must be dispensed withHIGH RISK MEDICATION sticker
Action taken
After understanding the lacunae in the system high alert policywasmodified and separate stickers were designed to ensure thatall high alert medications are labelled with instructions Evenfew more drugs like insulin LASA etc were added into thelist to ensure that we have covered all high risk drugs as well
The same was implemented effectively from October2011
Reduction of harm from high risk medications Article on Quality 165
Post implementation
A similar study was conducted on the same number ofpatients during February 2012eMarch 2012
The number of errors related to high alert drugs reducedto 12 with respect to focused trainings labelling posterscharts etc and none of the errors actually reached thepatient
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
Reduction of harm from high risk medications Article on Quality 165
Post implementation
A similar study was conducted on the same number ofpatients during February 2012eMarch 2012
The number of errors related to high alert drugs reducedto 12 with respect to focused trainings labelling posterscharts etc and none of the errors actually reached thepatient
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
Apollo hospitals httpwwwapollohospitalscomTwitter httpstwittercomHospitalsApolloYoutube httpwwwyoutubecomapollohospitalsindiaFacebook httpwwwfacebookcomTheApolloHospitalsSlideshare httpwwwslidesharenetApollo_HospitalsLinkedin httpwwwlinkedincomcompanyapollo-hospitalsBlogBlog httpwwwletstalkhealthin
