Standardized Medication Concentrations for Parenteral Infusion Medication Management: Revised: February 19, 2014

Medication Management Background Provincial Parenteral Manual Roll-out & Transition Access & Support Standardized Medication Concentrations (SMCs) SMC Lists & Policy What you need to do Next Steps Agenda

Collaborative approach to prevent and minimize medication errors and near misses to increase patient safety Addresses all medication aspects from prescription, selection, preparation, and dispensing to the administering of medication and ongoing monitoring of patients Medication Management Medication Concentration Narcotics Safety Heparin Safety Antimicrobial Stewardship Others? Concentrated Electrolytes High Alert Medication Medication Reconciliation Mission Vision Values Medication Management

The new Provincial Parenteral Monographs provides: Single common parenteral monograph throughout the province Ensures patient safety and consistent medication administration and management Electronic reference for drug therapy guidelines and parenteral drug information Provincial Parenteral Manual - Link Although PPM can be access electronically, a hard copy must be maintained for downtime instances Provincial Parenteral Monographs (PPM) NOTE:The new Provincial Parenteral Monographs are NOT a comprehensive drug reference – if further information required, please consult other sources (i.e. Drug Information Services)

Ongoing roll-out of the new PPM will take place as therapeutic drug classes are completed Use existing site specific monographs until new provincial monograph is available Provincial Parenteral Monographs (PPM) Parenteral Manual (top blue bar) Old legacy sites will link to new AHS monographs CompassionNet (homepage) AHS Provincial Parenteral Manual (InSite page) Use existing old legacy parenteral monographs No new monograph updated

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What are SMCs: Medication infusions which are mixed according to a limited number of pre-determined drug concentrations Focused on high alert medications Established based on stakeholder input, focusing on the Institute for Safe Medication Practices’ (ISMP) list of high- alert medications Took into account: legacy lists, parenteral drug monographs, stakeholder feedback, leading practices, availability from manufacturer, and concentrations implemented at other sites within Canada & USA Standardized Medication Concentrations (SMCs)

Two (2) NEW Standardized Medication Concentration Lists: Adult Standardized Medication Concentration List: Currently, a total of 50 drugs with 104 concentrations Neonatal Standardized Medication Concentration List: *** April 1 st : begin smart pump software upgrade & drug libraries updates *** Revise pre-printed patient care orders and mixing sheets based on new Standardized Medication Concentrations List Standardized Medication Concentrations (SMCs) NOTE:Roll-out for Insulin and Vasopressin will need to be deferred

Why SMC Lists? Safety Minimizing medication errors to ensure patient safety Decreasing number of concentration and volume options available for the same medication reduces the risk that a healthcare provider will select, dispense, or administer the wrong concentration Standardization and Consistency Reduce the number of steps and processes and the reliance on human memory and vigilance Compliance Accreditation Canada’s Medication Management ROP 2.5 – Major Test for Compliance: “The orgnizational limits and standardizes concentrations and volume options available for high-alert medications” Standardized Medication Concentrations (SMCs)

Facts: Medication errors are the LARGEST identified source of preventable hospital medical errors Parenteral Administration errors are three (3) times as likely to cause harm or death compared with other errors 79% of reported harmful or fatal medication errors involve the IV route 58% of these errors occurred during administration of the medication Healthcare expenses due to preventable errors cost Canadians $750 million/year A hospital patient can expect to be subjected to more than one (1) medication error a day (Institute of Medicine 2006) Standardized Medication Concentrations (SMCs)

Errors in the Medication Use Process : Standardized Medication Concentrations (SMCs)

Facts: We are Human – Humans are Fallible! Sometimes, we make mistakes, no matter how familiar we are We must design our work processes to help us reduce the possibility of mistakes/errors and ensure that mistakes/errors are detected and corrected. Standardized Medication Concentrations (SMCs) Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoent tihng is that the frist and lsat ltteer be at the rghit pclae. The rset can be a tatol mses and you can sitll raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh

Standardized Medication Concentrations (SMCs) Policy & Procedure:  Ordering Medications Concentrations may or may not be part of the order If ordering a non-SMC, must document clinical reason why and indicate clearly the preferred medication concentration  Processing Medication Orders Concentrations to be clarified by a Health Care Professional and documented as per site processes on chart

Standardized Medication Concentrations (SMCs) Policy & Procedure:  Preparing Medications Use ready-to –administer format whenever/wherever possible Use parenteral monographs for mixing instructions Labels & Instructions Standard Concentrations No label required High Concentrations Non-Standardized Concentrations IDC on calculations & preparation +

Standardized Medication Concentrations (SMCs) Policy & Procedure:  Administering Medications Utilize smart pump drug libraries If non-SMC are used, manual programming of the pump is required with verification via an IDC  Auditing Pharmacy to audit compliance by reviewing: infusions dispensed, medication orders, MARs, and/or patient charts Nursing to audit compliance using data from: smart pumps, MARs, and/or patient charts

Standardized Medication Concentrations (SMCs) What do you need to do?  Nursing CNEs to notify staff on new SMCs and how to how to mix and handle orders (either with no specified SMCs, or with non-SMC specified) Identify sources required: mixing sheets, pocket cards, posters, etc. Units to ensure appropriate drug supply in areas of med storage not supplied by Pharmacy (i.e. crash carts) Ensure smart pumps have version 12 drug library after April 1 st Audit compliance with SMCs (i.e. data from smart pumps, using MARs and/or patient profiles/charts)

Standardized Medication Concentrations (SMCs) What do you need to do?  Pharmacy Amend pharmacy computer system to reflect new SMCs Update stock in pharmacy and on nursing units if needed Update wardstock lists Purchase or make products whenever possible Update sterile manufacturing worksheets for IV room if needed Train staff on how to handle orders (either with no SMC specified, or with the wrong SMC specified) Audit compliance with SMCs (i.e. review of orders, infusions dispensed, review of MARs/patient profiles/charts)

Standardized Medication Concentrations (SMCs) What do you need to do?  Prescribers Ensure medication order comply with SMCs when ordering standardized concentrations (i.e. magnesium sulfate) Ensure using SMCs when mixing on own (i.e. anesthetists) Specify preferred concentration and clinical reason why SMC will not meet the patient’s needs of want to use and non-SMC  All users of PPCOs Ensure PPCOs comply with SMCs and revise as needed

What Now? Communicate Familiarize & Learn Educate Lead

March 3-7March 10-14March 17-21March 24-28March 31-April 4April 7-11April 14-18April 21-25April 28-May 2May 5-9 SMC Implementation April 1, 2014: Smart Pump Drug Library Update & SMC List Available RAH UofA Staff Training (provided by CNE) PharmacyTraining MCH Training Smart Pump Upgrade Legend: GNCH Roll-out: April 1 st, 2014

For More Information… Parenteral Monographs Smart Pump Library Policy and Procedures Will be located on CompassionNet once finalized

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