Medication Error Prevalence

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Medication Error Prevalence
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IOM Reports

• 1999
• Healthcare is not as safe as it can be and should
  be.
• Strategies for improvement

• 2001
• Reinventing the delivery of healthcare

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Consequences

• Costly to hospitals 17- 29 billion per year
• Patients loose trust in the healthcare system
• Patients pay in psychological and physical
  discomfort and healthcare professionals pay in
  frustration for the inability to deliver the best
  care.

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The Findings

• Errors are not the result of one persons
  reckless actions but of system failures.
• Systems analysis is essential to discover the
  failures.
• Front line staffs participation in the analysis
  is necessary to understand what is truly
  happening.
• Healthcare has become increasingly complex.
• Rapid changes in practice and technology has left
  healthcare unable to transfer the knowledge into
  practice.
• To align knowledge with practice, all
  stakeholders must work together to identify a
  limited number of priority conditions and develop
  strategies to improve the delivery of care for
  these conditions.

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Recommendations

• Establish a national focus
• Identify and learn from errors through mandatory
  and voluntary reporting systems
• Raise performance standards and expectations
• Establish a culture of safety
• Goal to reduce preventable errors by 50 over 5
  years

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The VisionRecommendations include adopting six
aims for improvement and ten rules for system
design.

• Aims
• Care must be
• Safe
• Patient Centered
• Effective
• Equitable
• Timely
• Efficient
• Aims must be emphasized and imbedded in all
  health delivery systems

• Rules
• Based on continuous healing
• Organized based on patient needs and values
• Controlled by patient
• Knowledge is shared
• Decision making is evidence based
• Safety is a system property
• Transparency is necessary
• Needs are anticipated
• Waste is continuously ?
• Cooperation among clinicians is a priority

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ADEs and Medication errors

• 7000 deaths annually related to prescription
  error
• Drug related morbidity and mortality may cost up
  to 77 billion annually
• Patients who experience an ADE have an average
  LOS 8-12 longer.
• Errors rates involving children are three times
  that of errors involving adults.

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Medication Safety Alerts

• 11/00
• an infant dies after receiving 5mg of morphine
  instead of the ordered .5mg.
• 5/01
• A 9-month-old died after receiving 5 mg of
  morphine instead of the ordered .5 mg of
  morphine.
• No leading zero
• Misread and transcribed as 5 mg

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A 9 Year Study

• 1987-1995
• All medication errors with potential for adverse
  outcome detected were recorded and analyzed
• Errors increased from 522 to 2115 and correlated
  to admissions.
• Most common dosing errors and inappropriate
  forms, and prescribing a medication for which the
  patient was allergic.
• Hospitalized patients are at a greater risk for
  an ADE
• Limited changes occurred as similar errors
  repeated with increasing frequency.
• Healthcare organizations and providers must
  incorporate reduction, prevention and detection
  mechanisms into daily provision of care.
• Arch of Internal Med. 1997 Jul 28157(14)1569-76

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Study Cost of ADEs in Hospitalized Patients

• Cohort study including 4108 admissions
• 190 ADEs 60 preventable
• Additional LOS 2.2
• Additional LOS for preventable 4.6
• Increased cost of 2595 for all ADES and 4685
  for preventable ADEs
• Equates to 2.8 million (700 bed hospital) and
  5.6 million (bed hospital)
• This does not include the cost of patient harm
  and malpractice payments
• JAMA Vol 277 No 4, Jan 1997

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Malpractice

• 1990-2003
• 7,472 medication related malpractice acts or
  omissions
• 26 of malpractice acts or omissions
• 920,577,368 in payments
• 2003
• 49 reports made against RNs
• 61 payments made by RNs
• Mean payment 181,162

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Where do errors occur and what is being done to
reduce incidence?

• Medication management system.
• Marketing
• Ordering/prescribing
• Transcribing
• Dispensing
• Administration
• Monitoring

• Interventions to reduce likelihood for ADEs and
  ADRs
• AERS
• CPOE
• Automated dispensing cabinets
• Bar coding
• NPSG

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Common causes

• Poor communication
• Ambiguities in product names, directions for use
  and strength designation on labels
• Poor procedures or technique
• Variation is the enemy of quality.

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Marketing

• FDA Gate keeper for medication safety.
• Estimated that half of the side effects from
  pharmaceuticals are avoidable.
• Premarket risk assessments and postmarket
  surveillance
• Complex system unclear roles and
  responsibility postmarket
• Global market
• Bates, D.W., L.L. Leape and S. Petrycki,
  Incidence and Preventability of Adverse Drug
  Events in Hospitalized Adults, J Gen Intern
  Med., 8289-294, 1993. Managing the risks and
  benefits from medical product use

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• It is simply not possible to identify all the
  side effects of drugs before they are marketed.
• Wood, Stein and Woosley, New England
  journal of Medicine, 339,pp. 1851-1854 (1998)

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Improvements in Post Market Surveillance

• Move from mandatory reporting of all user
  facilities to annual reports by a representative
  sample sentinel sites
• Establishment of an office to oversee post-market
  risk assessments (OPDRA Office of Post
  Marketing Risk Assessment)
• Expand AERS to integrate reporting of post
  marketing safety information worldwide

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Current Model New Model
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Model for Improvement
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Ordering/Prescribing

• Illegibility 6
• Abbreviations
• Improper Dosing 7
• Dosing Errors
• Ordering medications to which patient was
  allergic
• Duplicate therapy 5
• Unclear/incomplete medication history
• JAMA 1995274(1)29-43

• Standardized pre-printed orders
• Standard abbreviations including abb. Not to use.
• Calculators
• Pharmacy involvement
• Read back policies
• Medication reconciliation

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CPOE computerized physician order entry

• Although published studies report that CPOE
  reduces medication errors up to 81 a recent
  survey of hospitals responding to the Leap Frog
  Groups hospital Quality and Safety survey, only
  64 out of 1,143 have CPOE fully implemented.
• Koppel, Metlay, Cohen, Abaluck, Localio,
  Kimmel, Strom, JAMA.20052931197-1203

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Benefits of CPOE

• Decrease LOS
• Reduce costs
• Decrease medical errors
• Improve compliance with guidelines
• Decrease overuse, underuse and misuse.
• Study
• 2 year implementation within first 30 days,
  4,500 medication orders with 40 drug-drug
  interactions noted requiring intervention within
  first 4 months at approx. 5000 med orders/month,
  72 drug-drug interactions.

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Issues Associated with CPOE

• Substantial cost
• Technology
• Organizational analysis and process design
• Redesign
• Support
• Training
• Study
• 261 house staff surveyed, five focus groups and
  32 1 to 1 intensive interviews with house staff,
  IT, pharmacy, physician and nurses identified
  that the CPOE system facilitated 22 types of
  medication errors including inflexible ordering
  formats that generated wrong orders and inventory
  displays mistaken as dosage guidelines. These
  types of errors were experienced weekly or more
  often. (Jama, 20052931197-1203)

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Unexpected increase in mortality

• Study included children transferred to tertiary
  care childrens hospital during an 18 month
  period
• CPOE system was rapidly implemented over 6 days
  during this period
• Retrospective analysis 13 month before and 5
  months after implementation
• Mortality rate increased from 2.8 (39/1394)
  prior to implementation to 6.57 after (36/548)
• Pediatrics. 2005 Jan117(1)216-7

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Examples

• Lower case l misidentified by the software as I
  and instead of Lodine, pulled up Iodine
• Most commonly misidentified were I/l, O/0 and Z/2
• Many computer systems display drug doses using
  naked decimal points and unsafe abbreviation (QD
  and U)

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ISMP Recommendations

• List products by generic name using tall-man
  letters to distinguish look-alike, sound-alike
  medications. Ex. hydrOXYzine and hydrALAZINE.
• Express weights and measures in standard fashion
• List brand names in upper case to differentiate
  from generic standard in pharmaceutical industry
• Provide ways to communicate patient or medication
  related warnings related to prescribed
  medication i.e. colored font, italics
• 26 total recommendations as of 2003

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MOE One Study

• 500 bed hospital
• 7.9 one time operating and capital expense with
  1.35 annually
• Opted for MOE over CPOE
• Less costly
• Provides decision support
• Addresses legibility issues
• Cost return in short time

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Transcription

• Intervene to clarify unclear orders.
• Contact prescriber to clarify unapproved
  abbreviations even if they appear clear
• Use triggers to prompt.
• If two medical professionals can not read the
  order or to continue to have questions, contact
  the prescriber.

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Dispensing

• Labeling errors during repackaging
• Lack of access to the right medication at the
  right time
• Less control over inventory
• Poor/no audit trail

• Single dose units
• Mandatory bar coding
• Automated medication dispensing cabinets.

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Benefits of ADC

• Control over inventory
• Creates audit trail
• Links patient to medication
• Provides timely access to a greater number of
  medication
• Improved security for medications

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Issues with ADC

• Not enough cabinets to service the patient care
  area
• Override functions can facilitate orders carried
  out prior to review by pharmacy
• Reminders and alerts may not provide adequate
  information
• No forcing function to control and record
  narcotic wasting

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Administration

• Wrong patient
• Wrong medication
• Wrong time
• Wrong dose
• Wrong route

• Bar coded patient identification system
• Clear policies and procedures for medication
  administration including patient identification.
• Red rules to impress importance

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Red Rule

• PATIENT SAFETY ALERT
• ALL CLINICAL STAFF
• RED LETTER RULE 3
• MEDICATIONS
• When administering medications, the Medication
  Administration Record (MAR) and the medication
  in the original packet or unit dose must be
  brought to the patients bedside.
• The following steps must occur
• Verify patient identification using two
  identifiers (neither to be the patients room)
  resolve discrepancies before administering
  medication.
• Ensure compliance with the 5 Rights of
  Medication Administration
• Right Patient
• Right Drug
• Right Dose
• Right Route
• Right Time
• Validate with another RN a documented
  double-check for all insulin, heparin, warfarin
  and narcotic medications prior to the
  administration of the medication.
• THERE ARE NO EXCEPTIONS TO THIS RULE

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Monitoring

• Failure to recognize adverse reactions
• Failure to report adverse reactions
• Failure to educate patients about potential side
  effects.

• Prompt added to MAR to identify new medication
  and document patient response.
• Get patients involved in their healthcare
  decisions
• Computerized monitoring utilizing signals.
• Lab values
• Rash
• Fever
• Diarrhea

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• ADEs and ADRs can occur along the entire
  medication management system.
• Approval for public use
• Ordering
• Transcribing
• Administering
• Monitoring

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• Good systems Each system is designed to get
  exactly the results it gets.
• Constantly evaluate your systems and find
  opportunities for improvement.
• Quality is not perfection.

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Computerized Monitoring

• Computer assisted antibiotic dosing monitor
  tracks renal function daily and identifies
  patients who may receiving excessive doses of
  antibiotics.
• Integrated with lab, pharmacy and other patient
  specific information identifies allergies,
  drug-drug and food-drug contraindications
• Detects possible ADES through combinations of
  orders and lab results an order for a drug along
  with an abnormal lab value that would indicate a
  possible ADE

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Review Study

• 617 ADEs were discovered
• Chart review 398
• Computer monitoring 275
• Voluntary reporting 23
• Although chart review discovered the most,
  computer monitoring was considered more efficient
  because it discovered more than voluntary
  reporting and was less time consuming than chart
  review.
• J Am Med Inform Assoc 19985(3)305-14

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Reasons Model
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