Annual Topic of Current Interest Medication Incidents Annual Topic of Current Interest Medication Incidents 2001/2002 Annual Report: Hospital Pharmacy in Canada Survey

Medication Incident Reporting System and Review Medication Incident Reporting System and Review Medication Incident Reduction Strategies Medication Incident Reduction Strategies

Medication Safety Plan Establish a multidisciplinary medication safety committee Establish a multidisciplinary medication safety committee Adopt a safety culture: Encourage reporting and disclosure of medication incidents Adopt a safety culture: Encourage reporting and disclosure of medication incidents Implement “ Best Practices” and measure outcomes: medication incident reduction strategies Implement “ Best Practices” and measure outcomes: medication incident reduction strategies Inform health care professionals and patients of the outcomes of your medication safety initiatives Inform health care professionals and patients of the outcomes of your medication safety initiatives Caldwell et al. Medication Safety and Cost Recovery A four-Step Approach for Executives

Medication Incident Reporting Systems Medication incident reporting system is in use: 92% Medication incident reporting system is in use: 92% Written hospital policy: 88 % Written hospital policy: 88 % Clear definition of an error: 76% ( Qc: 50%) Clear definition of an error: 76% ( Qc: 50%) Reporting of “near-misses” : Reporting of “near-misses” : Prescribing errors detected in Rx: 21% Prescribing errors detected in Rx: 21% In pharmacy detected in Rx: 27% In pharmacy detected in Rx: 27% Before medication is administered: 96% Before medication is administered: 96% Hospital reporting data to: Hospital reporting data to: Provincial group: 8 % (Atlantic region) Provincial group: 8 % (Atlantic region) Other organizations (i.e: ISMP): 6 % Other organizations (i.e: ISMP): 6 %

Medication Incident Reporting Systems Medication incident report is part of the permanent patient / health record: 29% Medication incident report is part of the permanent patient / health record: 29% Individual medication incident report can be subpoenaed for legal proceedings: 44%? Individual medication incident report can be subpoenaed for legal proceedings: 44%? Review undertaken by the committee could be subpoenaed for legal proceedings: 71% ? Review undertaken by the committee could be subpoenaed for legal proceedings: 71% ?

Adopt a Safety Culture: Encourage Reporting Non punitive medication incident reporting Non punitive medication incident reporting Name of the person reporting the incident is on the form:94% Name of the person reporting the incident is on the form:94% Name of the person involved in the incident is on the form 40% Name of the person involved in the incident is on the form 40% Medication incidents are reported and openly discussed by staff without fear of reprisal : 72% ( 61% / 11%) Medication incidents are reported and openly discussed by staff without fear of reprisal : 72% ( 61% / 11%) Medication incident reports can be used during performance appraisals: 33 % Medication incident reports can be used during performance appraisals: 33 % Strategies to increase medication incident reporting: 68% Strategies to increase medication incident reporting: 68%

Adopt a Safety Culture: Encourage Disclosure Medication incidents are disclosed to patients and/or families Medication incidents are disclosed to patients and/or families Most of the time (  90%..): 18% Most of the time (  90%..): 18% Some of the time (  90%): 67% Some of the time (  90%): 67%

Mutidisciplinary Safety Committee: Medication Incident Review Designated committee responsible for medication incident review: 69% Designated committee responsible for medication incident review: 69% Membership of the committee: Membership of the committee: Patient representative Patient representative Information services Information services Mandate of the committee Mandate of the committee Promote a culture of safety (1) Promote a culture of safety (1) Position dedicated to safety initiatives: 21% Position dedicated to safety initiatives: 21% Pharmacist FTEs: Pharmacist FTEs:

Communicate information : Outcomes of Safety Initiatives Routinely provide to staff information regarding: Internal medication incidents: 54% Internal medication incidents: 54% Published medication incidents: 46% Published medication incidents: 46% Subscribe to ISMP newsletter: 63% Subscribe to ISMP newsletter: 63%

Implement « Best Practices »: Medication Incident Reduction Strategies Concentrated potassium chloride: Availability on nursing units 8% (10/123) : not available 8% (10/123) : not available 31% (38/123) : less than 10% 31% (38/123) : less than 10% 54% (67/123) : greater than 10% 54% (67/123) : greater than 10%

Implement « Best Practices »: Medication Incident Reduction Strategies There is a designated list of dangerous abbreviations that are not accepted There is a designated list of dangerous abbreviations that are not accepted 23% (28/123)

Implement « Best Practices »: Medication Incident Reduction Strategies Adults Adults 76% (71/93) Pediatrics Pediatrics 79% (41/52) Orders for chemotherapy include the total doses as well as mg/kg or mg/m2

Hospitals (n=) All (123) Bed SizeTeaching Status (29) (66) >500 (28) Yes (52) No (71) Computerized physician order entry (CPOE) Approved plan to implement Operational

Implement « Best Practices »: Medication Incident Reduction Strategies Patient allergy status is known prior to dispensing a medication Most of the time Most of the time59% Some of the time Some of the time 34% 34%

Implement « Best Practices »: Medication Incident Reduction Strategies  Single standard infusion concentrations are used in at least 90% cases for insulin 46% (56/123)

Implement « Best Practices »: Medication Incident Reduction Strategies  Vincristine is prepared and dispensed in an intravenous minibag or infusion bag (NOT a syringe) 31% (28/89)

Implement « Best Practices »: Medication Incident Reduction Strategies Bar coding is used in the medication use system Bar coding is used in the medication use system 11% (13/123)

Why this special interest topic? Provoke further review of medication use systems in Canadian hospitals Decrease the probability that a patient or health care worker will be harmed by a medication incident