NPR REPORTS, RULES AND MEDICATION SAFETY by Steven Botwinski, R.Ph., Yvonne Kimura, Pharm.D. Hao Luu, Programmer Bruce Matthias, R.Ph. The IN Group, Inc. February 18, 2009

Goals: Demonstrate how rules, NPR reports and customer defined screens can be used to aid in regulatory compliance Demonstrate how NPR reports can be used to increase the efficiency of clinical monitoring

JCAHO National Patient Safety Goal 2008 Goal 3E: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

Anticoagulation monitoring Anticoagulation protocol Baseline INR required (order entry- pharmacist) Administration current INR (eMAR-nurse) Clinical progress (daily rounds-pharmacist) Performance measures (pharmacy director)

Anticoagulation monitoring - Order entry Baseline INR required prior to starting warfarin Pharmacy rule for pop up screen to warn the pharmacist that no baseline INR has been ordered within 24 hours

Anticoagulation monitoring - Medication administration The medication should not be administered if the most recent (within 24 hours) INR is outside the acceptable range. eMAR rule to warn the nurse that the INR is outside the safe range Display INR value Require action and response

Anticoagulation monitoring - Clinical monitoring Pharmacist monitoring patient progress Patient response to therapy Potential drug interactions Monitoring all anticoagulants Use scheduled NPR report Screen patients Pertinent data (lab trends, other meds)

Anticoagulation monitoring - Performance measures Administrative report for all anticoagulant use Degree of compliance Institutional performance trends Detail for follow-up as needed Use NPR report Run for specific date range Use data from PHA, LAB, NUR, OE Include heparin, enoxaparin, argatroban and warfarin) for baseline labs and changing renal function if applicable

Black Box Warnings Types of Black Box Warnings Intervention required at order entry Informational for nursing Intervention required during therapy Can be a combination of the above

Black Box Warnings - Intervention at order entry PHA order entry Rule with pop-up screen Data used from other modules to prevent over flagging (example: female, childbearing age, pregnant? Yes, No, or information missing)

Black Box Warnings - Informational for nursing Information in entirety can be placed in special instructions to be viewed by nurse in eMAR Advantage: no need for external printer or separate routine Disadvantage: requires extra keystroke to seen entire text or RN may not notice it is there

Black Box Warnings - Intervention at administration Information in entirety can be placed in Rx comments to be viewed by nurse in eMAR Full text seen on Acknowledge Drawback: requres extra key stroke to view full text on first screen of eMAR

Black Box Warnings - Intervention at administration Information in entirety can be placed in admin criteria to be viewed by nurse in eMAR Will pop-up automatically for viewing in eMAR with each administration and on acknowledge (example: use for quinolones) Other potential uses: look-alike, sound-alike

Vaccine Administration

Vaccine Administration Vaccine administration requirements Record lot number and expiration Provide patient with current vaccine information sheet (VIS)

Vaccine Administration Create a CDS for eMAR Administration query to record lot number and expiration Prompt “Vaccine Information Sheet Given? Automatic launch to CDC website to obtain current VIS (www.immunize.org/vis)

www.immunize.org/vis/

www.cdc.gov/vaccines/pubs/vis/default.htm

Neonatal Dose Verification and Documentation Witness Dose verification and preparation verification by a second nurse Alleviate need to create a separate pediatric drug formulary Audit trail for policy adherence / accountability

Neonatal Dose Verification and Documentation Witness eMAR cosignature as part of the prescription audit trail is a great solution…. BUT eMAR cosignature has been an all or none phenomena once set up in the drug dictionary…. UNITIL NOW

Neonatal Dose Verification and Documentation Witness Set up eMAR rule If patient age is <30 days, require a cosignature for verification of dose and preparation Include the cosignature as part of the Rx audit trail Attach the eMAR rule at the global Customer Defined Parameter level