RX chapter 8: Medication Errors, Patient Safety and the Joint Commission

Consumer Medication Information (CMI) leaflets

-CMI are voluntarily provided by retails pharmacies, explaining how medication works and how and when to take it with common adverse effects and potential interactions

Retrospective analysis

-Retrospective DURs can be done individually (such as an MTM review) or, more commonly, with a system-wide review using aggregate data. -It involves reviewing profiles of medicaid patients to determine which MD's handwriting contributes to most prescribing errors and which MD use highest % brand name drugs (when cheaper alternatives available)

help prevent errors by organize educational programs****whose programs should be avoided and why?

-Staff education programs such as "in-services" should be provided whenever new high-alert drugs, new procedural changes aimed at preventing meds errors or new therapeutic guide lines -provide unbiased information therefore many hospitals now ***limit the use of pharmacutical companies to provide drug education***(with meals to entice participation) due to inherence bias

use safe practices for emergency medications/crash carts

-Staff must be trained to handle emergencies and crash cart meds. Meds should be **unit dose** and **age-specific**, including pediatric-specific dose. -If unit dose medication not available, have prefilled syringes and drips in cart because its easy for error to occur under the stress of a code. -emergency meds should be stored in sealed or locked containers in locked room and replace as soon as possible after use (through a cart exchange) -Monitor drug exp dates -trained RPH should be present at codes when possible

Avoid errors by Developing and Using Standard protocols***

-Standard protocols is for high-risk drugs increase the rate of appropriate prescribing based on published recommended guidelines and reduce chance of errors due to inappropriate prescribing.

Use soap and Water (not -alcohol based rubs) in these situations

-before eating -after using restroom -anytime there is visible soil (anything noticeable on hands) -after caring for patient with diarrhea or known C. difficile or spore forming organisms (alcohol-based rubs have poor activity against spores)**TEST -before caring for pt with food allergies

When to wash hands?

-before entering and after leaving pt room -between pt contacts if there is more than one pt per room -before and after removing gloves (new gloves with each patient) -before handling invasive devices, including injections -after coughing or sneezing -before handling food and oral medications

PCAs important SAFETY considerations ***

-complex device (require set-up and programming) which is a significant cause of preventable medication errors**** -pt may not be appropriate candidates for PCA. pt should be cooperative and have cognitive assessment prior to using PCA to ensure they can follow instructions -friends and family members should not administer PCA doses. This is a joint COMMISSION requirement****_TEST -PCAs has low but still present risk of respiratory depression. Risk increased with advanced age, obesity and concurrent use of CNS depressants

WITH PCAs, It is important to follow these safety steps*******

-limit opiods available in flor stock (use standard orders to avoid overdose) -educate staff about HYDROmorphone and morphine mix-ups -implement PCA protocols to include independent double-checking of drug, pump setting, and dosage -use **BAR-CODING**technology , scanning barcode on PCA bag help ensure correct [ ] is entered during PCA programming to ensure that right pt is getting meds -Assess patient's **pain, sedation, respiratory rate** on a scheduled basis

What are the duties of RPH in ICU?

-manage complex pts to ensure appropriate therapy -evaluate parenteral nutrition orders to ensure optimized regiments -in ED, pharmacist increase quality of care of children, tough to dose them -but typically a good deal of their time ideal with meds for MI's and stroke, including providing alteplase on-time and avoiding complications, e.g. ICH

Hand Hygiene

-many hospital infections spread by worker's hand--> needs hygiene for prevention -Pts are often carriers of resistance bacteria (MRSA and VRE) -**alcohol-based hand rubs (gel, rinse or foam) are effective in healthcare setting than plain soap or antimicrobial soap and water -avoid wearing jewelry under gloves (harbor bacteria and can tear gloves) -keep fingernails clipped short and clean

Errors of comission

-means something was done incorrectly, such as prescribing buproprion to pt with epilepsy or dispensing sulfamathoxazole to pt with sulfa allergy ex. failed to reduce vancomycin dose for patient with reduced renal function

IV medication preparation. What are laminar flow hoods?

-meds given IV cause severe adverse rxn and death if contamined because bypass protective mechanisms of skin barrier and GI -Hoods (ventilated device) keep sterile compound or parenteral drugs free of contaminants, and are used to keep the pharmacy area free of noxious fumes. ***Laminar flow means that air is moving in an uninterrupted, constant stream. The air is drawn through a high efficiency particulate air (HEPA) filter that catches particulates*******

The following practices ensure safe injection practice*****

-never reinsert used needles into multiple-dose vial or solution container, (whenever possible), use of single-dose vials is preferred over multiple-dose vials, esp if meds administer to multiple pts**** -needles need "engineered sharp protections"-reduces risk of exposure incident such as drawing needle into syringe barrel after use -avoid contamination to by by "NOT touching tip or plunger of syringe"****** -Disposable needles contaminated 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.***** -never remove a needle by unscrewing it -Use disposable needles/sharps should be discarded immediately after use ***without re-capping**into a shaprs container (a non-reusable plastic container that is puncture resistant, leak proof on the sides and bottom, properly labeled and closable) -Sharps containers should be easily accessible, replaced routinely, and not allowed to overfill. Never compress or "push down" on the contents of any sharps container. -If someone is stuck with a needle the proper department at the facility should be contacted immediately.

Why educate patients and their families?

-pt plays vital role in preventing medication errors when they asks questions about meds -pharmacists must be receptive and not defensive when pt questions any part of medication dispensing process (drug appearance, dose or something else) -written information about meds should be at comprehensible reading level -provide pictograms or other means of instructions for non-english speakers. (non-english speaking doesnt imply inability to understand simple instructions)

Potassium Chloride

-remove all KCL vials from floor stock -centralize KCL infusion preparation in the pharmacy -Use premixed containers -Use protocols for KCl delivery, including indications for : 1. KCL infusion 2. max rate of infusion 3. max allowable concentration 4. guidelines for when cardiac monitoring is required 5. stipulation that all KCl infusions must be given via a pump 6. prohibition of multiple simultaneous KCL solutions (e.g. no IV KCL while KCL is being infused in another IV) 7. Allow for automatic substitution of oral KCL for IV KCL, when appropraite

National patient safety goals (NPSGs)****

-set annually by joint commission for different type of healthcare settings to improve pt safety. NPSGs include: 1. Reduce likelihood of harm associated with anticoagulant therapy (require standardized dosing protocols, monitor INRs, use programmable pumps for heparin, provide education to patients and families) 2.Maintain and communicate accurate patient medication information (meds reconciliation, provide written information to patient and discharge counseling) 3. Implement evidence-based practices to reduce health-care associated infections **** (reduce risk from urinary catheter, proper hand hygience) *all insertions and removal should be done per protocol, ****assess the need so can remove catheter as soon as it is no longer needed and ventilators (elevate head-of-bed 30 -45 degrees, assess readiness to**wean off ventilator at least daily, use breaks or **reductions in sedative use if possible, consider DVT prophylaxis, use stress ulcer prophylaxis judiciously) 4. Use at least 2 pt identifiers when providing care, treatment and services (prevent misidentification errors-verified NAME and MEDICAL record number prior)

Reporting Medication errors in community setting

-staff RPH who discovers error should immediately report to corporate office (community setting) or owner (independent pharmacy setting), who is involved in quality assurance programs -mandated by state board of pharmacy -error investigations need to be done "as soon as 48 hrs of incident" so the sequences of events remain clear to clsoe involved -many states mandate the ethical requirement that errors be reported to pt and their prescriber ASAP

Heparin

-standardize heparin solutions-Use premixed and reduce the number of concentrations available -standardize administration procedures-place dose stickers on heparin bags and double check all rate changes. If a bolus is ordered, give it from a syringe, rather than modifying the rate of infusion -Differentiate all look-alike products -separate the storage of all drugs ordered in units -standardize the dosing using weight-based protocol -have infusion pump rate settings and line placement on dual channel pumps checked by 2 persons

Alsohol-based Hand rubs technique

-use enough gel (2-5 mL or quiz of a quarter) -rub hands together until rub dries (15-25 seconds) -hands should be completely drug before putting on gloves

Hand-Hygiene for Sterile compounding

-wash w/ soap and H20 up to the elbow using alcohol-based surgical hand scrub -needs to properly clean surfaces (bed rails, eating trays etc). -health professionals should be careful not to be sources of infection from contaminated clothing (including white coats and ties). Organisms that spead via surface contact include: **VRE, C. difficile, noroviruses and other intestinal tract pathogens

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

Laminar Hood technique and Safety

1. Do not place objects lined up in front of each other in laminar flow hood (place side by side so air flow is not interrupted) 2. Use mask that covers nose and mouth when working in hood 3. Miscellaneous items (calculator, pens) should not be put in hood 4. Any sterile component (syringes, needles, ampules, etc.) should only be opened or removed from their packaging within laminar-flow workspace. Do not tear paper open, it should be peeled open. Do not touch syringe tip and plunger, even with gloved fingers. 5. preparation has to be at least 6 inches back from the front of the hood 6. The hood is kept operating continously and all surfaces are cleaned prior to use from the back to front. If for any reason, the hood is turned off, it should be turned on for at least 30 minutes prior to use and thoroughly cleaned 7. Since contamination can cause death, any product whose purity is in doubt should be discarded

Common types of Hospital (Noscomial) Acquired infections

1. UTI from indwelling catheters (very common ***remove catheter as soon as possible*** 2. Blood stream infections from IV lines (central lines have highest risk) and catheters 3. Surgical site infections (see antibiotic prophylaxis ID chapter) 4. Decubitis ulcers 5. Hepatitis 6.***Clostridium difficile, other GI infections 7.Pneumonia (mostly due to ventilator use), bronchitis

transition in care include changes in setting, service, practitioner or level of care. This process comprises five steps:

1. develop a list of current meds 2. develop a list of meds to be prescribed 3. compare meds on 2 lists 4. take clinical decisions based on comparison and; 5. communicate the new list to appropriate caregivers and to the patients

ADCs important safety considerations

1. stocking errors (place drug in wrong drawer->wrong drug dispensed). Use Bar code scanning to ensure correct drug is placed into ADC) 2.wrong drug selected from screen or ADC 3. wrong dose selected from screen 4. Errors can occur due to overrides that are not subject to RPH's prospective order review

Methods to Improve ADC safety ****

1. the Joint Commission requires that RPH review the order before meds can be removed from ADC for pt, except in special circumstances. LIMIT override function to true emergencies and investigate all overrides 3. Barcode scanning improves safety-> scan barcode so right drug goes into ADC and scan pt's wrist to make sure drug goes to right pt. Medication administration records (MARS) should be accessible to practitioners while removing meds from ADC 3. Look-alike and sound-alike meds should be stored in different locations within ADC. and use Tall-Man's letters 4. Certain meds should not be put into ADCs, including warfarin and high-dose narcotics 5. Do not let nurses put meds back into medication compartment because might be placed in wrong area; its best to have separate drawer for all "returned" meds 6. Do not place machine in busy, noisy environment or in poor lighting--> errors increase. Avoid distractions , such as answering cell phones or social exchanges, should be reduced when stocking or removing ADCs.

DO not Use Error-Prone abbreviations, Symbols, and Dosage Designation****

Abbreviation are unsafe and contribute to many medical errors. Trailing zero after whole numbers (decimal) is not permitted, easily mistaken ie. 5.0 looks like 50 on a line paper Leading zeros are required because its easy to miss a decimal point placed before a number such as .5

Medication reconcillation

According to TJC, meds reconciliation involes comparing pt's meds orders to all of meds pt has been taking to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. Should be done at every transition

Medication errors vs. Adverse effects

Adverse effects are generally not avoidable, though they occur more if drug is given to pt with high risk complications Medication error is preventable

Indications for use on prescriptions***how does it help with errors?

An indication for use that is written on RX (such as lisinopril for BP) helps us assure appropriate prescribing and drug selection

How to avoid errors with direction on rx?

Avoid "AS DIRECTED" because patients often has no idea what this means and pharmacists cannot verify a proper dosing regiment - MD should provide proper direction***

BAR CODING*****Purpose?

Bar coding may be the most important medication error reduction tool in the arsenal right now. It follows the drug through medication use process to make sure it is being properly stocked (in right place or in right pocket in dispensing cabinet), through compounding if required and to patient

Stateboard requirement for stocking ADC

CA board specifically states that all drugs stocked in ADC are restocked by pharmacists/ intern/ technician under RPH supervision. Removable pockets or drawers transported between pharmacy and stocking facility must be transported in a secure tamper-evident container

CODE BLUE***

Code blue refers to a patient requiring emergency medical care, typically for cardiac and respiratory arrest. Overhead announcement will provide pt's location. the Code team will rush to the room and begin immediate resuscitative efforts.

How does computerized prescriber order entry (CPOE) help prevent errors?

Computerized physician order entry is a computer system that allows direct entry of medical orders by prescribers. Help minimizing the ambiguity resulting from hand-written orders Guidelines and patient labs can built-into CPOE system and alerts can notify prescribe if drug is inappropriate

LOOK-ALIKE, SOUND-ALIKE medications. how to avoid?

Drugs that are easily mixed up should be labeled with tall man's letters (e.g. CeleXa, CeleBREX) ISMP,FDA, the Joint Commissions and other safety-conscious organizations promote tall man's letter

How to involve patients in catching dispensing errors?

During counseling, pharmacists inform pt of indication and therapeutic goals and should open the bad, open the vial and show pt the medication (this can be tricky b/c lisinopril comes in various tablet sizes and colors-hopefully the same generic manufacturer can b chosen) Instruct patient to always read description so they are sure that it matches the tablets Patient is now equipped to monitor their condition and to help catch a dispensing error if one occurs

2 types of error classification

Error of Omission and Error of Commision

FDA requirements for barcoding

FDA requires bar coding on meds with (minimally) the drug's National Drug Code (NDC) number. it may also include others: lot numbers and expiration dates

This is a proactive method used to reduce frequency and consequences of errors

Failure Mode and effects Analysis (FMEA). used to analyze the design of the system in order to evaluate the potential for failures and to determine what potential effects could occur when the medication delivery system changes in any substantial way or if a potentially dangerous new drug will be added to the formulary

HEPA filters what % of air particles?

HEPA filters remove 99.97% of all air particles 0.3 mm or larger **** (cabinet is stainless steel with smooth design to keep out contaminants and reduce risk of joints and other spaces where spores might accumulate)

Which units has high incidents of preventable medication errors?

ICU, pediatric units and emergency department -Need to dedicate pharmacists to these units to assist in identify and prevent medication errors by developing process improvements designed to reduce drug errors

who requires that standard order sets be used for antithromotics?

Joint commision Standard order sheet should include instructions for initial dose of heparin and other high-risk antithrombotic, monitoring for bleeding, using appropariate antidots, monitoring for HIT and discontinuing heparin if HIT is suspected

The Joint commission on accreditation of the healthcare organizations (joint commission or TJC)

Joint commission is an independent, not-for-profit organization, that accredits and certifies more than 17,000 health care organizations and programs in US, including hospitals, health care networks, long term facilities, home care organizations, office-based surgery centers, independent laboratories -It focuses of highest quality and safety of cares -accredited organization must undergo an on-site survey (can be unannounced) at least every 3 yrs

Why should we not rely on medication packaging for identification purposes?

Look-alike packaging can contribute to errors. If unavoidable, separate look-alike drugs in the pharmacy units or repackage

Medication Guides (MedGuides)

MedGuides present important adverse events that can occur with over 300 medications. It is FDA-approved patient handouts and are considered part of the drug's labeling. To be dispense with each new and refill rx. Does not need to be dispense to inpatients routinely, but available upon request.

what is the advantage of bedside barcode?

Nurses using bedside barcode medication administration records (MARs) spend more time providing direct patient care, vurses nurses who use paper-based MARs

What vaccines needed for healthcare workers?

OSHA mandated healthcare workers be immunized for Hepatitis B and influenza (no vaccine available at present for Hep C and HIV)

Paitent controlled analgesic (PCA) Device overview

Opiods can be administered via PCA devices, allowing pt to treat pain quickly (there is no need to call the nurse or wait for the dose to arrive) -PCA allows administration of small doses to reduce side effects (particularly over-sedation) -BUT opiod naive or higher-than-normal doseses post surgically may require anti-emetics or anti-histamines

LOOK AT ISMP LIST of error-prone abbreviations, symbols, dose designations etc..

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PCA drug deliverly mimics***********_______?

PCA drug delivery can mimic the pain pattern for closely and provide good pain control Increasingly, PCA is administered with anesthetics for a synergistic benefit in pain relief

Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act)

Patient Safety Act authorized the creation of Patient Safety Organization (PSOs) to improve the quality and safety of health care delivery in US. Patient Safety Act encourages clincians and health care organizations to voluntarily report and share quality and patient safety information without fear of this information being used in legal proceedings

when is Patient isolation needed?

Patients (ie. bone marrow transplant) can be placed in isolation if high risk for infection or if they have highly contagious infection (ie. VRE or tuberculosis) -isolated pt have clear signs outside of their rooms and isolated cart outside room with required gown, gloves, or masks to be put on before entering room -regulated waste should be placed in closeable, leak proof containers and appropriately labeled or color-coded bags

What is the main emphasis of DURs

Promote patient safety by an increased review and awareness of outpatient prescribed drugs through: -retrospective analysis of patient drug usage, physician prescribing, and pharmacy dispensing activities -identification and review of critical patient profiles -regular reporting of activities and important findings to Medicaid providers and pharmacies -Awareness campaigns for new pharmaceutical products and techniques -research studies into drug-related trends and application of those studies into cost saving plans

Automated Dispensing Cabinet examples

Pyxis Omicell AccuDose ADCs is used by >1/2 Hospitals in US, replacing patient cassetts that had to be filled at least once daily and exchange

Follow requirements for risk evalulations and mitigation strategies (REMS) drugs

REMS is FDA program that requires specified training and various restrictions (patient requirements, user registries, etc) on certain drug. ex. Clozapine registry ex. APRISE programs for erythropoietin use in oncology ex. iPLEDGE program for isotretinoin

How to avoid errors with high alert drugs

Special Bins and labeling for high alert drugs, keep warning materials and materials should be dispensed with drug inside bin (ie syringes or MedGuides) -Drugs that bear a high risk of causing significant patient harm when used in error should be designated as "High Alert"

Can an analysis be done prospectively to identify pathways that could lead to errors and to identify ways to reduce the error risk? **

Yes (prospective is key word)

Root Cause Analysis (RCA)****

a root cause analysis is a retrospective investigation of an event that has already occurred, which includes reviewing the sequence of events that lead to the error. The information obtained in the analysis is used to design changes that will hopefully prevent future errors. (CORRECTIVE ACTION)

When is medication reconcillation accomplished?****

accomplished by reviewing the pt's complete med regiment at the time of admission, transfer, and discharge and comparing it with the regiment being considered for the new setting of care.

Agency for Healthcare Research and Quality (AHRQ)

administers the provisions of patient safety Act and Patient Safety Rule dealing with PSO oprtions. website: www.pso/ahrq.gov/

Vertical flow hoods are mainly used for what meds?

also called biological safety cabinets or chemotherapy hoods, blow air from top down to maintain serility and protect RPH or tech preparing the meds from breathing in dangerous fumes. They are mainly used for chemotherapy and other hazardous meds.

if using antimicrobial hand soaps, which kind is preferred?**

antimicrobial hand soaps that contain chlorhexidine (Hibiclens, others) may be preferred to soap and water to reduce infection. Triclosan may also be better but it can contaminate water supply (environmental concern)

Medication error definition (developed by National Coordinating Council on Medication Error Reporting and Prevention *NCCMERP)

any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health professionals, patient, or consumer

How does barcoding work?

barcode is used at the bedside to identify that correct durg (by scanning code on drug's packaging) going to the right patient (via scanning patient's wrist band) and confirms that dose is being given at the right time. Nurse may have a badge bar code to track to administer the drug

Monitor for food drug interactions

check for drug-food interactions routinely and have nutrition involved with effort when drugs with high rate of food interactions (such as warfarin) are ordered

Drug ultilization Reviews (DURs) was created by what act?

created by Omnibus Budget Reconcillation Act (OBRA) of 1990

-Outbreaks involving the transmission of blood born pathogens or other microbial pathogens to patient (and occasionally to healthcare workers) is due to?*********

due to unsafe injection technique ex. reuse of syringes in multiple syringes, contamination of IV bags with syringes, failure to follow basic injection safety and inappropriate care / maintenance of glucometer equipment used on multiple pts

Institute for Safe Medication Pactices newsletter (ISMP_

have information about medication related errors, adverse drug reaction, and recommendation to help reduce risk of medication errors and other adverse drug events at practice site. ISMP published monthly medication error report analysis and adverse drug rxn articles in journal, HOSPTIAL PHARMACY (free for hospital rph)

3 high alert drugs and safe use precautions

hypertonic saline heparin KCL

what is the purpose of REMS

in 2011, FDA started new REMS to reduce misuse of long acting opiods (morphines ER, fentanyl patches, hydromorphone, oxycodone, oxymorphone, methadone, buprenorphine) ***LOOOK UP FOR MORE INFO??

Error of Omission

means leaving something out that is needed for safety, such as missed instructions or failure to provide a dose at the required time. **ex. does not provide measuring device with clear instruction **ex. HCTZ dispensed when rx called for HCTZ/lisinopril

Measurement should be kept in what system?***

metric system only to express weights volume and units

Most common causes of medication errors***

not individual error BUT problems with the design of the medical system itself. Not blaming lousy Rph/Tech, but need to design better system

RCA is considered to be a single or repetitive process?

often considered as repetitive process and is frequently viewed as a continuous quality improvement (CQI) tool

what is required of prescriber if they placed an order outside of protocol?***

prescriber should be required to justify any order outside the protocol and a pharmacist should approve the request.

Reporting errors in hospital setting***..WHO should be INFORMED?

staff member should report medication error through the hospital's specific medication event system (either electronic or paper) *****the hospital rx and therapeutics (P&T) committee should be informated of the error as well as the medication safety committe

What is the best way to prevent similar problems from occurring in the future?

targeting corrective measures at the identified root causes

If abbreviations are used within an institution (such as hospital), they must not be on.....***

that institution's unapproved abbreviations list and on Joint Commision's do-not use list Best attempt to avoid abbreviations entirely ISMP list of error-prone abbreviations: www.ismp.org/tools/errorproneabbreviations.pdf

Why avoid multiple dose-vials?

these pose risk for cross-contamination (infection) and overdosing. If used, they should be (ideally) designated for a single patient and discard after done with that patient

sentinel event

unexpected occureence involving death or serous physical and psychological injury or risk therof

Infection in Hospital

-1 infection for every 20 pts -pt enters hospital for treatment of a condition and contract a different condition at the same facility (most resistant bacteria are in hospitals where sickest patients are at) ***ex. pseudomonas in moist environment of ventilator -these are largely preventable if proper techniques are followed. Many states now require hospitals to report infection rates and MEDICARE has begun to refuse reimbursement for hospital-acquired infections that are largely avoidable.

Universal precautions (UP)

-1985, HIV epidemic, isolated practices in US introduced new strategy for isolation precautions, later became Universal precaution -Blood is single most important sources of HIV, hepatitis B (HBV), and other blood born pathogens...Needs to prevent exposures to blood and deliver HBV vaccines. -lower risk sources include bodily fluids and universal precautions also apply to semen and vaginal secretions, tissues and the following fluids: CSF, synovial, pleural, peritoneal, pericardial and amniotic fluids -masks/ goggles covers nose and moth must be worn during procedures that can generate splashes of blood, body fluids. etc.. -contaminated gloves, clothing, other equipment should be placed in appropriately labelled containers

Example of DUR by state of wyoming

-2010 increase in fiscal restrains due to high costs ED visits -investigation shows pregnant women incompliant with asthma meds b/c safety concern -->increase ED visits for asthma -State initiated campaign to increase awareness of health risks due to discontinuation of meds during pregnancy

Hypertonic Saline

-Allow only commercially available, stand (e.g. isotonic) concentrations of NaCl outside the pharmacy -Limit options-do not stock 3% sodium chloride injection -Develop a protocol for administering NaCl for use in treating hyponatremia-covering the rate and volume of administration and frequency of serum sodium monitoring -Limit addition of sodium monitoring to enteral feedings to the pharmacy -In dialysis units, stock a single hypertonic concentration and store in a locked area with limited access and affix special hazard labeling