7/30/2017 1 Preventing Medication Errors in Practice Margo Karriker, PharmD, FSVHP, DICVP University of California, Davis University of California Veterinary Medical Center – San Diego 5th Annual UCI Conti Symposium on Veterinary Continuing Education August 6 th , 2017 To make no mistakes is not in the power of man; but from their errors and mistakes the wise and good learn wisdom for the future. Plutarch Objectives • Recognize errors happen • Examine error prevention initiatives in veterinary medicine • Compare initiatives in human medicine • Identify error prevention opportunities for your practice
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7/30/2017
1
Preventing
Medication Errors in
PracticeMargo Karriker, PharmD, FSVHP, DICVP
University of California, Davis
University of California Veterinary Medical Center – San Diego
5th Annual UCI Conti Symposium on Veterinary Continuing Education
August 6th, 2017
To make no mistakes is not in
the power of man; but from
their errors and mistakes the
wise and good learn wisdom
for the future.
Plutarch
Objectives
• Recognize errors happen
• Examine error prevention initiatives in veterinary medicine
• Compare initiatives in human medicine
• Identify error prevention opportunities for your practice
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2
How many of us have a
medication error reporting and
prevention/medication safety
program?
Healthcare in the United States is not as safe as it should be –
and can be… (Institute of Medicine. November 1999)
Healthcare in the United States is not as safe as it should be –
and can be… (Institute of Medicine. November 1999)
Four strategies for improvement:
• Establish a national focus to create leadership, research, tools,
and protocols to enhance the knowledge base about safety.
• Identify and learn from errors by developing a nationwide
public mandatory reporting system and encourage
organizations to participate in voluntary reporting.
• Raise performance standards and expectations for
improvement in safety through oversight organizations.
• Implement safety systems in organizations to ensure safe
practices at the delivery level.
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Institute of Safe Medication
Practices501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use
• Began in 1975, with a ongoing column in Hospital Pharmacy that increases understanding and educates healthcare professionals and others about medication error prevention
• Voluntary consumer and practitioner reporting program
• Med-ERRS (Medical Error Recognition and Revision Strategies) works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design.
• Newsletters, educational programs and patient-safety tools
virtual-reality-breathe-new-life-into-technology. July 28th 2017
Creating a Model Strategic Plan
Reduce the risk of errors with high-alert medications
prescribed and administered.
• Create and maintain and list of medications
• Establish the procedures required when these drugs are used
Creating a Model Strategic Plan
Establish a blame-free environment for reporting errors.
“I just don’t want to get anyone in trouble…”
• Survey staff about anxiety and fear about making and
reporting errors
• Consider anonymous reporting
• Link safety competence tenets to employee evaluations, not
frequency/pattern of reported errors
• Focus on systematic solutions to frequent causes of error
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Creating a Model Strategic Plan
Involve the community in medication safety initiatives.
• Communicate safety initiatives to clients
• Host client education training
Creating a Model Strategic Plan
Involve the community in medication safety initiatives.
• Rate of errors increased
• Incorrect dose
• Wrong medication taken/given
• Took/gave medication twice
• Cardiovascular drugs
• Analgesics
• Hormones and hormone antagonists
• Sedative/hypnotics/antipsychotics
Source: Hodges, N. L., Spiller, H. A., Casavant, M. J., Chounthirath, T., & Smith, G. A. (2017). Non-health care facility medication errors resulting in serious medical outcomes. Clinical toxicology, , 1-8.
Our program
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Medication Error Statistics
• Data collected from September 15, 2011 – February 25, 2016
• 657 total entries
• 603 entries evaluated
Inpatient
Outpatient
Potential
By Service
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
Pe
rce
nt
Service
Outpatient
Inpatient
Errors Reach Patient
68%
29%
3%
Inpatient
Reached
Patient
Did Not
Reach
Patient
Unknown 83%
16%
1%
Outpatient
Reached
Patient
Did Not
Reach
Patient
Unknown
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Cause Harm/ Change in
Treatment
• Inpatient
• 13% classified as
causing harm
• Of errors that reached
patients, 28% required
change in treatment
• Outpatient
• 11% classified as
causing harm
• Of errors that reached
patients, 9% required
change in treatment
Medication/Medication Class
0
20
40
60
80
100
120
140
High Alert Medications
• Inpatient
• 509 entries
• 42 unknown drug
involved
• 201 High Alert Meds
• Outpatient
• 81 entries
• 3 unknown drug
involved
• 9 High Alert Meds
39% - 48%
involving High
Alert
Medications
11% - 15%
involving High
Alert
Medications
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Inpatient Error Causes
Human
Communication
Labeling
Unknown
Other
Staff Education
• What is a medication error?
• Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in the control of the health care professional,
patient, or consumer.
How to report
• Easy to access
• Minimal time
investment
• Focuses on root
cause
• Non-punitive
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What should be reported
• Nothing is too trivial
• Near-misses should be reported
• Even if it didn’t reach the patient
• Anything that is unintended
• Even if no harm was caused
How we’re using the data
• Focus on improved
patient care
• Consistent,
constructive
feedback
• Need buy-in from
everyone
Summary
• Prioritize error reporting and prevention
• Include error prevention goals in your strategic plan
• Create a blame-free culture of medication safety
• Implement a continuous, sustainable error prevention
program
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Resources
• Institute of Safe Medication Practices
• www.ismp.org
• FDA Center for Veterinary Medicine: Consumer Updates