High-Alert Medications: Safeguarding Against Errors (Part 1)

Slides:



Advertisements
Similar presentations
Using the Insulin Subcutaneous Order & Blood Glucose Record – Adult
Advertisements

Please wait……….. CHAPTER 12 AUTOMATED DISPENSING CABINETS (ADCs) - is a computerized point-of-use medication management system that is designed to replace.
Eliminating Error-prone Abbreviations, Symbols, and Dose Designations
PATIENT SAFETY It’s Everyone’s Business
ORIENTATION FOR STUDENTS PATIENT SAFETY PERFORMANCE IMPROVEMENT Quality & Risk.
2013 Education. Background From a recent ISMP Medication Alert, hospitals have been advised to evaluate their insulin administration techniques and determine.
30 Safe Practices for Better Health Care AHRQ. Background The goal in the United States is to deliver safe, high-quality health care to patients in all.
TIGER Standards & Interoperability Collaborative Informatics and Technology in Nursing.
High-Alert Medications: Safeguarding Against Errors (Part 2)
Institute for Safe Medication Practices
Introduction:  The preparation of parenteral admixture usually involves the addition of one or more drugs to large volume solutions such as intravenous.
Protecting patients- now and in the future Linda Matthew Senior Pharmacist National Patient Safety Agency.
Legal Implications for Nursing. Legal Terms Negligence –A general term that refers to conduct that does not show due care –Occurs when someone fails to.
MEDICATION SAFETY Kim Donnelly, RPh
 Definition of Chemotherapeutic Drug Administration  Administration of Chemotherapeutic Agents  Dosage of chemotherapeutic administration  Equipment.
Medication Safety Standard 4 Part 4 –Medication management processes, partnering with patients and carers Margaret Duguid, Pharmaceutical Advisor Graham.
Error Prone Abbreviations
Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial Preparing Study Orders & Laptops Amy Fansler SHINE Project Director.
Standard 4: Medication Safety Advice Centre Network Meeting Margaret Duguid Pharmaceutical Advisor February 2013.
High Alert Medications Abdulhadi Burzangi Pharm.D
Some Important Tips for JCI Survey
Medication Safety Practices in Perianesthesia Care Jennifer Watson, PharmD Medication Safety Pharmacist Centracare – St. Cloud Hospital.
Recommended by the Sentinel Event Alert Advisory Group NATIONAL PATIENT SAFETY GOALS FY 2009.
Buyers Taking an Active Role in Patient Safety Patrick Gallagher, CPhT Pharmacy Buyer Marian Medical Center.
Pharmacy Services.
By Ruth Kavita Senior Pharmaceutical Technologist, KNH.
July 2012 Pharmacy Data Management/Drug Databases 1.
Australian Commission on Safety and Quality in Health Care
The Clinical Guide “A Guide to Implementing Renal Best Practice in Haemodialysis“ Chapter 5: Anticoagulation Team Leader: Angela Henson Co-authors: Franta.
History of patient safety : 1955 when Codman who is also known as father of Patient safety looked at the outcome of patient care 1984 Anaesthesia patient.
Dr. Rosaline Kinuthia Clinical pharmacist KNH. Optimize patients outcomes through the judicious, safe, efficacious, appropriate and cost effective use.
Application of Safety Principles to Labeling, Packaging and Nomenclature Decisions Michael R. Cohen, RPh, MS, ScD, FASHP Institute for Safe Medication.
Responsibilities and Principles of Drug Administration
Definition:  medication that have a higher likelihood of causing injury if they are misused. Errors with these medications are not necessarily more frequent-
Occurrence Reports. An occurrence report is a document used to record an event when it occurs Occurrences are reported each time an occurrence occurs.
Managing Hospital Safety: Common Safety Concerns (Hospital-focused presentation) Part 3 of 4.
Administration Safety PHCL 492. Standards for Medicines Management  ‘When required to administer medication a practitioner is accountable for his or.
Annual Topic of Current Interest Medication Incidents Annual Topic of Current Interest Medication Incidents 2001/2002 Annual Report: Hospital Pharmacy.
DVT Prevention and Anticoagulant Management
AFAMS EO Storage of ISMP High Alert Medications (Dari) 01/09/2013.
Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 2 Application of Pharmacology in Nursing Practice.
THE ROLE OF TECHNOLOGY IN THE MEDICATION-USE PROCESS
Principles of Medication Administration and Medication Safety Chapter 7 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of.
Emtenan AlHarbi,Mcs Clinical pharmacist
Results: The Staff Safety Assessment Survey Lisa Lubomski, PhD April 11, 2013.
CHSP and CalHEN Opioid Adverse Drug Event Prevention Gap Analysis: Survey Findings August 14, 2013, 2013.
Managing Hospital Safety: Common Safety Concerns Part 4 of 4.
The Pharmacy Technician
Medication Safety Lizabeth Martin, MD Faculty Fellowship: Safety and Quality Mentors: Lynn Martin and Sally Rampersad.
Informatics Technologies for Patient Safety Presented by Moira Jean Healey.
ADVERSE DRUG EVENT (ADE) Driver Diagram OHA HEN 2.0.
June 2011 Pharmacy Data Management/Drug Databases.
Institutional Pharmacy
Assuring Compliance with the JCAHO 2004 Standards: Medication Management Patricia C. Kienle, RPh, MPA, FASHP Medication Safety Manager Cardinal Health.
National Patient Safety Goals (NPSG) Online Orientation -the purpose is to improve patient safety -the goals focus on problems in health care safety and.
Chapter 31 Medication Administration. Injections: Intravenous  Three methods:  As mixtures within large volumes of IV fluids  By injection of a bolus.
©ECRI XIX. Drug Delivery Pumps TRAINING SEMINAR ON MEDICAL DEVICE ACCIDENT INVESTIGATION for Kingdom of Saudi Arabia Saudi Food & Drug Authority.
Chapter 14 Inventory Control.
Inventory Management Chapter 13.
Total Parenteral Nutrition
Reviewed By- Dr Vijay Agarwal Dr Chander Mohan Bhagat Dr Lallu Joseph
Preventing Medication Errors
Medication Errors Look-Alike/Sound-Alike Medications
علیرضا تسعیری - بیمارستان قلب و عروق جوادالائمه (ع) مشهد
30 Safe Practices for Better Health Care
Patient Safety and Quality Improvement
Medication Safety & Anticoagulation
Outline Why Focus on PN Safety? PN Safety Gap Analysis Survey Results
Preventing Medication Errors
Presentation transcript:

High-Alert Medications: Safeguarding Against Errors (Part 1)

Learning Objectives Discuss the concept of high-alert medications Identify the many drug classes considered to be high-alert status Describe various strategies for safeguarding the use of high-alert medications

High-Alert Medications High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error Errors may not be more common with these than with other medications, but the consequences of errors may be devastating I used the current ISMP definition

ISMP’s List of High-Alert Medications Adrenergic agents Anesthetics Antiarrhythmics Anticoagulants Cardioplegic solutions Chemotherapy Dextrose ≥20% Dialysis solutions Electrolytes (concentrated) Epidural/intrathecal agents Epoprostenol Inotropic agents Insulin/hypoglycemics Liposomal products Narcotics Neuromuscular blocking agents Nitroprusside Oxytocin Parenteral nutrition Promethazine Radiocontrast agents Sedatives Sterile water for injection This is the most current ISMP list with web site location – suggest deleting the previous three slides and including only this one. www.ismp.org/Tools/highalertmedications.pdf

High-Alert Status of Drugs: Differences Between Nurses’ and Pharmacists’ Beliefs Medication % Nurses % Pharm Dialysate solution 66 26 IV adrenergic agonists 92 63 IV adrenergic antagonists 81 43 Liposomal forms of drugs 68 39 Hypertonic sodium chloride 73 94 Warfarin 59 75 Subcutaneous insulin 72 Institute for Safe Medication Practices. ISMP Medication Safety Alert! October 16, 2003;8(21).

Drugs Most Frequently Considered High-Alert by Practitioners Medication High-Alert? Parenteral chemotherapy 98% IV potassium chloride 96% Neuromuscular blockers 94% Hypertonic sodium chloride 91% IV insulin 90% IV potassium phosphate IV heparin 87% IV thrombolytics 82% Institute for Safe Medication Practices. ISMP Medication Safety Alert! October 16, 2003;8(21).

Framework for Safeguarding High-Alert Medication Use

Primary Principles Reduce or eliminate the possibility of errors Make errors visible Minimize the consequences of errors

Key Concepts in Safeguarding High-Alert Medications Simplify Reduce steps and number of options Externalize or centralize error-prone processes Differentiate items Appearance, location Touch, color, smell, etc.

Key Concepts in Safeguarding High-Alert Medications (continued) Standardize Communication and dosing methods Redundancy Check systems, back-ups

Key Concepts in Safeguarding High-Alert Medications (continued) Reminders Improve access to information Constraints that limit access or use Forcing functions Fail-safes Use of defaults Patient monitoring Failure analysis for new products and procedures

Implement a Safety Checklist for High-Alert Drugs Develop policies regarding the use of high-alert drugs Assess and implement storage requirements of high-alert drugs Develop and institute standardized order sets Ensure the process of evaluating potential formulary additions identifies high-alert medications

Number of Steps in the Process Error Probability Rate Simplify Probability of no error when each step is 99% reliable Number of Steps in the Process Error Probability Rate 1 1% 25 22% 50 39% 100 63%

Simplify Reduce the number of steps and options Computerized order entry Unit-dose dispensing Dosing charts Limited choice of concentration Premixed solutions Do not eliminate crucial redundancies

Key Concepts in Safeguarding High-Alert Medications (continued) Simplify and reduce number of options through standardization Use a single heparin size/concentration Standardize concentrations of critical care drug infusions Use weight-based heparin protocol

Key Concepts in Safeguarding High-Alert Medications (continued) Externalize or centralize error-prone processes: IV drug preparation Use commercially prepared premixed products Premixed magnesium sulfate, heparin, etc. Centralize preparation of IV solutions Prepare pediatric IV medications in pharmacy Outsource of TPN and cardioplegic solutions

Key Concepts in Safeguarding High-Alert Medications (continued) Differentiate items that are similar but dangerous if confused Purchase one of the products from another source If hydroxyzine and hydralazine injections look alike, purchase one from another company Use “TALL-man” lettering hydrOXYzine versus hydrALAZINE Use other means to “make things look different” or call attention to important information Use stickers, labels, enhancement with pen or marker See http://www.ismp.org/tools/tallmanletters.pdf

Key Concepts in Safeguarding High-Alert Medications (continued) Differentiate items by touch, color, etc. Tactile cues Place tape on regular insulin vial for blind diabetic patients Octagonal shape of neuromuscular blocker container Use of color Use red to “draw out” warnings Color coding also can be a source of error Suggest eliminating “smell” - I like the idea but this is not mentioned in the chapter (at least not that I could find) and I am concerned that that someone might try to apply this to a hazardous drug.

Key Concepts in Safeguarding High-Alert Medications (continued) Bar code scan or separate problem products as effective deterrent for product selection errors Look-alike packaging Store hydroxyzine and hydralazine tablets apart Look-alike drug names Design computer mnemonics so similar names do not appear on same screen Avoid placing similar names (carboplatin/cisplatin, vinblastine/vincristine) next to one another on a preprinted chemotherapy form or order entry computer screen

Key Concepts in Safeguarding High-Alert Medications (continued) Standardize order communication Create, disseminate, and enforce ordering guidelines Standardize read-back procedure for verbal orders Standardize dosage units in smart pumps and autocompounders Eliminate acronyms, coined names, apothecary system, use of nonstandard symbols, etc. TPN: IV nutrition or Taxol, Platinol, Navelbine Irrigate wound with TAB

Key Concepts in Safeguarding High-Alert Medications (continued) System of independent checks (redundancies) Probability that two individuals will make the same error is small; therefore, having one person check the work of another is essential PCA pump rate and concentration set by one person with independent confirmation by another Calculations for pediatric patients, select high-alert medications, etc., performed independently by at least two individuals, with identical conclusions

Key Concepts in Safeguarding High-Alert Medications (continued) Use reminders Place auxiliary labels on containers for clinical warnings and error prevention messages Dilute Before Use For Oral Use Only Incorporate warnings into computer order processing and selection of medications from dispensing equipment Labels on IV lines to prevent mix-ups between IV lines and enteral feeding lines Protocols, checklists, visual and audible alarms Suggest not using the “check for pregnancy” example – Does this mean that you should only use it during pregnancy or does it mean not to use it in pregnancy?

Key Concepts in Safeguarding High-Alert Medications (continued) Improve access to information Computerized drug information resources (handheld) Computer order entry systems that merge patient and drug information, provide warnings, screen orders for safety, etc. Readily available texts in current publication Pharmacists present in patient care areas Internet connection I suggest removing the item about the medical librarian on clinical rounds to follow up on patients and staff information items – The librarian will not have the domain expertise to know what information should be provided to the patient. Also, the idea is not realistic.

Key Concepts in Safeguarding High-Alert Medications (continued) Use constraints that limit access in risky conditions Reduce access to dangerous items by careful selection of medications and quantities in storage Limit or prohibit access to pharmacy in nonaccredited facilities Move problem products out of reach Remove concentrated potassium chloride from clinical units Sequester neuromuscular blockers from other medications

Key Concepts in Safeguarding High-Alert Medications (continued) Limit drug use Peer reviewed drug approval process Staff credentialing with restricted access or usage rights Automatic reassessment of orders Institute automatic stop orders Use medications with reduced dosing frequency Establish parameters to change IV to PO as appropriate

Key Concepts in Safeguarding High-Alert Medications (continued) Forcing functions (“lock and key design”) Makes errors immediately visible; ensures that parts from different systems are not interchangeable; forces proper methods of use Enteral feeding tubes without Luer connection combined with systems that will not fit vascular access devices Oral syringe should not be able to fit onto an IV line Preprinted order forms or computer options that “force” selection from limited number of medications, available dosages, etc.

Key Concepts in Safeguarding High-Alert Medications (continued) Fail-safes Use products that design error out of the system Implementation of automatic fail-safe clamping mechanism on IV infusion pumps has protected patients from free-flow and saved many lives Dangerous order cannot be processed in computer system

Key Concepts in Safeguarding High-Alert Medications (continued) Use of defaults Pre-established parameters take effect unless action is taken to modify Clinical pathways Device defaults Morphine concentration default for PCA pump Pharmacy IV compounder defaults to drug concentrations available in pharmacy

Key Concepts in Safeguarding High-Alert Medications (continued) Patient monitoring More frequent and closer attention to vital signs, including quality of respirations More frequent and closer attention to neurological signs and laboratory results Include patient monitoring parameters in all protocols and order sets

Key Concepts in Safeguarding High-Alert Medications (continued) Failure analysis for new products prior to use Formal safety review (e.g., formulary committee, risk management committee) of new medications and drug delivery devices Examine for ambiguous or difficult-to-read labeling, error-prone packaging, sound-alike product names, etc. Conduct a failure mode and effects analysis to proactively anticipate and prevent errors

References Institute for Safe Medication Practices. ISMP’s list of high-alert medications. ISMP Medication Safety Alert! March 27, 2008;13(6). Institute for Safe Medication Practices. Survey on high-alert medications. Differences between nursing and pharmacy perspectives revealed. ISMP Medication Safety Alert! October 16, 2003;8(21).