High risk, High Return … Investing in Medication Safety ...€¦ · High risk, High Return … Investing in Medication Safety Penny Thornton Pharmacy Services Manager

High risk, High Return …Investing in Medication Safety

Penny ThorntonPharmacy Services Manager

Westmead Adult Hospital

The Hospital:a DANGEROUS place for patients

First National Patient Safety Report Aug 2001

Second National Report on Patient Safety – Improving Medication Safety July 2002

SIIP projects 2003-4

Collaboratives 2004

Safety & Quality Council Working Party – 2002_4

Safety & Quality Commission 2005 - ?

Focusing on medication safety ….

USADisguised Observer Studies …

• Barker & McConnell 1962 15%• Many US studies ~ 1982 ~ <5%

Medication safety: How to measure?

Unit dose drug distribution ….Introduced in the USA 1970s to facilitate charging per dose of medication

Chart Analysis Studies …• Harvard Medical Practice Study 1991Brennan TA, Leape LL, Laird NM et al. NEJM 324:370-63.7% admissions suffered adverse events, more than half of these were medication related

“……… It couldn’t apply here! ”

The Quality in Australian Health Care Study 1995

Wilson R McL, Runciman WB, Gibberd RW et al Med J Aust 163:458-71

~ 2% of hospital admissions associated with ADEs =140,000 hospital admissions annually are associated with problems in the use of medicines

“……… It couldn’t apply here! ”Disguised Observer StudiesAustralia: Ward stock distribution

Community Systems Foundation Study, 1973-4 55%Goodman, Woodbridge (Liverpool Hosp) 1979 13%Rippe, Hurley, (PANCH) 1988 17%Stewart, Naismith, Biro et al (RMH) 1991 18.3%McNally et al, (Sir Charles Gairdner) 1997 15.4%

Australia: Individual patient-based distribution

Thornton, Koller (Westmead) 1994 7.4%deClifford et al (Mornington Peninsula) 1994 6.1%McNally et al (Sir Charles Gairdner) 1997 4.8%

Reported incidentsReported incidents

DeathsChange in clinical management - ↑ LOS

No obvious effect

Inconvenience

Hospital Incidents

Patient SafetyIdentify and eliminate risks

Which risks?High Risk Groups? .. per ISMP

• adrenergic agonists, IV (e.g., epinephrine, phenylephrine, norepinephrine)

• adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)• anaesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)• antiarrhythmics, IV (e.g., lidocaine, amiodarone)• antithrombotic agents (anticoagulants), including warfarin, low-

molecular-weight• heparin, IV unfractionated heparin, Factor Xa inhibitors

(fondaparinux), direct• thrombin inhibitors (e.g., argatroban, lepirudin, bivalirudin),

thrombolytics (e.g.,• alteplase, reteplase, tenecteplase), and glycoprotein IIb/IIIa inhibitors

(e.g., eptifibatide) cardioplegic solutions• chemotherapeutic agents, parenteral and oral

High Risk Groups ? .. per ISMP• dextrose, hypertonic, 20% or greater• dialysis solutions, peritoneal and hemodialysis• epidural or intrathecal medications• hypoglycemics, oral• inotropic medications, IV (e.g., digoxin, milrinone)• liposomal forms of drugs (e.g., liposomal amphotericin B)• moderate sedation agents, IV (e.g., midazolam)• moderate sedation agents, oral, for children (e.g., chloral hydrate)• narcotics/opiates, IV, transdermal, and oral (including liquid

concentrates, immediate and sustained-release formulations)• neuromuscular blocking agents (e.g., succinylcholine, rocuronium,

vecuronium)• radiocontrast agents, IV• total parenteral nutrition solutions

High Risk Drugs ?ISMP’s High Risk list

• colchicine injection• epoprostenol (Flolan), IV• insulin, subcutaneous and

IV• magnesium sulfate

injection• methotrexate, oral, non-

oncologic use• opium tincture• oxytocin, IV• nitroprusside sodium for

injection

• potassium chloride for injection concentrate

• potassium phosphates injection

• promethazine, IV• sodium chloride for

injection, hypertonic (greater than 0.9% concentration)

• sterile water for injection, inhalation, and irrigation (excluding pour bottles) in

containers of 100 mL or more

High risk situationsCurrent threats…..• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE

Medicine patches are not Medicine patches are not bandband--aids!aids!

DonDon’’t let kids in your t let kids in your house copy you house copy you by sticking these on by sticking these on ……....The dose in this patchThe dose in this patchcan kill a child. can kill a child. Dispose of patches safely.Dispose of patches safely.

Patch labelling

Patch Trade Name Strength expression

Glyceryl trinitrate Nitro-Dur® 5mg/24hrs (10cm2)10mg/24hrs (20cm2)15mg/24hrs (30cm2)

Transiderm Nitro® 5mg/24hrs (25mg)10mg/24hrs (50mg)

High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE

Morphine & Oxycodone products

Watch the “C” look-alikes!

A patient was recently admitted with INR > 8, after she had inadvertently

been dispensed Coumadin 5mg instead of Coversyl 5mg in the community..

[Australian Incident 60 – April 2007]

Trademark Labelling

High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE

Promethazine extravasation

Line Labelling

?

High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE

Mixture strengths

High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE

High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE

High riskCurrent threats:• medication patches• LASA e.g. oxycodone• Wrong route errors• Strength expression• Wrong patient medications• Human/Device interface• Prescribing accountability• CPOE

Low risk – should we be concerned?

• Ignore?• Report near miss data, interventions?• Report incidents centrally, nationally? (e.g. IIMs

NSW, AIMS SA)

• Look at trends• Use case studies proactively to prevent further

occurrence• Prevent alignment of holes in Swiss cheese • Use failure mode analysis

Australianmedication incident

reporting –can we use it proactively?

High Returns• Clinical pharmacists

– Performing pharmaceutical review & reconciliation

• Continuity & efficiency in dispensing between healthcare sectors

• Individualised medication distribution systems• Accountable drug distribution – robotics?• Accountable prescribers

– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible

A prospective multicentre study of pharmacist initiatedchanges to drug therapy and patient management inacute care government funded hospitalsMichael J. Dooley, Karen M. Allen,Christopher J. Doecke,Kirsten J. Galbraith,George R. Taylor,Jennifer Bright & Dianne L. CareyBr J Clin Pharmacol 2003: 57 :4 513–521 513

$ 23:1 saving through utilisation of clinical pharmacy services

High Returns• Clinical pharmacists

– Performing pharmaceutical review & reconciliation

• Continuity & efficiency in dispensing between healthcare sectors

• Individualised medication distribution systems• Accountable drug distribution – robotics?• Accountable prescribers

– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible

High Returns• Clinical pharmacists

– Performing pharmaceutical review & reconciliation

• Continuity & efficiency in dispensing between healthcare sectors

• Individualised medication distribution systems• Accountable drug distribution – robotics?• Accountable prescribers

– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible

Distribution in hospitals

• Full ward stock

• Individual patient supply

• Unit dose Safety

USA

Australia

Investment in individual patient drug distribution

• Vastly improved error rates• Valuable drug utilisation reporting• Dramatically decreased cost of

distributed inventory• Workforce intensive

– Extended pharmacy service hours?– Automation?

High Returns• Clinical pharmacists

– Performing pharmaceutical review & reconciliation

• Continuity & efficiency in dispensing between healthcare sectors

• Individualised medication distribution systems• Accountable drug distribution – automation? robotics?• Accountable prescribers

– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible

Ward- based dispensing machines

Robotic dispensing

High Returns• Clinical pharmacists

– Performing pharmaceutical review & reconciliation

• Continuity & efficiency in dispensing between healthcare sectors

• Individualised medication distribution systems• Accountable drug distribution – automation? robotics?• Accountable prescribers

– Simulation training – competence– Fully oriented– Utilising readily available and easily read policies– Readily accessible drug information (e.g. CIAP)– CPOE which is rapidly responsive, clear & accessible

Human factors engineering

Trapping error• Human factors

– Pilots have to pass a 2 day course in human factors as part of qualification process

– Junior staff empowered to warn seniors of impending problems– Senior staff trained to listen and share accountability

• Assertiveness• Teamwork• Expert decision making• Efficiency• Use of simulation to rehearse

strategies for dealing with unexpected emergencies

• Use of graded assertiveness focusing on WHAT is wrong rather than WHO is wrong.

What can we easily change for maximum benefit?

• Targeted alerts – Promethazine injection– Anticoagulants– LASA products

• Use pre-mixed electrolyte IV solutions• Simplification and continuity of systems

– NIMC

What can we easily change for maximum benefit?

• TALLman letters– oxyNORM, oxyCONTIN, msCONTIN– loSEC, laSIX– ValACIclovir, ValGANciclovir

• Use generic name/route identification– Oxycodone sustained release oral tabs

What is harder to change but possible in the workplace? - Culture

Nursing– checking processes– drawing up oral mixtures in IV syringe

Prescribing– Understanding accountability in prescribing– Best use of pharmaceutical reforms

Pharmacy practices– Clinical pharmacy to all patient beds– Pharmacists’ desire to play a key role in drug

distribution?

What is harder to change in the bigger picture?

• Therapeutic product labelling– Generic name prominence– User oriented terminology

• Osmolality?? SI units – µg?– Strength expression

• Consistent mixture strength per mL?• Global standards – e.g. colour coding

– Parenteral line labelling– Brand packaging– Oral dispensers/syringes

Achieving System Change

• a practical approach - use efficiency!

• make it easy for Doctors, Pharmacists and Nurses to do the right thing -choose the safest option

• be non-punitive• a quality process • find measurable outcomes - errors

avoided? MSSA score?

Quality Assurance is the most accessible strategy

MSSA tool www.cec.health.nsw.gov.au/tools

Value of learning from near-miss incidents

• Rate of error occurrence is too low to obtain meaningful data from one site

• Best value is learning from qualitative• Encourage centralised reporting of

near misses• Use local failure mode analysis

(FMEA)

Be proactive!Report incidents or near misses to

[email protected]

….. thank you