1. Medication Safety Lizabeth Martin, MD Faculty Fellowship: Safety and Quality Mentors: Lynn Martin and Sally Rampersad

2. Overview Background and Objectives Methods Phase 1: Data Phase 2: Medication Safety Event Phase 3: Countermeasures and Implementation Next Steps

3. Background Medication errors are dangerous and often preventable 1 1/12,500 anesthetics (pediatric) 2 Anesthesiologists high risk Prescribe, prepare, administer, monitor, record medications Work environment fast-paced, distractions Common safety mechanisms are absent High risk medications used frequently Guidelines for preparation, organization not well defined 1. Merry and Anderson. Medication errors—the new approaches to prevention. Pediatric Anesthesia 2011; 21:743-53. 2. Wake up Safe Safety Alert, Pediatric Anes Quality Improvement Initiative. Decreasing the Risk of IV Medn Errors. June, 2011.

4. Project Objective Observe medication preparation and administration by anesthesiologists at SCH Identify areas of risk Generate countermeasures Improve Safety and Quality of Patient Care System changes Tools for providers Awareness

5. Methods Phase 1 Design: Quality Improvement project Multidisciplinary team formed: Anesthesiologists, nurse anesthetists, pediatric anesthesia fellows, residents, pharmacists, nurses Data collection Phase 2 3-day CPI event Failure Mode Effect Analysis (FMEA) to identify areas of risk Develop countermeasures to target Phase 3 Countermeasure implementation and assessment

6. Phase 1: Data Collection

7. Audit Tool

8. “Pre-Errors”

9. “Errors”

10. I. Pre-errors Number of pre-errors Percent of total syringes Unlabeled syringe133.2% Syringe has no name/illegible92.2% No concentration4711.5% Syringe content different from label 30.7% No expiration time for propofol297.1% Total10124.7% (No expiration date)(129)(31.5%) 83 cases, 133 hours Total syringes prepared 334 Average 5 syringes per case (3 pre-induction, 2 post-induction)

13. II. Errors Omission = 2 Repetition = 0 Insertion = 0 Substitution = 0 Incorrect Dose = 0 Incorrect Route = 0 Recording = 5 1 error every 13 cases No correlation with case or provider type

14. III. Other Medication Processes Distractions Medication Administration: 6 Medication Preparation: 16 Infusion pump programing: 3 CIS post-operative order entry: 4 Verbal Orders (39): Dose Specified: 18/39 Repeat back: 23/39 Infusions used (17): 2 nd provider check: 4/17 Pump errors: 0/17

15. Current Standards-Anesthesia Literature Systematic countermeasures to decrease medication errors Carefully read label before preparation/administration Optimize label legibility Label ALL syringes Formally organize workspace Consider: color coding, two person checks, prefilled syringes Jensen et al. Evidence based strategies for preventing drug admin errors during anaesthesia. Anesthesia, 2004; (59):493-504 ASPF safe medication handling recommendations: http://www.apsf.org/resources_video2.php

16. Use commercially available products, minimize med preparation by non- pharmacists Anesthesia medication tray Physical separation of look-alike, sound-alikes NMB visually (fluorescent label, ect), physically separate from other drugs Labeling Avoid handwritten labels Preprinted labels Stand practice for infusion /lines/epidural tubing labeling High alert medications  two provider check Staff education re risk reduction, communication tools Standardization, handoffs TeamSTEPPS, Human Factors training Enhance communication re medications given in OR Guidelines for verbal orders/readbacks ISMP review (SCH)

17. Phase 2: Focused CPI Event January 17-19, 2012

18. Process Map 5 Categories Process Steps (blue) Failure Modes (yellow)

21. Failure Mode Effects Analysis: FMEA 1.Each failure mode scored Severity Occurrence Detection 2.Scores over 40 included 3.Remaining failure modes reviewed High impact Low effort DILUTION ERROR: Severity: 5 Occurrence: 4 Detection: 3 5 x 4 x 3 = 60

22. Targets Identified 1.Anesthesia Cart Organization (administer) Standardized Physical separation of high risk medication 2.Communication (prescribe, administer, record) Shared mental model Infusions High risk medication 3.Medication preparation and syringe labeling (prepare, dispense)

23. Phase 3: Implementation and Reassessment

24. Countermeasure 1: Standardized Cart Layout

25. Countermeasure 2: Communication Tools Closed loop communication Between anesthesia providers in OR Repeat backs Medication recorded by person administering Infusion 2 provider check “D-C-W-D-C” ICU hand-offs Provider handoffs New infusion in OR High Risk medications

26. Countermeasure 3: Prefilled syringes and dispensary Pre-prepared syringes Level 5 error proofing Standard dilution and syringes sizes Less waste Dispensary One piece flow-obtain medications Obtain or “pre-pick” medications from secure room Emergency trays only in cart Improve efficiency, waste

27. Next Steps… Continued scripting and process development Internal trialing External trialing Collaboration with pharmacy Determine outcome measures for reassessment

28. Questions?