1. Preventing Medication Errors and Omissions
Are Key to Keeping Kidney Patients Safe

2. Medication Errors & Omission Facts
On average, dialysis patients take 6 to 10 different medications each day.
Most dialysis patients report that they only “sometimes” discuss all of their medications with their doctor.
In ESRD, medication errors are the most common patient safety event.
Medication omissions are the most common medication error.
Renal Physicians Association: Health and safety survey to improve patient safety in end stage renal disease: Report of findings from the ESRD patient survey, 2007.
Garrick et al., Patient Safety and Hemodialysis, Clin J Am Soc Nephrol 7: 680–688, April, 2012

3. What errors occur? Administering the wrong medication or dosage.
Giving medication at the wrong time.
Failing to give a patient one of their medications.
Not reconciling medications when patients transition in and out of care centers (Hospitals, Dialysis Units, Doctor Offices, Nursing facilities, etc.)

4. Where do errors occur? Dialysis Unit At home or care facility
In the hospital

5. When do errors occur? Medication errors occur during Prescribing
Transcribing
Dispensing
Reconciling

6. When do errors occur?
Prescribing and transcribing stage: failure to consider drug interactions or allergies, misinterpretation of drug prescriptions.
Dispensing and administration stage: failure to insure 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.
Reconciling stage: failure to record in the discharge summary an accurate list of medications prescribed at discharge, failure to insure this list is the same as recorded in the medical record, and failure to insure that the discharge medication list is the same as the list the patient is following.

7. Prescribing and Transcribing
In addition to ordering medications, remember to order labs to monitor the dosing.
For example:
Antibiotic levels (vancomycin)
Hgb/Hct
Iron/TIBC, ferritin
iPTH, calcium, phosphorus, Vitamin D 25OH

8. Prescribing and Transcribing
Avoid using abbreviations and symbols on the Joint Commission’s “Do Not Use List”
Do Not Use
Potential Problem
Use 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 missed
Write X mg
Write 0.X mg
MSMSO4 and MgSO4
Can mean morphine sulfate or magnesium sulfate Confused for one another
Write "morphine sulfate“
Write "magnesium sulfate”

9. Dispensing and Administering
Know why a medication is given.
Know other medications in the same class or taken for a similar purpose.
Avoid “grab and go.” Read the medication label before dispensing.
Verify dosage, concentration, units of a medication prior to dispensing it.
Clearly label syringes, solutions, medication packaging.
Review patient allergies.
Ask for help or clarification if uncertain about any aspect of a medication.

10. Dispensing and Administering
Don’t administer a medication unless you know why it is being given.
Know the common medications given in dialysis so as to avoid duplication and insure medication is appropriate.
Anemia—Aranesp, Epogen, Micera, Procrit, etc.
Iron—Venofer, Ferrlecit, ferrous sulfate, sodium ferric glucconate, iron sucrose, iron dextran, etc.
Activated Vitamin D—Calcitriol, Rocaltrol, Hectoral, Zemplar, doxercalciferol, paricalcitrol, calcifediol, Rayaldee, etc.

11. Reconciling
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)

12. Reconciling
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.
Ledger S, Choma G, “Medication reconciliation in hemodialysis patients.” CANNT J. 2008;18(4):41-3.

13. Components of Medication Reconciling
Collect an accurate medication history, comparing what has been ordered for the patient with what the patient is actually taking.
Make certain medications and doses are appropriate for patients with decreased renal function and particular 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.

14. Summary of Medication Reconciling
Medication reconciliation is a critical component of 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 their setting.

15. To Combat Medication Errors & Omissions Encourage A Culture of Safety
The Agency for Healthcare Research and Quality (AHRQ) has defined culture of safety as follows:
The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management.
Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

16. Encourage a Culture of Safety
Patient Engagement—let patients know the names, doses, and indications of the medications they are receiving.
Know and follow the policies and procedures of your organization.
Be mindful of factors impacting the quality of care delivered.
Focus on changes associated with transitions of care.
Empower individuals to report errors.

17. Risk Factors for Medication Errors Associated with Health Care Providers
Inadequate drug knowledge and experience.
Inadequate knowledge of the patient.
Inadequate perception of the risk.
Overworked or fatigued health care professionals.
Physical and emotional health issues of the provider.
Poor communication between health care professional, staff, and patients.
WHO Technical Series on Safer Primary Care:

18. Risk Factors for Medication Errors Associated with the Work Environment
Workload and time pressures.
Distractions and interruptions (by both health care staff and patients.)
Lack of standardized protocols and procedures.
Inadequate resources.
Issues with the physical work environment (e.g., lighting, temperature, ventilation, etc.)
WHO Technical Series on Safer Primary Care:

19. Risk Factors for Medication Errors Associated with Medications
Sound alike medication names.
Similarities of labeling and packaging.
Variety or medication concentrations or dosages.
Confusion between generic and name brand medications.
Lack of labeling of syringes.

20. Create a safe environment where individuals are empowered to report errors without blame while maintaining individual accountability for patient safety within the health care team.
Culture of Safety

21. Encourage a Culture of Safety When medication errors occur…
Stabilize patient.
Follow your facility’s procedures.
Notify the clinical charge nurse.
Notify the responsible physician/health care provider.
Tell the patient what has happened. It’s okay to apologize for a mistake.
Review potential adverse outcomes with physician and patient.
Maintain patient safety at all times. This may require stopping dialysis, giving additional medications, or calling EMS to transport patient to a hospital.
Once patient’s safety is confirmed, document the adverse event per your facility’s policy.
Review the error as a team to identify systems and procedures that could prevent similar incidents in the future.

22. Encourage a Culture of Safety Develop Policies and Procedures
Review 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.
Review examples of Quality Improvement Projects (QIPs) and develop QIPS appropriate for your facility.

23. Encourage a Culture of Safety Educate patients and caregivers on their medications
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. Take this list to all your doctor visits and keep a copy in your wallet or purse.
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.

24. Encourage a Culture of Safety Medication Safety Best Practices
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 admission, transfer, and discharge.

25. Additional Resources
RPA National Dialysis Safety Webinar on Medication Management
World Health Organization Medication Safety eng.pdf
Management of Polypharmacy in Dialysis Patients, Seminars in Dialysis -