Medication Safety and Quality Improvement
What does code blue mean?
A code blue refers to a patient requiring emergency medical care, typically for cardiac or respiratory arrest. The overhead announcement and/or paging system will provide the patient's location. The code team (often including a pharmacist) will rush to the room and begin immediate resuscitative efforts.
What are the benefits of using a CPOE and CDS tool?
A much greater benefit is seen with the combination of CPOE and clinical decision support (CDS) tools. Clinical guidelines and patient labs can be built into the CPOE system and alerts can notify a prescriber if the drug is inappropriate, or if labs indicate that the drug could be unsafe (such as a high potassium level and a new order for a potassium-sparing agent)
What is a root cause analysis?
A root cause analysis (RCA) is a retrospective investigation of an event that has already occurred which includes reviewing the sequence of events that led to the error.
What is a sentinel event?
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. When a sentinel event occurs, it is important to find out what went wrong and implement measures to prevent it from happening again.
What contributes to medical errors?
Abbreviations are unsafe and contribute to many medical errors. ISMP also publishes a list of error-prone abbreviations, symbols, and dosage designations which includes those on TJC's list and many others.
What are examples of high-alert medications?
Acute Care, Community/Ambulatory and/or Long-Term Care Settings ■ Anesthetics, IV or inhaled (e.g., propofol) ■ Antiarrhythmics, IV (e.g., amiodarone) ■ Anticoagulants/Antithrombotics (e.g., heparin, warfarin) ■ Chemotherapeutics (e.g., methotrexate) ■ Epidural/intrathecal drugs ■ Hypertonic saline (greater than 0.9%) ■ Immunosuppressants (e.g., cyclosporine) ■ Inotropics (e.g., digoxin) ■ Insulins (e.g., insulin aspart, insulin U-500) ■ Magnesium sulfate injection ■ Opioids ■ Oral hypoglycemics (e.g., sulfonylureas) ■ Parenteral nutrition ■ Potassium chloride and phosphates for injection ■ Sterile water for injection
What is used for hand hygiene?
Alcohol-based hand rubs (gel, rinse or foam) are considered more effective in the healthcare setting than plain soap or antimicrobial soap and water, but soap and water are preferable in some situations. Antimicrobial hand soaps that contain chlorhexidine (Hibiclens, others) may be preferable to reduce infections in healthcare facilities.
What other analyses can be done for medical errors?
An analysis can also be done prospectively to identify pathways that could lead to errors and to identify ways to reduce the error risk. Failure mode and effects analysis (FMEA) is a proactive method used to reduce the frequency and consequences of errors.
What are the benefits of using barcoding?
Barcoding may be the most important medication error reduction tool available right now. The barcode follows the drug through the medication use process to make sure it is being properly stocked (such as in the right space in the pharmacy or in the right pocket in the dispensing cabinet), through compounding (if required) and to the patient. The barcode is used at the bedside to identify that the correct drug (by scanning the barcode on the drug's packaging) is going to the right patient (by scanning the barcode on the patient's wristband) and confirms that the dose is being given at the right time.
When should soap and water be used?
Before eating. After using the restroom. Anytime there is visible soil (anything noticeable on the hands). After caring for a patient with diarrhea or known C. difficile or spore-forming organisms; alcohol-based hand rubs have poor activity against spores. Handwashing physically removes spores. Before caring for patients with food allergies.
When to perform hand hygiene?
Before entering and after leaving patient rooms and between patient contacts if there is more than one patient per room. ■ Before donning and after removing gloves (use new gloves with each patient). ■ Before handling invasive devices, including injections. ■ After coughing or sneezing. ■ Before handling food and oral medications.
What is a problem with using MS, MSO4 and MgSO4?
Can mean morphine sulfate or magnesium sulfate Confused with one another Instead, Write "morphine sulfate" Instead, Write "magnesium sulfate"
What is a CPOE?
Computerized physician/provider order entry (CPOE) is a computerized process that allows direct entry of medical orders by prescribers.
What is a problem with using Trailing zero (X.O mg) Lack of leading zero (.X mg)?
Decimal point is missed resulting in a 10-fold dosing error Instead, Write X mg or Write O.X mg
Are medical errors the same things as ADRS?
Do not confuse medication errors with adverse drug reactions (ADRs). ADRs are generally not avoidable, although they may be more likely to occur if the drug is given to a patient at high-risk for certain complications.
Which at-risk behaviors can compromise patient safety?
Drug and Patient-Related ■ Failure to check/reconcile home medications and doses ■Dispensing medications without complete knowledge of the medication ■ Not questioning unusual doses ■ Not checking/verifying allergies Communication ■ Not addressing questions/concerns ■ Rushed communication Technology ■Overriding computer alerts without proper consideration ■ Not using available technology Work Environment ■ Trying to do multiple things vs. focusing on a single complex task ■ Inadequate supervision and orientation/training
Drugs with a higher risk for harm should get what label?
Drugs with a heightened risk of causing significant patient harm if used in error, should be designated as high-alert. High-alert medications can be used safely by developing protocols or order sets for use, using premixed products whenever possible, limiting concentrations available in the institution and stocking high-alert products only in the pharmacy.
It is important that heparin vials should not be present in which areas?
Due to the high-risk associated with heparin overdose, high concentration heparin vials should not be present in patient care areas. Instead, therapeutic doses should be sent by the pharmacy department.
What is error of commission?
Error of Commission Something was done incorrectly Example: prescribing bupropion to a patient with a history of seizures
What is error of omission?
Error of Omission Something was left out that is needed for safety Example: failing to warn a patient about an important side effect with a new medication
What is MTM?
Errors may be discovered during a comprehensive medication review (CMR), through the process of medication therapy management (MTM). A personal medication record (PMR) is prepared, and a medication-related action plan (MAP) is developed, preferably by a pharmacist-led team. The next steps involve interventions, referrals, documentation and plans for follow-up. Patients targeted for MTM include those with multiple chronic conditions who are taking multiple drugs and are likely to incur annual costs for covered drugs that exceed a predetermined level.
What is the most common cause of medical errors per experts?
Experts in medication safety agree that the most common cause of medication errors is a problem with the design of the medical system itself, not usually an individual making an error.
What are precautions to take with insulin?
If U-500 is stocked, specify conditions under which it is to be used, which product will be stocked (vials and U-500 syringes vs. pens), and how doses will be supplied Standardize all insulin infusions to one concentration Develop protocols for insulin infusions, transition from infusion to SC and sliding scale orders; use standard orders for management of hypoglycemia Do not use "U" for units; always label with "units" or "units = mL", but never just "mL" Do not place insulin in automated dispensing cabinets; all insulin orders should be reviewed by a pharmacist prior to dispensing
What happens if a patient has a question about medications?
If a patient questions any part of the medication dispensing process, whether it is about the drug's appearance, dose or something else, the pharmacist must be receptive and responsive (not defensive). It may be necessary to provide pictures or other means of instruction to patients who do not speak English or are unable to read English. Attempts must be made to communicate to the patient in their language, using on-site staff or dial-in translation services.
What are airborne precautions?
Intended to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air. Patient should be placed in an airborne infection isolation room (AIIR). An AIIR is a single-patient room that is equipped with special air and ventilation handling systems. The air is exhausted directly to the outside or re-circulated through HEPA filtration before being returned. Healthcare personnel wear a mask or respirator (N95 level or higher), depending on the disease, which is donned prior to room entry. Airborne precautions are recommended for patients with active pulmonary tuberculosis, measles or varicella virus (chickenpox).
How to respond to medical errors?
Internal notification: who should be notified within the institution and within what time frame? External reporting: who should be notified outside of the institution? Disclosure: what information should be shared with the patient/family? Who will be present when this occurs? Investigation: what is the process for immediate and long term internal investigation of an error? Improvement: what process will ensure that immediate and long-term preventative actions are taken?
What are PCA safety steps?
Limit the opioids available in floor stock. Use standard order sets (set drug dosages, especially for opioid-naive patients) so that drugs are not over-dosed. Educate staff about HYDROmorphone and morphine mix- ups. Implement PCA protocols that include independent double-checking of the drug, pump setting, and dosage. The concentration on the MAR should match the PCA label. Use barcoding technology. Some infusion pumps incorporate barcoding technology. Scanning the barcode on the PCA would help ensure the correct concentration is entered during PCA programming. It will also ensure that the right patient is getting the medication. Assess the patient's pain, sedation and respiratory rate on a scheduled basis.
How to prevent look-alike sound alike drugs?
Look-alike, sound-alike medications are a common cause of medication errors. Drugs that are easily mixed up should be labeled with tall man letters (the letters that are different are tall man). Here are two examples: ■ CeleXA, CeleBREX ■ predniSONE, prednisoLONE Using tall man letters, which mix upper and lower case letters, draws attention to the dissimilarities in the drug names. The letters that are upper cases are the ones that are different between the two look-alike, sound-alike drugs.
Which system should measurements be recorded in only?
Measurements should be recorded in the metric system only.
Where can medical errors be reported online?
Medication errors and close calls can be reported on the ISMP website (www.ismp.org). Professionals and consumers should be encouraged to report medication errors using this site even if the error was reported internally.
What is medication reconciliation?
Medication reconciliation involves comparing a patient's medication orders to all of the medications that the patient has been taking (home medications including OTC and dietary supplements). This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors or drug interactions.
How is a medication reconciliation done?
Medication reconciliation should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions of care include changes in setting, service, practitioner or level of care. Common examples are hospital admission, transfer into or out of an ICU and at hospital discharge. This process comprises five steps: Develop a list of current medications Develop a list of medications to be prescribed Compare the medications on the two lists Note discrepancies and make clinical decisions based on the comparison Communicate the new list to appropriate caregivers and to the patient
What is a problem with using "U", "u" (unit)?
Mistaken for "0" (zero), the number "4" (four) or "cc" Instead, Write "unit"
What is a problem with using "IU" (International Unit)?
Mistaken for IV (intravenous) or the number 10 (ten) Instead, Write "International Unit"
What is a problem with using Q.D., QD, q.d., qd (daily) or Q.O.D., QOD, q.o.d., qod (every other day)?
Mistaken for each other Period after the Q mistaken for "I" and the "O" mistaken for "I" Instead, Write "daily" or Write "every other day"
What are automated dispensing cabinets (ADC)?
Most pharmacy interns will have seen automated dispensing cabinets (ADCs) while on clinical rotations. Common names are Pyxis, Omnicell, ScriptPro and AccuDose.
What are select national patient safety goals?
NPSG 01.01.01: Use at least two patient identifiers when providing care, treatment and services. Appropriate identifiers: name, medical record number, date of birth Inappropriate non-patient specific identifiers: zip code, physician name, room number NPSG 02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. Includes lab and blood culture results; protocols must include acceptable length of time for reporting. NPSG 03.04.01: Label all medications, medication containers and other solutions on and off the sterile field in perioperative and other procedural settings. Numerous errors have been associated with removing medications from their original containers and placing them into unlabeled containers. NPSG 03.05.01: Reduce the likelihood of harm associated with anticoagulant therapy (see text). NPSG 03.06.01: Maintain and communicate accurate patient medication information (see text). NPSG 07.01.01: Comply with the Centers for Disease Control (CDC) hand hygiene guidelines.
How often are national patient safety goals set?
National patient safety goals (NPSGs) are set annually by TJC for different types of healthcare settings (e.g., ambulatory care, behavioral health, hospital).
What are safe injection practices in healthcare settings?
Never administer an oral solution/suspension intravenously; fatal errors have occurred. Use oral syringes (which are difficult or impossible to attach to a needle for IV injection) and label oral syringes "for oral use only." Never reinsert used needles into a multiple-dose vial or solution container. Single-dose vials are preferred over multiple-dose vials, especially when medications will be administered to multiple patients. Needles used for withdrawing blood or any other bodily fluid, or used for administering medications or other fluids should preferably have "engineered sharps protection" which reduces the risk of an exposure incident by a mechanism such as drawing the needle into the syringe barrel after use. Never touch the tip or plunger of a syringe. Disposable needles that are contaminated (e.g., with drugs, chemicals or blood products) should never be removed from their original syringes, unless no other option is available. Throw the entire needle/syringe assembly (needle attached to the syringe) into the red plastic sharps container. Immediately discard used disposable needles or sharps into a sharps container without recapping. The only time that recapping a needle is permitted is when the sharps container is not immediately available; in that case, use the one-hand method to recap until the sharps container can be reached: (1) Place the cap on a table or counter next to something firm to push the cap against; (2) Hold the syringe with the needle attached and slip the needle into the cap without using the other hand. Push the capped needle on the firm surface to "seat" the cap onto the needle using only the one hand. Sharps containers should be easily accessible and not allowed to overfill; they should be routinely replaced.
What are PCAS?
Opioids are effective agents used for moderate to severe post- surgical pain and are the mainstay of treatment. These may be administered with patient controlled analgesia (PCA) devices. PCAs allow the patient to treat pain quickly (there is no need to call the nurse and wait for the dose to arrive) and allow the administration of small doses, which helps reduce side effects (particularly over-sedation).
What are precautions to take with potassium chloride?
Remove all KCI vials from floor stock; all KCI infusions prepared in the pharmacy Use premixed containers Use protocols for KCI delivery which include indications for IV administration, maximum rate of infusion, maximum allowable concentration, guidelines for when cardiac monitoring is required, stipulation that all KCI infusions must be given via a pump, prohibition of multiple simultaneous KCI solutions (e.g., no IV KCI while KCI is being infused in another IV) Allow for automatic substitution of oral KCI for IV KCI, when appropriate Label all fluids containing potassium with a "Potassium Added" sticker
What are the five rights of medication administration?
Right Patient Right Medication Right Dose Right Route Right Time
What are methods to improve ADC safety?
TJC requires that the pharmacist review the order before the medication can be removed from the ADC for a patient, except in special circumstances (an override). The override function should be limited to true emergencies and all overrides should be investigated. The most common error associated with ADC use is giving the wrong drug or dose to a patient. The patient's MAR should be accessible to practitioners while they are removing medications from the ADC. Barcode scanning improves ADC safety. The drug can be scanned to make sure it is going into the right place in the cabinet and can ensure that the right drug is being pulled. Prior to administration, the patient's wristband can be scanned to make sure the drug is going to the right patient. Look-alike, sound-alike medications should be stored in different locations within the ADC. Using computerized alerts, ideally pop-up alerts that require a confirmation when medications with high potential for mix-up in a given setting are selected, can help reduce error risk. Certain medications should not be put into the ADCs, including insulin, warfarin and high-dose narcotics (such as hydromorphone 10 mg/mL and morphine 20 mg/mL). Nurses should not be permitted to put medications back into the medication compartment because it might be placed in the wrong area; it is best to have a separate drawer for all "returned" medications. If the machine is in a busy, noisy environment, or in one with poor lighting, errors increase.
What is MERP?
The ISMP National Medication Errors Reporting Program (MERP) is a confidential national voluntary reporting program that provides expert analysis of the system causes of medication errors and provides recommendations for prevention.
Which two organizations are involved in medication safety improvement?
The Joint Commission (TJC) and the Institute for Safe Medication Practices (ISMP) are two organizations actively involved in improving medication safety.
What is the Joint Commission?
The Joint Commission on Accreditation of Healthcare organizations (TJC) is an independent, not-for-profit organization that accredits and certifies more than 17,000 healthcare organizations and programs in the U.S., including hospitals, healthcare networks, long-term care facilities, home care organizations, office-based surgery centers and independent laboratories.
What are PCA safety considerations?
The devices can be complex and require set-up and programming. This is a significant cause of preventable medication errors. PCAs should be used only by well- coordinated healthcare teams. Patients may not be appropriate candidates for PCA treatment. They should be cooperative and should have a cognitive assessment prior to using the PCA to ensure that they can follow instructions. Friends and family members should not administer PCA doses. This is a TJC requirement. PCAs do not frequently cause respiratory depression, but the risk is present. Advanced age, obesity and concurrent use of CNS depressants (in addition to higher opioid doses) increases risk.
What is the definition of medical error?
The formal definition of a medication error developed by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer."
Which organizations in the hospital need to be informed of errors?
The hospital's Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee (or similar entity) should be informed of the error.
It is important that medications in the crash carts are what?
The medications should be unit dose and age-specific, including pediatric-specific doses.
How to reduce catheter bloodstream infections?
The most important and most cost-effective strategy to minimize catheter-related bloodstream infections (CRBSI) is through aseptic technique during catheter insertion, including proper handwashing and utilization of standard protocols/catheter insertion checklist. It is also important to minimize use of intravascular catheters, if possible, through intravenous to oral route protocols and setting appropriate time limits for catheter use. For example, peripheral catheters should be removed/ replaced every 2-3 days to minimize risk for infection. Other strategies shown to reduce the risk of CRBSI, include the use of skin antiseptics (2% chlorhexidine), antibiotic impregnated central venous catheters, and antibiotic/ ethanol lock therapy, but must be weighed against the potential risk for increased rates of resistance.
How can a pharmacist be involved in MTM?
The pharmacist can form a partnership with the patient and prescriber to remedy any issues or lapses. Often, these reviews identify missed therapy such as lack of an ACE inhibitor or ARB in patients with diabetes and albuminuria, missing beta blocker therapy post-MI, missing bisphosphonate therapy with high-dose chronic steroids, and others, since these are easily searchable in databases.
What are important elements of this goal: NPSG 03.05.01: Reduce the likelihood of harm associated with anticoagulant therapy?
There are many important elements to this goal including the requirements to use standardized dosing protocols and programmable pumps for heparin and to provide education to patients and families. Protocols should include starting dose ranges, alternate dosing strategies to address drug-drug interactions, communication with the dietary department to address drug-food interactions, requirements for a baseline INR, frequency of INR monitoring and monitoring for bleeding and HIT.
What recommendations are included with this goal: NPSG 07.03.01; 07.04.01; 07.05.01; 07.06.01: Implement evidence-based practices to reduce healthcare associated infections?
These include recommendations to prevent healthcare- associated infections with multidrug-resistant organisms (MRSA, C. difficile, VRE, multidrug-resistant gram negative bacteria)
What is included in this goal: NPSG 03.06.01: Maintain and communicate accurate patient medication information?
This includes medication reconciliation, providing written information to the patient and conducting discharge counseling. The medication name, dose, frequency, route and indication (at the minimum) should be confirmed.
What kind of process is RCA considered?
Thus, RCA is often considered to be a repetitive process, and is frequently viewed as an important continuous quality improvement (CQl) tool.
What are common nosocomial (hospital-acquired) infections?
Urinary tract infections from indwelling catheters (very common). Remove the catheter as soon as possible - preventing catheter associated infections is one of TJC's NPSGs. ■ Blood stream infections from IV lines (central lines have the highest risk) and catheters ■ Surgical site infections ■ Decubitus ulcers ■ Hepatitis ■ Clostridium difficile, other Gl infections ■ Pneumonia (mostly due to ventilator use), bronchitis
What is the alcohol based hand rubs technique?
Use enough gel (2-5 mL or about the size of a quarter). Rub hands together until the rub dries (15 - 25 seconds). Hands should be completely dry before putting on gloves.
Why should as directed not be used on prescriptions?
Using the term "as directed" is not acceptable on prescriptions because the patient often has no idea what this means and the pharmacist cannot verify a proper dosing regimen.
What is the soap and water technique?
Wet both sides of hands, apply soap, rub together for at least 15 (slow) seconds. Rinse thoroughly. Dry with paper towel and use the towel to turn off the water.
What are contact precautions?
■ Intended to prevent transmission of infectious agents which are spread by direct and indirect contact with the patient and the patient's environment. ■ Single patient rooms are preferred. If not available, keep > 3 feet spatial separation between beds to prevent inadvertent sharing of items between patients. ■ Healthcare personnel caring for these patients wear a gown and gloves for all interactions that may involve contact with the patient or contaminated areas in the patient's room. ■ Contact precautions are recommended for patients colonized or infected with MRSA and VRE and patients with C. difficile infection.
What are droplet precautions?
■ Intended to prevent transmission of pathogens spread through close respiratory contact with respiratory secretions. ■Single patient rooms are preferred. If not available, keeping > 3 feet spatial separation and drawing a curtain between beds is especially important for diseases transmitted via droplets. ■ Healthcare personnel wear a mask (a respirator is not necessary) for close contact with the patient. The mask is donned upon entry to the patient's room. ■ Droplet precautions are recommended for patients with active B. pertussis, influenza virus, respiratory syncytial virus (RSV), adenovirus, rhinovirus, N. meningitidis, and group A streptococcus (for the first 24 hours of antimicrobial therapy).
