Medication Safety Results from the Hospital Pharmacy in Canada report Medication Safety Results from the Hospital Pharmacy in Canada report Patricia Lefebvre.

Medication Safety Medication Safety

Results from the Hospital Results from the Hospital Pharmacy in Canada reportPharmacy in Canada report

Patricia LefebvrePatricia Lefebvre

Millcroft Pharmacy Leadership Millcroft Pharmacy Leadership ConferenceConference

June 1-3, 2007June 1-3, 2007

ObjectiveObjective

Provide participants with Provide participants with a view of the state of a view of the state of patient safety from a patient safety from a pharmacy perspective in pharmacy perspective in Canada Canada

Highlights of the Highlights of the 2005/2006 Annual Report 2005/2006 Annual Report – Hospital Pharmacy in – Hospital Pharmacy in Canada Canada

Medication ErrorsMedication Errors

MeMedicatdication Errorsion Errors MEDMARX 2000-2004 MEDMARX 2000-2004 Medications most commonly involvedMedications most commonly involved

Hospital Pharmacy, 2006:41 S3-S10

2005/06 Hospital Pharmacy in 2005/06 Hospital Pharmacy in Canada: survey methodologyCanada: survey methodology

List of hospital pharmacies and membership list List of hospital pharmacies and membership list of the Association of Canadian Academic of the Association of Canadian Academic Healthcare Organizations (ACAHO) and Healthcare Organizations (ACAHO) and telephone survey to obtain name and e-mail telephone survey to obtain name and e-mail address of the Director of Pharmacy and the address of the Director of Pharmacy and the hospital’s Chief Executive Officerhospital’s Chief Executive Officer

E-mails sent to Directors of Pharmacy and CEOs E-mails sent to Directors of Pharmacy and CEOs in June 2006; second E-mail to Directors of in June 2006; second E-mail to Directors of Pharmacy in July. Pharmacy in July.

Period to fill survey: June 23 to September 1, 06Period to fill survey: June 23 to September 1, 06 Eligibility: total of 100 beds and at least 50 Eligibility: total of 100 beds and at least 50

acute care beds acute care beds Response rate: 74% (142/193)Response rate: 74% (142/193) Hospital Demographic Info, Qc: 30% (42/142)Hospital Demographic Info, Qc: 30% (42/142) Québec response rate: 71% (42/59)Québec response rate: 71% (42/59)

Disclosure PolicyDisclosure Policy

Hospital has a policy on Hospital has a policy on the disclosure of the disclosure of incidents to patients incidents to patients and/or their familiesand/or their families (ROP – Culture)(ROP – Culture)

2005/06 2005/06 2003/042003/04

80 % 80 % 63 % 63 %

Disclosure PolicyDisclosure Policy

Disclosure is Disclosure is documented in the documented in the health recordhealth record

2005/06 2005/06 2003/042003/04

9191%% 81%81%

Medication Incident Medication Incident Reporting Reporting

A medication incident A medication incident reporting system is in reporting system is in use use

2005/06 2005/06 2003/042003/04

96%96% 100%100%

Medication Incident Medication Incident Reporting Reporting

Medication incident reports Medication incident reports can be used during an can be used during an individual healthcare individual healthcare provider’s performance provider’s performance assessmentassessment

2005/06 2005/06 2003/042003/04

12% 12% 21% 21%

Respondents:Respondents: Academic Health Centres: 0%Academic Health Centres: 0% Non Academic Health Centres: Non Academic Health Centres:

16%16%

Committee responsible for Committee responsible for the review of medication the review of medication

incidentsincidents

Committee responsible for the Committee responsible for the review of medication incidents review of medication incidents

2005/06 2005/06 2003/04 2003/04

80%80% 80% 80%

If yes, committee is dedicated If yes, committee is dedicated to Medication Safetyto Medication Safety

4444%% 17% 17%

Medication safety self-Medication safety self-assessmentassessment

Medication safety Medication safety self-assessment has self-assessment has been completed been completed (ROP)(ROP)

2005/06 2005/06 2003/042003/04

71%71% 51%51%

ISMP:ISMP: 91%91% Autres: 6% Autres: 6% (Qc: 31 %)(Qc: 31 %)

Medication History TakingMedication History Taking

When a patient visits the ED, When a patient visits the ED, a comprehensive medication a comprehensive medication

history is conductedhistory is conducted 45% 45%

The patient’s medication history The patient’s medication history is reconciled with medication is reconciled with medication orders written at the time of orders written at the time of admission or ER visit admission or ER visit

45% 45%

Medication History TakingMedication History Taking

When a patient is admitted to the When a patient is admitted to the organization, a comprehensive organization, a comprehensive medication history is conductedmedication history is conducted

(POR – communication – and with the involvement of the (POR – communication – and with the involvement of the

patient/client)patient/client)

42%42%

Medication history is reconciled Medication history is reconciled with medication orders written at with medication orders written at the time of admission the time of admission

46%46%

Medication History Taking Medication History Taking

When patient is transferred When patient is transferred between levels of care between levels of care within the facilitywithin the facility, , reconcile the patient’s reconcile the patient’s medications and medications and communicate that communicate that information to the next information to the next provider of care provider of care

(POR – communication, with the patient/client)

38% 38% (All: 20% / Sel: 78%)(All: 20% / Sel: 78%)

Medication History TakingMedication History Taking

When patient is transferred When patient is transferred outside the facilityoutside the facility, , reconcile the patient’s reconcile the patient’s medications and medications and communicate that communicate that information to the next information to the next provider of care provider of care

(POR – communication, with the patient/client)

35% 35% (All: 8% /Sel: 90%)(All: 8% /Sel: 90%)

Medication History Medication History Taking Taking

Implementation of Implementation of medication reconciliation medication reconciliation is planned or underwayis planned or underway

The facility has examined The facility has examined the desirability and the desirability and feasibility but additional feasibility but additional resources would be resources would be requiredrequired

The facility has not yet The facility has not yet examined the desirability examined the desirability and feasibilityand feasibility

The facility has examined The facility has examined the desirability and the desirability and feasibility.. But.. There feasibility.. But.. There are not enough other are not enough other supportssupports

43%

34%

22%

13%

Upon transfer between levels of care and/or at the time of discharge, the more significant barriers to provide a reconciled list of the patient’s medication are:

Ordering Ordering

OperationalOperational

Approved plan to Approved plan to implementimplement

No CPOE plan approvedNo CPOE plan approved

Integrated with a Integrated with a clinical decision clinical decision support systemsupport system

Interface with PIS Interface with PIS

Computerized Prescriber Order Entry Systems (CPOE)

2005/06 2003/04

6% 5%

23% 18%

70% 76%

N=6 N=1

N=4 N=2

Verbal Medication Verbal Medication OrdersOrders

Verbal and telephone orders Verbal and telephone orders are limited to situations in are limited to situations in which the patient is at risk for which the patient is at risk for harm and physician is unable harm and physician is unable to physically write a medication to physically write a medication orderorder

= 90% = 90% 2005/06 2003/042005/06 2003/04

4242% % 38%38%

OrderingOrdering

There is a list of dangerous There is a list of dangerous abbreviations that are NOT abbreviations that are NOT accepted in the organizationaccepted in the organization

2005/062005/06 2003/04 2003/04

58%58% 40% 40%

Formal process to review and Formal process to review and approveapprove

Pre-printed Pre-printed medication ordersmedication orders

Prescriber order Prescriber order sets (i.e: computer sets (i.e: computer order entry)order entry)

Infusion dosage Infusion dosage charts and charts and guidelinesguidelines

2005/06

87%

42%

77%

Ordering Ordering

Pharmacy ManagementPharmacy ManagementDispense MedicationDispense Medication

The patient’s allergy status is known prior to a medication order being dispensed

= 90% = 90%

2005/06 2003/042005/06 2003/04

6868% % 72%72%

Pharmacy ManagementPharmacy ManagementDispense MedicationDispense Medication

Drug distribution systemsDrug distribution systems

2005/06 2003/04 2005/06 2003/04 2001/022001/02

Unit dose Unit dose (= 90% of beds) :(= 90% of beds) : 38% 38% 31% 31% 24% 24%

Centralized automated dispensing – UD : Centralized automated dispensing – UD :

66% 66% 61% 61% Automation used (65 respondents)Automation used (65 respondents)

Canister : 83% (54/65) Canister : 83% (54/65) Robotic :17% (11/65) Robotic :17% (11/65)

Pharmacy ManagementPharmacy ManagementDispense MedicationDispense Medication

Drug distribution systems (Cont’d)Drug distribution systems (Cont’d) 2005/06 2003/042005/06 2003/04

Unit based automated dispensing systems Unit based automated dispensing systems

32% 32% 20%20% Unit based automated dispensing (=90% of beds)Unit based automated dispensing (=90% of beds)

n= 8n= 8 n = 6n = 6

Unit dose – IV Admixture Services (=90% of beds) Unit dose – IV Admixture Services (=90% of beds) : :

62% 62% 56 %56 %

Pharmacy ManagementPharmacy ManagementSelect medication Select medication

Bar Coding is used in the Bar Coding is used in the Medication-Use-System Medication-Use-System to:to:

drug selection prior to drug selection prior to dispensing from the dispensing from the pharmacypharmacy

drug selection prior to drug selection prior to patient administrationpatient administration

Identify patient during Identify patient during medication medication administrationadministration

Return doses to inventory Return doses to inventory in the pharmacyin the pharmacy

stocking of unit-dose stocking of unit-dose binsbins

stocking of automated stocking of automated dispensing cabinetsdispensing cabinets

2005/06 2003/04 (35%, 50/142)

26% 16%

4% 3%

8% 3%

42% 34%

22% 13%

22% 16%

Pharmacy Management:Pharmacy Management:Medication InventoryMedication Inventory

Standardize and limit the number of available Standardize and limit the number of available infusion concentrations for the following high-alert infusion concentrations for the following high-alert medicationsmedications(ROP: medication use) (ROP: medication use)

2005/06 2003/042005/06 2003/04

HeparinHeparin 75% 75% 81% 81%

InsulinInsulin 48% 48% 47% 47%

Morphine Morphine 57% 57% 47%47%

Hydromor-Hydromor- 53% 53% 41% 41% phone phone

Pharmacy Management:Pharmacy Management:Medication InventoryMedication Inventory

Remove concentrated Remove concentrated electrolytes from electrolytes from patient/client care units patient/client care units

(ROP – medication use)(ROP – medication use)

94% of respondents (133/142)94% of respondents (133/142) 2005/06 2003/042005/06 2003/04

KCLKCL 85% 85% 72% 72%Other 53%Other 53%

Pharmacy Management:Pharmacy Management:Medication InventoryMedication Inventory

Remove concentrated Remove concentrated narcotics from narcotics from patient/client care unitspatient/client care units (MSSS directives)(MSSS directives)

94% of respondents (133/142)94% of respondents (133/142)

2005/06 2003/042005/06 2003/04

65% 65% 47% 47%

Administration Administration Management:Management:

Administer MedicationAdminister Medication

=90% of beds=90% of beds

2005/06 2003/042005/06 2003/04

40% 40% 31% 31%

Policy requiring that two patient identifiers (neither to be the patient’s room number) are checked before administering medications

2005/06 2003/04

C-MARs: ? 56%

E-MARs ?

Bedside, Bar Code 8% (n =4) 3%

Smart pump ? (All, Selected patients)

Administration Administration Management:Management:

Document AdministrationDocument Administration

Education Education

Provide patient with a Provide patient with a copy of the MAR or copy of the MAR or similar documentsimilar document

Allow viewing of the Allow viewing of the MAR by the patientMAR by the patient

Provide counselling Provide counselling pamphlets for each pamphlets for each prescribed medicationprescribed medication

Provide a pharmacist’s Provide a pharmacist’s consultation during in consultation during in hospital stayhospital stay

Provide contact Provide contact information for other information for other available sources of available sources of drug informationdrug information

Process to facilitate patient teaching with regards to their medication therapy (ROP):

2005/06 selected all

30% 1%

21% 5%

65% 1%

78% 2%

62% 2%

Dedicated staff for DI /DUE Dedicated staff for DI /DUE 37% (2005/06)37% (2005/06)

52% (2003/04)52% (2003/04)

Drug InformationDrug Information Pharmacist: 1.4 FTEPharmacist: 1.4 FTE Support staff: 0.7 FTESupport staff: 0.7 FTE

Drug Use EvaluationDrug Use Evaluation Pharmacist: 1.1 FTEPharmacist: 1.1 FTE Support staff: 0.4 FTESupport staff: 0.4 FTE

Drug Information & Drug Information & Drug Use EvaluationDrug Use Evaluation

Monitor Evaluate/ Monitor Evaluate/ Response:Response:

Intervene for medication Intervene for medication errors / adverse drug errors / adverse drug

eventsevents

45% ME - decentralized pharmacists

94% ME with negative outcome - decentralized pharmacists

Bond & al. Pharmacotherapy 2001;21(9)

Monitor Evaluate/ Monitor Evaluate/ Response:Response:

Intervene for medication Intervene for medication errors / adverse drug errors / adverse drug

eventsevents

Bond & al. Pharmacotherapy 2002;22(2)

Proportion of time spent by Proportion of time spent by Pharmacists in each activity: Pharmacists in each activity:

Clinical ServicesClinical Services

2005/06 2003/04

Drug DistributionDrug Distribution43%43% 48%48%Clinical ServicesClinical Services 41% 38% 41% 38% TeachingTeaching 6% 6% 5% 5%ResearchResearch 2% 2% 1% 1% Non-patient Non-patient 8% 8% 8% 8%carecare

Strategies implemented Strategies implemented to improve internal to improve internal reporting of ADEs reporting of ADEs

2005/062005/062003/042003/04

41% 38%41% 38%

Strategies implemented Strategies implemented to trace and document to trace and document the occurrence of ADEsthe occurrence of ADEs

2005/062005/06 2003/042003/04 41%41% 54% 54%

Monitoring and Monitoring and SurveillanceSurveillance

Preventing Medication Preventing Medication Errors:Errors:

Quality Chasm SeriesQuality Chasm Series At least 25% of all medication-At least 25% of all medication-

related injuries are preventablerelated injuries are preventable

HCP should seek to create high-HCP should seek to create high-reliability organizations that reliability organizations that constantly improve the safety and constantly improve the safety and quality of medication use;quality of medication use;

should implement active should implement active internal monitoring programs so internal monitoring programs so that progress toward improved that progress toward improved medication safety can be medication safety can be accurately demonstratedaccurately demonstrated

Establish and maintain a strong Establish and maintain a strong provider-patient partnershipprovider-patient partnership

Preventing Medication Preventing Medication Errors:Errors:

Quality Chasm Series Quality Chasm Series (cont’d)(cont’d)

Effective Error Prevention Effective Error Prevention Strategies are available, in the Strategies are available, in the

hospital settinghospital setting:: Good evidence for:Good evidence for:

the effectiveness of the effectiveness of computerized order entry with computerized order entry with clinical decision-support systems clinical decision-support systems and for clinical decision-support and for clinical decision-support systems themselves;systems themselves;

Pharmacists participation on Pharmacists participation on hospital roundshospital rounds

Show promise, but their efficay has Show promise, but their efficay has not yet been clearly demonstrated:not yet been clearly demonstrated:

Bar codingBar coding Smart intravenous (IV) pumpsSmart intravenous (IV) pumps

Internet sitesInternet sites

Preventing Medication Errors: Quality Chasm Preventing Medication Errors: Quality Chasm Series. http://www.nap.edu/catalog/11623.htmlSeries. http://www.nap.edu/catalog/11623.html

Conseil canadien d’agrément des services de Conseil canadien d’agrément des services de santé. Buts du CCASS en matière de sécurité des santé. Buts du CCASS en matière de sécurité des patients et pratiques organisationnelles requises patients et pratiques organisationnelles requises (POR). (POR). www.cchasa-ccass.cawww.cchasa-ccass.ca

Rapport annuel 200506 sur les pharmacies Rapport annuel 200506 sur les pharmacies hospitalières au Canada hospitalières au Canada www.lillyhospitalsurvey.cawww.lillyhospitalsurvey.ca. .

Joint Commission on Accreditation of Healthcare Joint Commission on Accreditation of Healthcare Organizations. 2006 National Patient Safety Organizations. 2006 National Patient Safety Goals. Goals. www.jcaho.orgwww.jcaho.org..

The Institute for Safe Medication Practices (ISMP The Institute for Safe Medication Practices (ISMP US et ISMP Canada). US et ISMP Canada). www.ismp.orgwww.ismp.org et et www.ismp-canada.orgwww.ismp-canada.org..

Institut canadien pour la sécurité des patients. Institut canadien pour la sécurité des patients. http://www.patientsafetyinstitute.ca/accueil.htmlhttp://www.patientsafetyinstitute.ca/accueil.html

Kit de départ: bilan comparatif des médicaments Kit de départ: bilan comparatif des médicaments http://soinsplussecuritairesmaintenant.cahttp://soinsplussecuritairesmaintenant.ca

Internet sitesInternet sites Société canadienne des pharmaciens Société canadienne des pharmaciens

d’hôpitaux. Lignes directrices sur la d’hôpitaux. Lignes directrices sur la déclaration des erreurs de médication déclaration des erreurs de médication et la prévention des erreurs/incidents et la prévention des erreurs/incidents de médication. de médication. www.cshp.cawww.cshp.ca

American Society of Health-Systems American Society of Health-Systems Pharmacists. ASHP Guidelines on Pharmacists. ASHP Guidelines on Reporting Medication Errors/ Preventing Reporting Medication Errors/ Preventing Medication Errors. Medication Errors. www.ashp.orgwww.ashp.org..        

National Coordinating Council on National Coordinating Council on Medication Error Reporting and Medication Error Reporting and Prevention (NCC MERP). Prevention (NCC MERP). www.nccmerp.orgwww.nccmerp.org..

United States Pharmacopeia. Summary United States Pharmacopeia. Summary of the information submitted to of the information submitted to MEDMARX a national database for MEDMARX a national database for hospital medication error reporting. hospital medication error reporting. www.usp.orgwww.usp.org