PREVENTING MEDICAL ERRORS: JCAHO UPDATE Medication Use Policies

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PREVENTING MEDICAL ERRORSJCAHO
UPDATE-Medication Use Policies

• Shands Jacksonville Medical Center

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Accreditation and Credit

• Accreditation The University of Florida College
  of Medicine is accredited by the Accreditation
  Council for Continuing Medical Education to
  provide continuing medical education for
  physicians.
• Credit The University of Florida College of
  Medicine designates this educational activity for
  a maximum of 1 AMA PRA Category 1 Credit(s).
  Physicians should only claim credit commensurate
  with the extent of their participation in the
  activity.

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Disclosure

• Author Pamela Schauben, MS, RPh
• Department of Pharmacy
• Shands Jacksonville
• Pamela Schauben has indicated that she has no
  financial relationships to disclose.

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General Information

• Requirements for Successful Completion In order
  to receive credit, UF physicians at Shands
  Jacksonville must view all PowerPoint slides and
  complete a separate online post-test. One CME
  credit will be awarded upon successful completion
  of the post-test.
• Media Internet Release Date  March 1,
  2006 Expiration Date       March 1, 2007
• Estimated time to complete 60 minutes
• Sponsorship  This activity is sponsored by the
  University of Florida College of Medicine

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Intended Audience

• University of Florida Physicians practicing at
  Shands Jacksonville Medical Center

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Learning Objectives

• Upon completion of this activity, participants
  should be able to
• Identify specific Shands Jacksonville Patient
  Safety Goals and JCAHO medication-related
  standards,
• which include

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Learning Objectives (cont.)

• Maintaining awareness of look-alike and
  sound-alike drug names
• Clearly specifying dosage form, drug strength,
  and complete directions on prescriptions
• Learning the list of prohibited abbreviations
• Obtaining and documenting a complete list of
  patients medications
• Reviewing certain policies and procedures for
  high risk meds and emergency access to meds
• Communicating patients medications to next
  provider of care

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What is the new survey process?

• UNANNOUNCED! (1 hr notice)
• Patient selected randomly
• Patient followed to each area (e.g., ED, OR, Cath
  Lab, etc.)
• Physicians, nurses, etc. who interacted with the
  patient are interviewed
• Current charts scrutinized

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What is our role?

• Be prepared
• Be able to explain our policies!
• Make sure charts are compliant
• Show that we are providing safe, quality care
  to our patients

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Recent Survey Questions.
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Question 1

• Does an indication for each medication need to be
  specified?

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Indication for Use of Drugs?

• YES! Each drug ordered must have an indication
  written SOMEWHERE in the medical record.
• Example Bisacodyl 5 mg 1 tablet po BID PRN
• Chart must list constipation or prevention of
  constipation
• Can be in the order, the progress notes, the HP,
  OR the nurses note (preferably the order for
  prns)
• Medication Orders SH core CP2.49p

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Question 2

• Can two prn medications with similar
  indications be prescribed?

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Two prn medications for same condition?

• Yes... as long as they include instructions for
  when to use each drug
• Example
• Morphine 2mg IV q4h prn severe pain
• Lortab 5/500 mg PO q6h prn moderate pain
• Acetaminophen 650mg PO q4h prn mild pain
• Unless otherwise specified by the prescriber
• Mild pain 1-4 Moderate pain 5-6
  Severe pain 7-10
• Pain Management SJ A-02-005

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Question 3

• What do you do if you need medication
  information?

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Medication Information
Ask your pharmacist OR Use Micromedex!

• Drug info program on all
• computers in the hospital-
• ask your pharmacist
• if you need help using it

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Question 4

• Tell me what you have done about high risk
  medications?

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High-Alert Med Policy

• Gives recommendations for safe use of the most
  dangerous medications
• Example Amiodarone
• Assure correct dose and rate for indication
• Use filter
• Extravasation precautions
• Must be in glass bottle for maintenance

• High Alert Medications SJ Rx-11-057

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Question 5

• What have you done about SALAD drugs?

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Look-alike, Sound-alike Drugs

• We read back and spell out any sound-alike
  medications on verbal/telephone orders
• Medication Orders SH core CP2.49p
• Pharmacy has added Tallman lettering to the
  Pyxis
• Helps to distinguish meds that look alike
• Ex.chlorPROPamide vs. chlorproMAZine
• High Alert Medications SJ Rx-11-057

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Question 6

• How do you handle medication orders with ranges?
• Example 1 to 2 tablets Q 3-4 hours prn pain?

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Range Order Policy

• Begin with the smallest dose
• If no relief within
• Thirty minutes (for IV administration)
• One hour (for oral or IM medication)
• Use the remainder of the dose (up to the next
  prescribed amount)
• For subsequent doses, the total amount
  administered to obtain relief may be given
• Medications Prescribed With a Dose Range SJ
  Rx-11-043

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Example (dosage)

• Morphine 2-4mg IV Q 3 hrs prn pain
• Give 2 mg
• Reassess pain in 30 minutes (IV med)
• If pain is not relieved, an additional 2 mg may
  be given.
• For subsequent doses, 4 mg may be given at the
  appropriate time interval

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Example (frequency)

• Orders indicating a frequency range
• The shortest frequency is allowable for as
  needed orders.
• Example
• Percocet 1 tablet every 4-6 hours prn pain
• Doses can be given as frequently as every four
  hours, upon request by the patient.

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Titrating orders

• Orders for medications that require titration
  must contain parameters.
• Example
• Dopamine 400mg/250ml, start at
• 5 mcg/kg/min, titrate to systolic of 90mmHg.

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Question 7

• Under what circumstances can medications be
  obtained prior to a pharmacist review?

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Medications can be removed without pharmacist
review

• In an emergency that is documented in the medical
  record
• Example patient needs naloxone STAT
• Only 1 episode may be treated before pharmacist
  review
• In specialized areas where a licensed independent
  practitioner (LIP) is overseeing medication use
• (must be physically present)
• Examples OR, Radiology
• Emergency Access to Medication SJ Rx-11-042

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Question 8

• How long do you keep multi-dose vials?

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Multi-dose Vials

• Maximum 28 days
• if contaminated, must discard earlier
• Vial must be dated when opened
• Lidocaine exception-
• Only a single use then discard!!!

• Multidose Vials SJ Rx-01-011

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Question 9

• What are the requirements to take telephone or
  verbal orders?

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Telephone/verbal orders

• TO for emergency only if the prescriber is in
  the hospital
• VO - for emergency only or if prescriber is
  gloved
• Must write down order and read it back, then
  document
• (Ex T.O./RB Dr. Jekyll/Ms.Hyde, RN)

• Physician Orders SJ MS-01-002

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Question 10

• Is it acceptable to write resume preop meds or
  resume meds for transfer orders?

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Resume meds?

• No, it is not acceptable to write blanket
  orders such as resume meds. Each order must be
  re-written if a patient is post-op or has been
  transferred between levels of care.
• Other blanket orders to avoid Rx to dose if
  test is negative/positive, give
• give 1mg/kg (must specify dose)
• Medical Staff Rules and Regulation
• Orders for Care and Treatment of Patients SH core
  CP2.48p

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OTHER REQUIREMENTS

• All orders must be signed to be implemented
  (including pre-printed)
• Do not cross out previously written orders. A
  new order must be written (e.g., discontinue .
• Medical Staff Rules and Regulations

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Question 11

• Are the following orders written correctly?
• Levothyroxine 75 µ daily
• 2 gms MgSO4 IV x 1 dose
• Xanax .5 mg 1 tablet PO prior to MRI
• Heparin 5000u SQ Q12H
• Nexium 40 mg po QD
• D/C all abx
• Vancomycin 1 gram IV QOD
• Start SSI protocol 2

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All contain inappropriate abbreviations

• Levothyroxine 75 µ daily
• Write mcg or microgram instead of µ
• 2 gms MgSO4 IV x 1 dose
• Write out magnesium sulfate can be mistaken for
  morphine sulfate
• Xanax .5 mg 1 tablet PO prior to MRI
• Use leading zero before a decimal point (0.5) and
  do not use a leading zero after (5)

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All contain inappropriate abbreviations

• Heparin 5000 u SQ Q12H
• Write out units
• Nexium 40 mg po QD
• Write out daily or QDay
• D/C all abx
• Write out antibiotics
• Vancomycin 1 gram IV QOD
• Write out every other day
• Start SSI protocol 2
• Write out sliding scale insulin

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Prohibited abbreviations
Physician Orders SJ MS-01-002
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Medication Reconciliation

• Specific process under development
• Nursing to document medication history on Home
  Med form
• Pharmacy to reconcile _at_ admission, treatment, and
  postoperatively
• At discharge, prescriber must document the plan
  for each medication on Home Med list (circle
  continue, discontinue or revised)

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POST TESTFor UF Faculty at Shands Jacksonville
Complete and submit the online posttest (see next
slide) and you will receive a confirmation email
indicating the number of questions you answered
correctly. If you answered at least 7 questions
correctly, one CME credit for Preventing Medical
Errors will be added into the College of
Medicine CME transcript system. The test may be
retaken only once. You may request a copy of
your CME transcript from the UF Jacksonville CME
Office by calling 244-3158 or emailing
bobbi.cox_at_jax.ufl.edu
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CME for Florida License

• It is important to note that this one-hour CME
  activity was designed to partially meet the
  TWO-hour course requirement for Preventing
  Medical Errors required for medical licenses in
  Florida.

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POST TESTTo complete 10-question posttest, click
on url belowhttp//www.hscj.ufl.edu/cme/pme.asp
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