2. MEDICATION SAFETY Meeting HFAP Accreditation Standards for Pharmacy Services and Medication Use Part One

3. n HFAP Chapter 25 keeps you in compliance with the Medicare Conditions of Participation

4. Medication Safety Series 1. Prescribing challenges 2. Procurement in an era of drug shortages – keeping it safe 3. Preparation and dispensing – includes sterile preparation 4. Administration of medications – timing, unit dose, bedside medication verification 5. Monitoring of therapy, Medication Use Evaluations

5. Prescribing Challenges - Objectives n Describe the optimal environment for safe prescribing n List the necessary tools for enhancing the knowledge of medications n Discuss the advantages and disadvantages of computerized physician order entry (CPOE)

6. The Problem n The Institute of Medicine Report revealed that errors in medical care are responsible for many deaths n Many health care providers are not aware of their responsibilities n Medication errors responsible for numerous adverse outcomes, including death n This results in high cost (emotional and financial)

7. Who are the participants? n Physicians n Nurses n Pharmacists n Respiratory Therapists n Patients n The casual observers who can alert the care providers about opportunities for errors

8. RESPONSIBILITIES

9. Regulatory Standards n HFAP – Chapter 25 n CMS Conditions of Participation 482.25

10. The Medication Use Process Components n Prescribing n Procurement n Preparation n Dispensing n Administration n Monitoring

11. Where Do Errors Occur? Prescribing39% Transcribing11% Dispensing12% Administering38%

12. PRESCRIBING 25.01.12, 25.01.13 n Is a collaborative effort n There is an increasing body of knowledge –New therapeutic entities –Drug interactions –Allergies database –Food-drug interactions –Post-marketing data

13. PRESCRIBING n Physician (and other prescribers) responsibilities: –Diagnosis –Drug and dosing choices –Medication reconciliation n Pharmacist responsibilities ( 25.01.15, 25.01.16 ) –Drug information –Protocol-based management of patient medications –Review of physician orders

14. Training, Memory and Best Efforts As Safety System Tools n 1980: medical school graduates needed to really know 60 drugs well n 2000: this number was estimated at 600 drugs n 2012: add another 100-200 drugs n Drug-drug interactions increase exponentially with these numbers

15. Training, Memory and Best Efforts As Safety System Tools DDI = drug-drug interaction Karas S. Ann Emerg Med 1981; 10:627-630 MedicationsPotential DDIs 21 46 828 16120

16. HIGH ALERT MEDICATIONS 25.01.01, 25.01.20 n Adrenergic agonists n Intravenous adrenergic antagonists n Amiodarone/Amrinone n Benzodiazepines (especially midazolam) n Intravenous calcium n Chemotherapeutic agents

17. THE ABBREVIATION PROBLEM nUnU n ug n q.d. n qod n SC n TIW

18. Medication Prescribing Process Components: Communication n Written Prescription Orders n Medication Ordering Systems n Electronic Order Transmission n Dosage Calculations n Verbal Orders n Medication reconciliation Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

19. Written Medication Orders: Illegible Handwriting n 16% of physicians have illegible handwriting. 1 n Common cause of prescribing errors. 2, 3, 4 n Delays medication administration. 5 n Interrupts workflow. 5 n Prevalent and expensive claim in malpractice cases. 3 1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8; 3. Cabral JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm 1993; 50: 305-14; 5. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

22. Illegible Handwriting: Error Prevention n Prescribers’ Obligation n Write/Print More Carefully n Computers n Verbal Communications

23. Written Medication Orders: Complete Information n Patient’s Name n Patient-Specific Data n Generic and Brand Name n Drug Strength n Dosage Form n Amount n Directions for Use n Purpose n Refills Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

25. Written Medication Orders: Patient-Specific Information n Age n Weight n Renal and Hepatic Function n Concurrent Disease States n Laboratory Test Results n Concurrent Medications n Allergies n Medical/Surgical/Family History n Pregnancy/Lactation Status Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

26. Written Medication Orders: Do Not Use Abbreviations n Drug names n “QD” or “OD” for the word daily n Letter “U” for unit n “µg” for microgram (use mcg) n “QOD” for every other day n “sc” or “sq” for subcutaneous n “a/” or “&” for and n “cc” for cubic centimeter n “D/C” for discontinue or discharge Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. Jones EH. Clev Clin J Med 1997; 64: 355-9.

29. Written Medication Orders: Decimals n Avoid whenever possible 1 –Use 500 mg for 0.5 g –Use 125 mcg for 0.125 mg n Never leave a decimal point “naked” 1, 2, 3 –Haldol.5 mg  Haldol 0.5 mg n Never use a terminal zero –-Colchicine 1 mg not 1.0 mg n Space between name and dose 1,3 –Inderal40 mg  Inderal 40 mg 1.Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1- 8.23. 2. Jones EH. Clev Clin J Med 1997; 64: 355-9. 3.Cohen MR. Am Pharm 1992; NS32; 32-3.

31. Written Medication Orders: Drug Names n “Look-Alike” or “Sound-Alike” Drug Names n “Confirmation Bias” n Addition of Suffixes –Example Adalat CC 30 mg vs. Adalat 30 mg Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. Cohen MR. Am Pharm 1992; NS32: 21-2.

32. Look-alike And Sound-alike Drug Names USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.www.usp.org/reporting/review/qr66.pdf Zyrtec®Zantac® Prilosec®Plendil® Neoral®Nizoral® Lomotil®Lamisil® Fosamax®Flomax® Cardura®Cardene® LorazepamAlprazolam Accutane®Accupril®

33. Medication Prescribing Process: Computerized Prescriber Order Entry (CPOE) –Computer with 3 Interacting Databases Drug History Drug Information/Guidelines Database Patient-Specific Information –Avoids Illegible Prescriptions or orders Improper Terminology Ambiguous Orders Incomplete Information Schiff GD. JAMA 1998; 279: 1024-9.

34. Computerized Physician Order Entry (CPOE) n Provides Decision Support n Warns of Drug Interactions –Drug-Drug –Drug-Allergy –Drug-Food n Checks Dosing n Reduces Transcription Error n Reduces number of lost orders n Reduces duplicative diagnostic testing n Recommends cost effective, therapeutic alternatives

35. CPOE Advantages n Automate ordering process n Reduces Order Errors –Standardized, legible complete orders –Alerts n Data collected on variances in practice

36. Improved Quality n CPOE allows for physician reminders of best practice or evidence-based guidelines n Indiana University study –Pneumococcal vaccine in eligible patients 0.8% 36.0% –Heparin prophylaxis 18.9% 32%

37. CPOE Disadvantages n Errors still possible n Alerts n Multiple steps n Access

38. Dosage Calculations n Recognized cause of medication errors n Use patient-specific information –height –weight –age –body system function Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

39. Dosage Calculations: Error Prevention n Avoid calculations n Cross-checking Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. ISMP Medication Safety Alert 1996; 1 (15).

40. Verbal Orders: Error Prevention n Avoid when possible n Enunciate slowly and distinctly n State numbers like pilots (i.e., “one-five mg” for 15 mg) n Spell out difficult drug names n Specify concentrations Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

41. Conflict Resolution n Communication is essential n No one is right all the time n Take the time to listen n Beware of instilling an atmosphere of fear n Interdisciplinary collaboration Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

42. Patient Education n Educate patients about their medications n Purpose of each medication n Name of drug, dose, how to take, etc. n Provide patients with understandable written instructions n Lack of involving patients in check systems n Inform patients about potential for error with drugs known to be problematic

43. PRESCRIBING REVIEW n Right indication n Right drug choice n Correct dosage n Absence of contraindications –Allergies –Drug interactions (food, other drugs) –Pregnancy and lactation

44. HIGH ALERT MEDICATIONS n Insulin n Lidocaine n Intravenous magnesium sulfate n Opiate narcotics n Neuromuscular blocking agents n Intravenous potassium n Intravenous sodium chloride (high concentration)

45. PROBLEMS n Lack of knowledge of proper dose n Outdated information n Illegible handwriting n Incomplete orders n Use of the apothecary system n Order on the wrong chart n Nameless prescription

46. PROBLEMS n Ordering a total course of therapy instead of daily doses n Lack of knowledge about proper routes of administration n Ability to bypass controls in automated systems n Verbal orders poorly communicated

47. SOLUTIONS n Clear handwriting (Print) n Avoid abbreviations when errors could occur n Prescriber order entry n Avoid verbal orders n Double check doses n Review cases of polypharmacy

48. SUMMARY n Prescribing inappropriately can result in serious medication errors. n Major advances have been made in improving prescribing safety n Technology is our friend n Interdisciplinary interactions go a long way toward preventing errors

49. NEXT SESSION n Medication procurement in an era of medication shortages n Compounding pharmacies – friend or foe?