Sanford Health

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Patient Safety Past, Present, Future Molly
McDaniel, PharmD Patient Safety Program Manager
Sanford Health
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Patient Safety Past, Present, Future

• Background on the Patient Safety Movement
• National Patient Safety Goals
• National Quality Forum Safe Practices
• Case Study - Medication Reconciliation

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Background on the Patient Safety Movement
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Institute of Medicine (IOM)

• IOM
• established in 1970 by the National Academy of
  Sciences
• advisor to the federal government
• chartered to identify issues surrounding public
  health (medical care research education)
• To Err is Human Building a Safer Health System
• IOM report released in 1999
• highlighted literature suggesting that
  44,000-98,000 deaths occur each year from medical
  errors and 7,000 deaths can be attributed to
  medication errors alone
• report received increased media attention basis
  for the patient safety movement

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What We Do Know

• Etiology of medical errors is related to system
  issues, not individual performance
• Past attempts to reduce medical errors, such as
  blame and re-train, increase vigilance,
  multiple checks, etc., have failed
• Historically, lack of system design engineering
  concepts in health-care have contributed to
  errors
• Fragmentation rather than collaboration in
  healthcare
• Pharmacists play a vital role in the prevention
  of adverse drug events and medication error
  reduction

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What We Do NOT Know

• The extent of actual and/or potential
  (near-miss) medical errors that actually exist
• true magnitude of the problem has not been
  identified due to reporting issues
• How to interpret and assess data submitted from
  mandatory and/or voluntary reporting
• consensus on universal standardized definitions
  and protocols surrounding the identification and
  categorization of errors is lacking

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• Every system will perfectly produce what it has
  been designed to produce.
• - Donald Berwick, M.D.

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Medicine is the only industry that can market
its mistakes. - Lucian Leape, M.D.
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Are we safe yet????
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Human Error Rates
Salvendy G. Handbook of human factors
ergonomics 1997.
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Medication Errors Putting it in Perspective

• 1.5 Million Americans are harmed or
  killed by medication related mistakes each year
• Average passenger load on 747 450 people
• 9 - 747 airplanes crashing each day for a year

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Institute of MedicinePreventing Medication
Errors

• Committee estimates that on average, a hospital
  patient is subject to at least ONE ERROR PER DAY,
  with considerable variation in error rates across
  facilities.

Preventing Medication Errors Quality Chasm
Series. Institute of Medicine, 2006.
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The Safety Iceberg
Above the waterline and visible.

• Claims
• Adverse
• Events

• Near Misses
• Dangerous
• situations
• Deviations,
• variances

Below the water line and often not visible.
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Swiss Cheese Model
Triggers
Failed or absent defenses (latent conditions)
World
Institution
Organization
Profession
Team
Human Factors Theory(The Swiss Cheese Model)
Individual
Accident
Technical
To Do No Harm by Julianne Morath
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Swiss Cheese Model Omission of Lovenox
Physician
Pharmacist
Nurse
Patient
Swiss Cheese Model. Duke University Medical
Center 2005.
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Omission of Lovenox

• Physician orders 100mg Lovenox x1 dose than
  1mg/kg BID for patient with bilateral pulmonary
  embolism
• Pharmacist entered 100mg dose and put other dose
  on hold while clarifying patients weight renal
  function
• Nurse signs off Lovenox order even though
  Lovenox was not on the eMAR

• Patient with recent bilateral PE diagnosis not
  on therapeutic anticoagulation for 11 days not
  picked up by physician or nurse taking care of
  patient.
• Pt transferred 6 times b/w units yet no one on
  the team noticed the omitted Lovenox

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Omission of Lovenox

• What communication happens between
  pharmacists during shift handoff?
• Was physician/RN looking at eMAR daily to
  review medications pt was receiving?
• Was there critical thinking about the patients
  diagnosis and current medications being given?

Swiss Cheese Model. Duke University Medical
Center 2005. Smetzer J, Cohen MR, Jenkins R, ed.
ISMP Medication Safety Alert 2007.
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Swiss Cheese Model - Hydromorphone 7 yo male on
epidural
Physician
Clinical Infomatics
Pharmacy
Nurse
Patient
Swiss Cheese Model. Duke University Medical
Center 2005.
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Hydromorphone Overdose

• Physician has order set against epidural policy
• Transcription Error when updating Orthopedic
  Peds Admission orders
• 0.07mg/kg/dose Dilaudid (error)
• 0.007mg/kg/dose Dilaudid (correct)

• Pharmacist entered order and overrode alerts
• - Exceeds recommended max single dose by 369
• - Exceeds recommended daily dose by 840
• - Did not use order set to enter order, may
  have seen max dose 0.7mg in Admin
  instructions

Swiss Cheese Model. Duke University Medical
Center 2005. Smetzer J, Cohen MR, Jenkins R, ed.
ISMP Medication Safety Alert 2007.
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Hydromorphone Overdose

• Two RNs pulled three 1mg carpujets to give
  2.2mg dose ( 8h apart)
• Hydromorphone not regularly used on Peds
• Error discovered by MDA when removing epidural

Swiss Cheese Model. Duke University Medical
Center 2005. Smetzer J, Cohen MR, Jenkins R, ed.
ISMP Medication Safety Alert 2007.
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National Patient Safety Goals
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National Patient Safety Goals
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2009 National Patient Safety Goals

• Improve the accuracy of Patient Identification
• Improve the effectiveness of Communication
• Improve the safety of using medications
• Reduce the likelihood of patient harm associated
  with anticoagulation therapy
• Reduce the risk of healthcare associated
  infections
• Accurately and completely reconcile medications
  across the continuum of care

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2009 National Patient Safety Goals

• Reduce the risk of patient harm resulting from
  falls
• Encourage patients active involvement in their
  own care as a patient safety strategy
• The organization identifies safety risks inherent
  in its patient population
• Improve recognition and response to changes in
  patient condition
• Universal Protocol prevent wrong site, wrong
  procedure, wrong person surgeries

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National Quality Forum Safe Practices
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NQF 2009 Safe Practices for Better Healthcare
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NQF 2009 Safe Practices for Better Healthcare 7
functional categories

• Creating and Sustaining a Culture of Safety (4)
• Informed consent, life-sustaining treatment,
  disclosure, and care of the caregiver (4)
• Matching healthcare needs with service delivery
  capability (3)

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NQF 2009 Safe Practices for Better Healthcare 7
functional categories

• Information transfer and clear communication (5)
• Medication Management (2)
• Prevention of healthcare-associated infections
  (7)
• Condition and site-specific practices (9)

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New Pediatric CT Imaging Safe Practice 34
New Falls Safe Practice 33
Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention Safe Practice 26
New Glycemic Control Safe Practice 32
Improving Patient Safety Through Condition and
Site Specific Practices
New Organ Donation Safe Practice 31
Pressure Ulcer Prevention Safe Practice 27
Contrast Media-Induced Complication
Prevention Safe Practice 30
Venous Thromboembolism Prevention Safe Practice
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Anticoagulation Therapy Safe Practice 29
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NQF2009 Safe Practices for Better Healthcare

• Visit www.qualityforum.org

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Medication Reconciliation
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Importance of Taking an Accurate Medication
History
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What is Medication Reconciliation?

• A systematic process to decrease medication
  errors and the potential for patient harm by
• Obtaining and verifying patients current
  medication regimens
• Documenting patients complete medication lists
  within medical records
• Comparing medication lists to medicines
  prescribed by the facility
• Reconciling (resolving) medication discrepancies
• Providing and communicating updated medication
  lists, highlighting any changes, to patients and
  to the next provider of service at all
  transitions in care.

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Case Study How to Rec a family member
11-21-08 - 72 year old white male with hx of
diabetes, chronic renal disease and coronary
artery disease transferred to Sanford/USD Medical
Center with left ankle fracture, fevers and
chills. During transport patient was receiving IV
morphine for pain. The family member removed a
Fentanyl patch when patient arrived to the
hospital.
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Case Study How to Rec a family member
11-23-08 Patient taken to OR by Ortho for ID of
obviously infected tissue from the left ankle.
Prior to surgery, a Fentanyl patch was placed
with dose taken from admission home medication
list (125 mcg/hr).
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Case Study How to Rec a family member
11-24-08 at 0330 patient was difficult to arouse
and unable to complete a sentence or answer
questions. Glucose checked and was found to be
36patient given skim milk and orange
juicepatient felt better and glucose rechecked
at 69.hospitalist called and IV fluids
changed.keep an eye on sugars.
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Case Study How to Rec a family member
at 0600 O2 sats low..O2 titrated up and RT
called as patient vomited and appeared to
aspiratept suctioned and place on 15L O2 per
non-rebreather.Narcan given and patient
transferred to Critical Care Unit with
respiratory distress..RN went to place another
Fentanyl patch (75mcg/hr) and was verbalizing
this to the patient when patients wife stated
that the patient was not on 75mcg but rather
25mcg..Pulmonary MD consulted and patient was
diagnosed Acute aspiration
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Medication History is the Key to Med Rec Success
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Patient Center 1000 Med History Pilot

• Patient Center 1000
• Data Collected from September 9th October 2nd
  2008
• Elective Surgical Patients
• Case Managers Prioritized Patient List
• Approximately 10 patients/day
• 40 different physicians involved
• Pharmacist hours 0530-1400 (M-F)

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Medication History Pilot Results

• N 100 Patients Analyzed
• Mean number of medications/patient
• 11.1 medications (range 2-32)
• Mean time to conduct medication history/follow-up
  with discrepancies
• 17.5 minutes (range 3-60)
• Discrepancy/Intervention was noted when the
  pharmacist changed something on the HMS from what
  was written on the list from the case manager
  based on a pre-op call or if the pharmacist had
  to clarify a med/dose with a pharmacy, PCP etc.

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Medication History Pilot Results

• Home Med Sheet (HMS) Accuracy
• 2.5 discrepancies/patient
• 23 of all medications were discrepant
• 77 of patients had at least 1 discrepancy
• 59 of discrepant medications were prescription
  drugs
• HMS after pharmacist review
• 99 completeness of form
• 74 of HMS were signed appropriately by the MD

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Med Rec Admission Team

• Resource Reallocation for Medication Histories
• Case Managers
• Pharmacists
• Start Date May, 2009 with M-F coverage
• In-depth education on how to take a complete and
  accurate medication history
• Case Managers of Patient Center 1000 and HVA
• Pharmacists
• Center for Joint Success and Bariatric Class

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Med Rec Admission Team

• Obtained a complete and accurate medication
  history on
• over 2000 Patients and Prevented over 5000
  Medication Errors

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Medication History Strategies

• Patient
• Family / Caregiver
• Patients medication bottles
• Patients community pharmacy(s)
• Patients primary care or specialty physicians
  and their offices or clinic
• Past Medical Records
• Patients own medication list

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Medication History Strategies

• Prescription Medications
• Sample Medications
• Over-the-counter (OTC) drugs
• Vitamins/Herbals/Supplements
• Often Forgotten Inhalers/Nebulizers, Patches,
  Eye and Ear Drops, Creams/Ointments

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Medication History Strategies

• Incorporating various types of probing
  questions into the patient interview may help
  trigger the patients memory
• Do you take anything that you buy at the grocery
  store, pharmacy or health food store without a
  prescription?
• What do you take when you get a headache?
• What do you take for allergies, cold?
• Do you take any medications monthly?
• Do you put any medications on your skin?
• Do you use any eye drops?

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Medication Scripting Project

• Written Communication
• Bring in a list of current medications
  (prescription, over-the-counter and herbals)
• Verbal Communication
• This script is used for all reminder of scheduled
  appointment calls to patients
• Plan to add a script to on-hold messages for
  patient to hear
• Please remember to bring in all the medications
  you take at home or an update home medication
  list.
• Plan to add the same script for all reminder of
  scheduled appointment calls to patients
• TV Spots
• Screening for Life Events

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Questions?Molly McDaniel, PharmDPatient
Safety Program ManagerSanford Health605-333-7496
mcdaniem_at_sanfordhealth.org