1. MODULE 3 Medication Omissions or Errors Medication Omissions or Errors

2. Preventing Medication Omissions and Errors Is Key to Keeping Kidney Patients Safe MODULE 3 Medication Omissions or Errors

3. ESRD Patient Statistics The average dialysis patient takes 6 to 10 medicines a day. 1 On average, each patient required 4.7 ±1.8 type of medications - Average was 10.0 ± 4.9 tablets per day - 15.0% needed at least 7 types of medication - 12.4% had to take more than 15 tablets each day 2 Medications commonly given with dialysis include ESAs, iron preparations, vitamin D preparations and antibiotics. 1. Curtin RB, Svarstad BL, Keller TH. Hemodialysis patients’ noncompliance with oral medications. ANNA J. 1999;26:307-316. Kaplan B, Mason NA, Shimp LA, Ascione FJ. Chronic hemodialysis patients, part I: Characterization and drug-related problems. Ann Pharmacother. 1994;28:316-319. 2. Szeto C, et. al. Relation between number of prescribed medication and outcome in peritoneal dialysis patients. Clinical Nephrology. 2006;66(4):256-262. 3 MODULE 3 Medication Omissions or Errors

4. Medication Errors Administering the wrong medication or the wrong dosage Giving medication at the wrong time Patient failing to receive one of his/her medications Failing to reconcile medications when patients return to the facility from hospital or other facility MODULE 3 Medication Omissions or Errors

5. Consequences of Medication Errors 1.Harm from receiving a wrong medicine 2.Harm from omitting a prescribed medication 3.Harm from Poor Medication Reconciliation Omitting previously prescribed medications Prescribing duplicate medications or several drugs in the same class Prescribing medications that are contra- indicated (e.g., allergies) MODULE 3 Medication Omissions or Errors

6. Facts About Medication Errors A study of medication-related problems in hemodialysis patients found adverse drug events correlated with the number of co-morbidities. The results showed one medication-related problem for every 3.1 medication exposures. Most common problems were: - drug use without indication (30.9%) - lack of laboratory testing to monitor medication therapy (27.6%) - indication without drug use ( 17.5%) dosing errors (15.4%). 1 MODULE 3 Medication Omissions or Errors 1. Manley HJ et al. Factors Associated With Medication-Related Problems in Ambulatory Hemodialysis Patients. American Journal of Kidney Disease. February 2003;41(2):386-393.

7. Facts About Medication Errors Warfarin is frequently cited as a leading drug involved in adverse drug events. Patients who reported receiving medication instructions from a physician, nurse or pharmacist, had 60% fewer warfarin-related hospitalizations in the subsequent two years. 1 The most common medication error: a patient failing to receive one of their medications (63% sometimes or rarely) or being given the wrong dose of medication (37% sometimes or rarely). 2 MODULE 3 Medication Omissions or Errors 1. Metlay JP, Hennessy S, Localio AR, Han X, Yang W, Cohen A, et al. Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. Journal of General Internal Medicine. October 2008;23: 1589-94. 2. Garrick R, Kliger A, Stefanchik B. Patient and Facility Safety in Hemodialysis: Opportunities and Strategies to Develop a Culture of Safety. CJASN. April 2012; 4:680-8.

8. Facts About Medication Errors Health professionals who continually update their knowledge of drugs make fewer medication errors than those who do not. 1 Drug types associated with medication errors: –Anticoagulants (inadequate therapeutic dosing, no laboratory follow-up) –Cardiovascular agents (overdose) –Chemotherapeutic agents (overdose) –Diuretics (overdose, no laboratory follow-up) –Diabetic medications (overdose, wrong type of insulin) –Nonsteroidal anti-inflammatory drugs (extended use, overdose) –Total parenteral nutrition solutions (given peripherally, inaccurate component amount) 2 MODULE 3 Medication Omissions or Errors 1. Pié A, Warholak TL. Medication Safety: What You Can Do to Prevent Errors. Renal Business Today. December 2008;3(12): 28-31. 2. Hughes RG, Ortiz E. Medication Errors: Why They Happen, and How They Can be Prevented. American Journal of Nursing. 2005;105(3):14-24.

9. When Medication Errors Occur Ordering and transcription stage: failure to consider drug interactions or allergies, misinterpretation of drug prescriptions. Dispensing and administration stage: failure to ensure concordance with prescribed medication, and failure to accurately record the drug name and formulation, dose, route of administration, time and administration technique in the medical record. Discharge summaries: failure to record in the discharge summary an accurate list of medications prescribed at discharge, failure to assure this list is the same as recorded in the medical record and failure to assure that the discharge medication list is the same as the list given to the patient. MODULE 3 Medication Omissions or Errors

10. Factors Contributing to Medication Errors Failure of the person administering a medication to read the label before it is dispensed or restocked: “grab and go" Failure to adjust dosage based on a patient’s decreased renal function Not labeling or poor labeling of syringes/solutions/other medication packages Intimidation or reluctance to ask for help or clarification Failure to educate patients about indication and dosage regimen MODULE 3 Medication Omissions or Errors

11. Factors Contributing to Medication Errors Using medications without complete knowledge of the medication and potential interactions Failure to double check high-alert medications, such as heparin, before dispensing or administering Not communicating important information (e.g., patient allergies, diagnosis/co-morbid conditions, weight, renal function, etc.) Failure to use tools or procedures to ensure medication continuity Overriding computer alerts without due consideration MODULE 3 Medication Omissions or Errors

12. Why Reconcile Medications? Medication reconciliation is an effective process to reduce errors and harm associated with loss of medication information, as patients transfer among community-based and hospital providers. It may prevent up to 70% of all potential errors and 15% of all adverse drug events. -Joint Commission (2006) MODULE 3 Medication Omissions or Errors

13. Medication Reconciliation in Hemodialysis Patients A 2008 study evaluated the potential impact of medication reconciliation and optimization in the ambulatory care setting at the time of patient transfer from an in-center dialysis unit to a satellite dialysis unit. –78.8% of patients had at least one unintended medication variance –The majority of unintended variances (56%) were caused by the physician/nurse practitioner omitting an order for medication that the patient was taking 1 1. Ledger S, Choma G, “Medication reconciliation in hemodialysis patients.” CANNT J. 2008;18(4):41-3. MODULE 3 Medication Omissions or Errors

14. Components of Medication Reconciliation Collect an accurate medication history, including what has been ordered for the patient, and what the patient is really taking Make certain medications and doses are appropriate for patients with decreased renal function and co-morbidities Document changes made at each treatment venue – CKD care to dialysis unit, dialysis unit to hospital, and hospital to dialysis unit. Educate patients about medications, including name, indication and dosage regimen MODULE 3 Medication Omissions or Errors

15. Medication Reconciliation Summary Medication reconciliation is important in providing quality patient care In dialysis units medication reconciliation is particularly important due to the complexity of the patients Components of medication reconciliation include: Collecting an accurate medication history Making certain the medications and the doses are appropriate Educating the Patients about the Medications Documenting each change that is made along the way There are several approaches to reducing medication errors and each facility should develop processes that best fit MODULE 3 Medication Omissions or Errors

16. Developing Policies and Procedures Review current policies and procedures to ensure they meet current recommendations for preventing medication omissions and errors, including: –Standardized process for medication reconciliation –Review of medication changes after each provider visit –Standardized handoff after hospitalization Review CMS Conditions for Coverage for ESRD Facilities Consider using a process analysis fishbone to examine policies and procedures Review examples of Quality Improvement Projects (QIPs) and develop QIPS appropriate for your facility. MODULE 3 Medication Omissions or Errors

17. Process Analysis Fishbone A process analysis fishbone is a diagrammatic way to examine the policies, procedures, people, and equipment involved in a process leading to an outcome. Providers may use the process analysis to develop Quality Improvement Projects (QIPs) MODULE 3 Medication Omissions or Errors

18. Focused Education Program for Patients, Caregivers and Staff Educate patients and caregivers on their medications and encourage the following: Know your medicines. Keep a list of the names of your medicines, how much you take, and when you take them. Include over-the-counter medicines, vitamins, and supplements and herbs. Take this list to all your doctor visits. Follow the directions. Take your medicines exactly as prescribed. Don't take medications prescribed for someone else. Ask questions. If you don't know the answers to these questions, ask your doctor or pharmacist. - Why am I taking this medicine? - What are the common problems to watch out for? - What should I do if they occur? - When should I stop this medicine? - Can I take this medicine with the other medicines on my list? Provide patients and caregivers with Dialysis Safety: What Patients Need to Know as a take-home guide. MODULE 3 Medication Omissions or Errors

19. Medication Safety Best Practices Improving medication systems should result in a reduction in harm to patients. Achieving breakthrough levels of improvement in reducing harm from medications requires that an organization make changes to improve four fundamental areas in parallel: Culture: Develop a culture of safety where staff and leaders are committed to safety and staff are safety conscious and freely report concerns. High-Hazard Medications: Decrease risk of harm from those medications known to cause the most severe adverse drug events (ADEs). Core Medication Processes: Improve processes for ordering, dispensing, and administering medications. Reconciliation: Ensure that medication information is reconciled at transition points, including arrival, transfer and discharge/departure. MODULE 3 Medication Omissions or Errors

20. Medication Safety Best Practices Ensure medication continuity with tools such as Discharge Instructions Template Avoid using abbreviations and symbols on the Joint Commission “Do Not Use” list (put as next slide) Educate patients and care givers about medication safety MODULE 3 Medication Omissions or Errors

21. The Joint Commission - Official “Do Not Use” List 1 Do Not UsePotential ProblemUse Instead U (unit)Mistaken for “0” (zero), the number “4” (four) or “cc” Write "unit" IU (International Unit)Mistaken for IV (intravenous) or the number 10 (ten) Write "International Unit" Q.D., QD, q.d., qd (daily)Q.O.D., QOD, q.o.d, qod (every other day) Mistaken for each other Period after the Q mistaken for "I" and the "O" mistaken for "I“ Write "daily“ Write "every other day" Trailing zero (X.0 mg)* Lack of leading zero (.X mg) Decimal point is missedWrite X mg Write 0.X mg MSMSO4 and MgSO4Can mean morphine sulfate or magnesium sulfate Confused for one another Write "morphine sulfate“ Write "magnesium sulfate" 1 Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. *Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation. MODULE 3 Medication Omissions or Errors

23. Which of the following abbreviations is on the “Do Not Use” list? A.U B.IU C.QD D.QOD E.All of the above MODULE 3 Medication Omissions or Errors

24. Which of the following abbreviations is on the “Do Not Use” list? A.U B.IU C.QD D.QOD E.All of the above MODULE 3 Medication Omissions or Errors

25. What is the most common medication error? A.Receiving the wrong drug dose B.Receiving the wrong drug C.Failing to receive drug dose D.Failing to record dose MODULE 3 Medication Omissions or Errors

26. What is the most common medication error? A.Receiving the wrong dose B.Receiving the wrong drug C.Failing to receive dose D.Failing to record dose MODULE 3 Medication Omissions or Errors

27. How many medications do most ESRD patients take per day? A.1-3 B.3-5 C.6-10 D.11-15 MODULE 3 Medication Omissions or Errors

28. How many medications do most ESRD patients take per day? A.1-3 B.3-5 C.6-10 D.11-15 MODULE 3 Medication Omissions or Errors

29. When should a patient’s medications be reconciled? A.When the patient moves from CKD care to the dialysis unit B.When the patient moves from the dialysis unit to the hospital C.When the patient moves from the hospital to dialysis unit D.All of the above MODULE 3 Medication Omissions or Errors

30. When should a patient’s medications be reconciled? A.When the patient moves from CKD care to the dialysis unit B.When the patient moves from the dialysis unit to the hospital C.When the patient moves from the hospital to dialysis unit D.All of the above MODULE 3 Medication Omissions or Errors

31. True or False: Warfarin is frequently cited as a leading drug involved in adverse drug events. MODULE 3 Medication Omissions or Errors

32. True or False: Warfarin is frequently cited as a leading drug involved in adverse drug events. TRUE Warfarin is frequently cited as a leading drug involved in adverse drug events. Patients who reported receiving medication instructions from a physician or nurse, as well as a pharmacist, had a 60% reduced rate of a warfarin-related hospitalization in the subsequent two years. MODULE 3 Medication Omissions or Errors

33. Additional Resources About Medication Omissions or Errors The Joint Commission http://www.jointcommission.org National Coordinating Council for Medication Error Reporting and Prevention http://www.nccmerp.org/councilRecs.html California HealthCare Foundation http://www.chcf.org/topics/hospitals/index.cfm?itemID=12682 MODULE 3 Medication Omissions or Errors

34. Additional Resources About Medication Omissions or Errors Agency for Healthcare Quality and Research http://www.ahrq.gov/qual/errorsix.htm US Food and Drug Administration http://www.fda.gov/medwatch/how.htm Keeping Kidney Patients Safe, Discharge Instructions Template http://www.kidneypatientsafety.org/pdf/bestpractices/Nephrophiles_medication.pdf Keeping Kidney Patients Safe, Dialysis Safety: What Patients Need to Know http://www.kidneypatientsafety.org/toolkit.aspx MODULE 3 Medication Omissions or Errors