Interior Health Medication Management Audit

File No. 11-009R December 24, 2012

Medication Management Audit – Acute Care P REP ARED BY:

Internal Audit and Advisory Services: Melanie Libbrecht, Clinical Internal Auditor Rob Desjardins, Senior Internal Auditor Givonna De Bruin, Corporate Director, Internal Audit

DIS TRIBUTION:

For Action: VP, Acute Services Regional Director, Pharmacy Chief Nursing Officer & Professional Practice Lead Chief Project Officer and Corporate Director, Capital Planning HAMAC Health Informatics Strategy Council For Information: Relevant Leadership Teams Pharmacy and Therapeutics Committee Senior Executive Team Quality Care Committee

Distribution Limitation: This report is for internal use only. The report may include policy advice and recommendations protected by the Freedom of Information and Protection of Privacy Act. Copies are not to be distributed without the express written consent of the Corporate Director, Internal Audit.

Internal Audit…Adding value across the region

TABLE OF CONTENTS Executive Summary ................................................................................................................. 3 Summary of Recommendations.............................................................................................. 6 Management Responses ......................................................................................................... 8 Detailed Report .......................................................................................................................12 Background .................................................................................................................12 Objectives ....................................................................................................................15 Methodology and Scope .............................................................................................15 Overall Findings and Recommendation ....................................................................16 Detailed Site Findings and Recommendations .........................................................18 Leading Practices and Improvement Opportunities ................................................. 31 Acknowledgements .....................................................................................................35 Glossary of Abbreviations......................................................................................................36 Appendix 1: Site Specific Findings........................................................................................37 Tertiary Hospitals ........................................................................................................37 Regional Hospitals ......................................................................................................38 Community Hospitals..................................................................................................39 Appendix 2: Compiled Site Audit Findings ...........................................................................41 Appendix 3: SOGH Summary Findings .................................................................................45

Internal Audit | Medication Management Practices Audit

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EXECUTIVE SUMMARY The Canadian Adverse Events Study published in 2004 found that as many as 24,000 Canadians die annually due to preventable adverse events. Among those cases, 24% were related to medication or fluid administration 1. A 2008 survey by the Commonwealth Fund identified that nearly one in ten Canadians with health problems reported receiving the wrong medication or dose from a pharmacy or hospital within the previous two years 2. In 2007 Health Authorities in British Columbia began implementation of the BC Patient Safety and Learning System (PSLS). In the three years since, there have been 36,185 medication related events reported across the province of BC representing 26% of all reported events. In 2011, within Interior Health (IH), there were 5,306 medication related events which represents 20.3% of all reported events. Experts agree that less than 10% of medication related events are reported through a voluntary reporting system 3. This audit was conducted to evaluate current medication management practices in acute care as compared to key standards, policies and leading practices. Additionally, recommendations made by Institute of Safe Medication Practices (ISMP) in their Report to Vernon Jubilee Hospital (VJH), Supplemental Medication Safety Report: Identified Vulnerabilities and Recommendations (April 8, 2010), (referred to as the ‘ISMP VJH Report’) were included in the audit tool to determine whether recommendations were implemented across IH. Also, the timing of the audit (April, May 2012) provided management with a baseline measurement of current medication management practices prior to the implementation of the IH Clinical Practice Standard and Procedure: Medication Management: Acute Care Nursing (July 2012). Lastly, the audit assisted management with preparations for the Accreditation Canada visit in the Fall of 2012.

Conclusion In Internal Audit’s opinion, there exists a moderate to high risk of significant patient harm associated with the current medication management practices as observed in selected medical surgical inpatient units.

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Baker, G.R. et al. (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170 (11): 1678-1686. Health Council of Canada. (2009). Safer Health Care for ‘Sicker’ Canadians: International comparisons of health care quality and safety. Toronto: Health Council. www.healthcouncilcanada.ca. Pepper, G. (1995). Errors in drug administration by nurses. American Journal of Health System Pharmacists, 52, 390-395.


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Overall, across the sample of eight largest acute care sites, Internal Audit found 56% compliance with standard practices and policy. Additionally, of the 10 practice standards recommended 4 in the ISMP VJH Report, only one was found to be consistently implemented across IH. There are multiple opportunities for substantial improvement by complying with established IH clinical practice standards and procedures, established IH policies, and by incorporating leading practices into the medication management process. Of note, Computer Physician Order Entry (CPOE) and Barcode Medication Administration (BCMA) is a leading practice in use at South Okanagan General Hospital (SOGH) in Oliver, BC, to improve safe medication practices. Internal Audit found 73% compliance with audited practices at SOGH.

Key Findings Across IH, in the medication management process categories of Prescribing, Transcribing, Dispensing and Administering, the category with the highest average risk was found in Administering (32%). Low to moderate average risks were found in Prescribing, Transcribing, and Dispensing. An average risk of 38% was noted in Support of Practice, which includes education, reporting of adverse events, and environment of care (Chart 1). Chart 1: IH Areas with Moderate to High Risk Prescribing 12% Transcribing 2% Other 38%

Dispensing 16%

Administering 32%

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The ISMP VJH Report had 45 recommendations. Internal Audit reviewed 10 for compliance across IH.


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High risk practices (not in accordance with audit criteria and potentially high risk exists to patients and/or staff) included: • • • • • • • • • •

Staff did not check the patient identification (ID) band for two unique identifiers. Staff did not check the patient allergy band prior to medication administration. Medication carts were left unlocked while unattended. High alert medications were rarely double-checked prior to administration. All sites used ‘Do Not Use’ abbreviations on patient charts. Unit dose medications were opened prior to being taken to the patient location. Three sites pre-poured medications and placed medications in unlabeled med cups. Narcotic containing syringes intended for multiple doses were in medication carts. Medications from multi-dose containers were placed in unlabeled medication cups. Wastage of controlled substances was not always witnessed and recorded by two licensed staff. • The Medication Administration Record (MAR) was not taken with medications to the patient location. • There were frequent interruptions in the medication administration process. • Confidentiality of patient health information was not always protected.

Moderate risk practices (not in accordance with audit criteria and moderate risk exists to patients and/or staff) included: • • • • • • • •

Physician verbal orders were routinely given in non-emergent situations. Telephone and verbal orders were not signed off by the physician within 48 hours. Nursing orientation and continuing education on medication management and medication safety varied significantly between sites. Limited trending of PSLS events; responsibility for this practice was not clear. Medication rooms and storage areas were cluttered with items not related to the medication management process. Hallways were congested with equipment which are distracters to medication safety. Open mouthed sharps containers allowed access to used sharps and discarded narcotics. The Best Possible Medication History (BPMH) was not always on the patient’s chart and the BPMH and Medication Reconciliation was not consistently completed; this practice is currently a work in progress.

Going forward, management and clinicians should continue to strive towards achieving safe medication practices. Multi-disciplinary teams need to work together to promote a culture of safety, and to implement recognized improvement strategies that support safe medication practices and minimize risk to the patient.


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SUMMARY OF RECOMMENDATIONS 1. Finalize and/or continue to implement the following IH Clinical Practice Standards and Procedures: • • •

Medication Management: Acute Care Nursing (July, 2012); Acute Care Best Possible Medication History ( February, 2012); and, High Alert Medication Management (draft Oct, 2011).

2. The Health Authority Medical Advisory Committee should ensure that all physicians are aware of, and comply with, the IH policy Safe Communication of Medication Orders (PHB0100). 3. The Acute Services Leadership Team, with assistance from the Professional Practice Office and Pharmacy, should develop a Safe Medication Management Practices education program for initial orientation of medical, nursing and pharmacy staff and require annual competency validation. 4. Pharmacy should ensure that staff have easy access to current medication related resources on the IH InsideNet. 5. The Acute Services Leadership Team should: • ensure PSLS incident trending is completed at each site; and, • continue to educate staff as to the linkages between incident reporting and overall quality improvement and patient safety. 6. The Acute Services Leadership Team should request Transformation, Innovation and Change to conduct a Lean review of nursing medication rooms and Pyxis® areas to eliminate waste and improve efficiency. 7. Capital Planning should utilize the CSA standards for Canadian Health Care Facilities (Z8000-11) for new space or renovated patient care areas to minimize interruptions and provide sufficient work areas, lighting and storage for the medication management process. 8. Pharmacy should develop a business case to: • • • •

continue the implementation of Pyxis® automated medication dispensing cabinets in all patient care areas; support the expansion of IV admixture services to each acute care site; provide additional clinical pharmacists on patient care units; and, increase Pharmacy operating hours to support improved patient care and reduce the time the automated dispensing cabinets are on ‘over-ride’.

9. The Pharmacy and Therapeutics Committee should establish a regional multi-disciplinary Medication Management and Safety working group consisting of medical staff, nursing,


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Pharmacy, and Quality to implement recognized improvement strategies that support safe medication practices that minimizes risk to patients. 10. The Acute Services Leadership Team should implement an on-going quality assurance program to monitor compliance with medication related standards and policies. 11. The Pharmacy Leadership Team should: • strengthen controls for Pyxis® user access; • require completion of the online Pyxis® education and competency training program prior to granting Pyxis® user access; and, • conduct a narcotic and controlled substances diversion risk assessment and enhance controls to address identified risks. 12. The Health Informatics Strategy Council should consider the IH-wide implementation of Computer Physician Order Entry and Barcode Medication Administration as a long-term initiative.


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MANAGEMENT RESPONSES PROVIDED BY CHIEF OF PROFESSIONAL PRACTICE & NURSING On behalf of the Acute Care Leadership Team and the Professional Practice Office, thank you for your careful and thoughtful audit of the medication management practices in Acute Care. The audit included aspects of safe medication handling that are multidisciplinary in nature, and have far reaching impacts in Interior Health. The recommendations arising from the audit were system-focused, and intended to improve the compliance to existing policies and procedures. As Chief Nursing Officer and Professional Practice Lead, I am pleased that the audit and its resulting recommendations are so clearly focused on system improvement with a focus on quality. I am delighted to work with my colleague Kevin Peters, Director, Pharmacy Services and others on these important recommendations. More specifically, the Professional Practice Office, under my leadership, will be responsible for the following action items: Recommendation #1A – Accepted. Review and develop an implementation strategy, including timeframe and evaluation measures to address the July 2012 Medication Management Acute Care Nursing Clinical Practice Standards. Completion: April 2013 Recommendation #3 – Accepted. Develop a Safe Medication Management Practices education program inclusive of: - education required at Orientation for all disciplines - education on IH Policies for Safe Medication Management Completion: April 2013 Explore strategies to initiate an annual competency process. Determine if a strategy can be developed that is feasible from a financial and human resource perspective. Completion: April 2013 Implement the Safe Medication Management Practices education across IH, with a goal of 20% of staff completing the learning module each quarter of 2013 fiscal year. Completion: March 2014 Recommendation #5 – Modified Working with PSLS leaders and Health Business Analytics, develop a quarterly track/trend report to be circulated to Managers/Directors on a quarterly basis. This will require the development of indicators that can inform Managers/Directors about their units in comparison to others in relation to reported medication incidents/errors/near misses. Complete: June 2013 Internal Audit | Medication Management Practices Audit

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Develop a communication strategy with Quality Improvement, PSLS, Communications and Pharmacy to enhance reporting of medication errors through PSLS. Complete: April 2013 Recommendation #9: Modified Refresh the terms of reference for the IH P&T committee to include oversight of medication safety. Create a multidisciplinary sub-committee to IH P&T to review tracking/trending reports on issues related to medication safety across IH; by program, by site, and by community, reporting quarterly to the IH P&T committee. Complete: April 2013 Recommendation #10: Declined Rationale: The development of a sub-committee to IH P&T (as outlined above) will hold responsibility for quality assurance for Safe Medication Management Practices across IH. The link to IH P&T with a requirement for quarterly reporting will satisfy this recommendation, and support a quality assurance process across IH. Some recommendations have been refined to provide clarity and to link action items into an integrated planning process. While I recognize the importance of each of the recommendations in supporting quality practice in medication administration and management, the timeline for completion of each of the recommendations is linked to the complexity of the planning processes required in each case. I look forward to noting improvements in these areas in future audits of medication management practices in acute care. Sincerely, Heather Cook Chief Nursing Officer & Professional Practice Lead


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PROVIDED BY REGIONAL DIRECTOR, PHARMACY SERVICES Thank you for the comprehensive review of medication management practices in Acute Care. The audit included the major components of safe medication handling, with particular attention to the administration phase of the medication process. At this final point in the medication process, it is imperative that care providers have the tools, education, and environment to minimize the risk of human error. The recommendations arising from the audit are appropriate and will lead to necessary improvements in the medication system. While some of the recommendations can be initiated relatively quickly, several recommendations are resource intensive and may have to be prioritized and implemented over a number of years. It is encouraging that most of the recommendations are already encompassed in the current Pharmacy Services Plan. The initial priority should be implementation and continuing education around the existing policies and clinical practice standards. Simplified access to tools and materials has been a long standing concern among clinical staff and should be addressed with support from IMIT. Early consideration of the medication process during new building projects or ward renovations will help create an environment that is conducive to safe medication management. Pharmacy has not always been involved at the design phase of nursing unit renovations and would be pleased to participate in the development of common standards. The recommendation for business case development for specific Pharmacy services is appropriate and necessary. Each of the four facets within the recommendation will require substantial investments of capital or operating funding. The best approach may be to separate the business case into distinct plans or develop phases over several years. The recommendation for clinical pharmacists (8c) is already in the Budget Management Planning process, and should be the first priority as it offers the greatest net value. The terms of reference for the IH Pharmacy and Therapeutics Committee are being refreshed to clarify oversight of medication safety. A separate committee that is responsible for identifying and resolving medication management and safety concerns may be helpful in creating specific action plans for identified risk areas. This new committee should include membership from frontline nursing and pharmacy staff. Now that automated dispensing cabinets (Pyxis®) are well established in most areas of IH, it is important to ensure that the appropriate training and user control mechanisms are sustained. This recommendation also applies to the smart infusion pumps. One benefit of automated medication systems is the opportunity to use the information in the system to proactively identify safety risks, including diversion of narcotics. The ongoing review, analysis and communication of the information are a responsible part of using these systems and will require dedicated staff resources.


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The Pharmacy leadership team finds the audit consistent with the Pharmacy vision of “caring for every patient through appropriate, timely, and safe medication management” and is enthusiastic about working with colleagues in medicine, nursing, and quality to improve the medication management process. Sincerely, Kevin Peters, Director, Pharmacy Services on behalf of the Pharmacy Management Team.


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DETAILED REPORT

BACKGROUND The Canadian Adverse Events Study published in 2004 found that as many as 24,000 Canadians die annually due to preventable adverse events. Among those cases, 24% are related to medication or fluid administration1. A 2008 survey by the Commonwealth Fund identified that nearly one in 10 Canadians with health problems reported receiving the wrong medication or dose from a pharmacy or hospital within the previous two years2. In the three years since the implementation of the BC PSLS, there were 36,185 medication related events reported across the province. This represents 26% of all reported events. In 2011, within IH, there were 5,306 medication related events which represents 20.3% of all reported events. Experts agree that less than 10% of medication related events are reported through a voluntary reporting system3. Research reported, to date, confirms that medication errors are a major threat to patient safety, and that these errors can be attributed to all involved disciplines and to all stages of the medication process. The inherent risk in the medication management process is the potential for catastrophic patient harm. Some of the factors giving rise to this inherent risk include: •

The complexities of the medication management process including communication between clinicians such as physicians, pharmacists and nurses, and the number of people involved in the process, all of which increase the opportunity for error.

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The frequent use of medications that bear a heightened risk of causing significant patient harm when used in error; common among this group of high alert medications are anticoagulants, insulins and opioids.

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The prevalence of a large number of medications which are similar in appearance or similar in name (look alike/sound alike medications) increases the risk of medication errors occurring.

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The presence of poly-pharmacy or the use of multiple medications, especially in the elderly population, increases the risk of adverse drug interactions.


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The medication management process includes four categories: 1. Prescribing - the correct drug, dose, interval, duration. 2. Transcribing - reading and interpreting written prescriptions correctly and transferring this information to a computer system or patient chart. 3. Dispensing - pharmacy reviewing for “correctness,” processing the order, preparing the drug, and dispensing in a timely manner. 4. Administering - ‘7 Rights’; right patient, right drug, right dose, right route, right time, right indication, right documentation. Within the medication management process, there are multiple opportunities for error, as identified in Chart 2. Chart 2: National Reported Errors by Category 5

Administering 38%

Dispensing 11%

Prescribing 39%

Transcribing 12%

Support of Practice, which includes education, reporting of adverse events, and environment of care, enhances the medication management process. Within Support of Practice, there are applicable standards and regulations and when they are not in place or adhered to, they pose a risk in the medication management process and to patient safety. Practice realities and the literature have identified a number of barriers to safe medication management. These include, but are not limited to:  Miscommunication amongst caregivers including: illegible handwriting, misplaced decimal points, misunderstood abbreviations, and misreading or misinterpreting physician orders.

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Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. Editors Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. 1999. Institute of Medicine, National Academy Press, Washington, D.C.


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 Distractions and interruptions in the medication administration process are a major environmental issue contributing to errors. Another form of distraction that can lead to errors is the unavailability of medications at the time of administration, requiring the nurse to spend time looking for the medication in various places.  Stress from a heavy workload is a common cause of medication errors, followed by fatigue from lack of sleep, and excessive overtime.  Technological failures and workarounds; although policies and procedures related to medication management standards and operation of equipment exist, many errors occur as a result of staff not following these policies and procedures.  Space limitations and poor design of medication rooms.  A knowledge deficit in preparing and administering medication; new staff orientation varies across clinical settings, and competency assessment of regular and casual staff in relation to medication management, medication knowledge, and medication safety is inconsistent. Internal Audit included this project in the 2011-2012 Board approved Annual Audit Plan at the request of the Pharmacy and Quality and Accreditation leadership teams. This audit was intended to provide a baseline measurement of current medication management practices prior to the implementation of the IH Clinical Practice Standard and Procedure: Medication Management: Acute Care Nursing (July 2012); and to assist management with preparations for the Accreditation Canada visit in the Fall of 2012.


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OBJECTIVES The objectives of this audit engagement were to: 1. Determine whether current medication management practices across Interior Health meet Accreditation Canada Required Organization Practices (ROPs), IH Clinical Practice Standards and Procedures (CPSP), IH policies and recommended practices from the ISMP Canada. 2. Identify any significant practice-related risks (patient, staff, or organizational) in the medication management process. 3. Analyze leading practices in medication management and identify potential opportunities for practice improvement.

METHODOLOGY AND SCOPE Using a standard risk-based audit tool developed by Internal Audit, the auditors measured current compliance with:  Accreditation Canada Qmentum Program (ACQP) o Managing Medications (Version 4, January 2012)  IH Clinical Practice Standards and Procedures, specifically: o Medication Management: Acute Care Nursing (July 2012) o High Alert Medication Management (draft Oct 2011) o Acute Care Best Possible Medication History (BPMH) (Feb 2012)  IH policies including: o Controlled Substances (PHK0600) o Safe Communication of Medication Orders (PHB0100) o Facility Identification Banding for Emergency Patients (AH1500) o Incident Management (AK0400) o Privacy and Management of Confidential Information (AR0400)  Recommended practices as identified by ISMP (Canada) Report to Vernon Jubilee Hospital, Supplemental Medication Safety Report: Identified Vulnerabilities and Recommendations (April 8, 2010).


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A sample of medical and surgical inpatient units in tertiary and acute care facilities across Interior Health were selected including the two tertiary hospitals (Kelowna General Hospital (KGH) and Royal Inland Hospital (RIH)), four service area hospitals (East Kootenay Regional Hospital (EKH), Kootenay Boundary Regional Hospital (KBH), Penticton Regional Hospital (PRH) and VJH), and two community hospitals (Shuswap Lake General Hospital (SLH) and Cariboo Memorial Hospital (CMH)). SOGH was included as an ancillary project to audit the site’s medication management practices which incorporates computer physician order entry and bar-coding technologies. Specialty nursing areas including the Intensive Care Unit, Emergency Department, and Post Anesthetic Recovery were excluded from the scope of the audit.

OVERALL FINDINGS AND RECOMMENDATION The following findings and recommendations relate to the practices and document reviewed in relation to this audit. Findings were assigned a rating as follows: High Risk: not in accordance with practice standards and/or policies and potentially high risk exists to patients and/or staff. Moderate Risk: not in accordance with practice standards and/or policies and moderate risk exists to patients and/or staff. Overall, across the sample of eight acute care sites, where practices were observed on medical/surgical units, Internal Audit found 56% compliance with established standards and policies (Table 1). The sites were consistent with compliance rates in the range of 50% - 61%.

Table 1: Overall Compliance Rates by Site KGH

RIH

VJH PRH

EKH KBH CMH SLH

Overall

Practice meets standard

56%

56%

60%

54%

61%

53% 60% 50%

56%

Practice does not meet standard - action required

21%

25%

21%

19%

22%

25% 19% 31%

23%

Practice does not meet standard - urgent action required

23%

19%

19%

26%

17%

22% 21% 19%

21%

Across IH, in the medication management processes categories of Prescribing, Transcribing, Dispensing, and Administering, the category with the highest average risk was found in Administering (32%). Low to moderate average risks were found in the categories of Internal Audit | Medication Management Practices Audit

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Prescribing, Transcribing, and Dispensing. An average risk of 38% was noted in Support of Practice, which includes education, reporting of adverse events, and environment of care (Chart 1). Chart 1: IH Areas with Moderate to High Risk Prescribing 12% Transcribing 2% Other 38%

Dispensing 16%

Administering 32%

Appendix 1 presents a brief summary of the audited sites. Specific practices which were in 100% compliance, or low risk, across all sites audited included:  Minimizing the number of medications and stock drugs available (such as heparin, narcotics, and concentrated electrolytes) to increase patient safety;  Using the MAR or Physician Order to dispense medication to increase patient safety;  Providing education on infusion pumps to increase patient safety;  Provision of a Pharmacist On-Call to support staff in safe medication practices;  Staff awareness of the difference between the Registered Nurse (RN) and Licensed Practical Nurse (LPN) Scope of Practice; and,  Staff were knowledeable about Emergecy Response codes. At the time of the audit, the IH Clinical Practice Standard and Procedure - Medication Management: Acute Care Nursing; Acute Care Best Possible Medication History; and the High Alert Medication Management, were in draft. Internal Audit provided the Professional Practice Office, Pharmacy, and Quality with the site specific audit findings and provided suggestions for policy improvement. These key policies need to be finalized and implementation plans completed to ensure consistent guidance is available to all nursing staff for practice improvement to occur.


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Recommendation 1: Finalize and/or continue to implement the following IH Clinical Practice Standards and Procedures: a) Medication Management: Acute Care Nursing (July, 2012); b) Acute Care Best Possible Medication History (February, 2012); and, c) High Alert Medication Management (draft Oct, 2011).

DETAILED SITE FINDINGS AND RECOMMENDATIONS The following section provides a detailed description of each of the medication management practice findings, according to risk rating, and sorted by the categories of the medication management process (prescribing, transcribing, dispensing and administering) and support of practice. Specific practice standards and risk ratings by site can be found in Appendix 2. A reference to the relevant section of the audit tool is included in brackets ( ). As the finalization and implementation of the medication related IH Clinical Practice Standards and Procedures (Recommendation 1) across all acute care sites is expected to address many of the audit risks identified, the additional recommendations relate to other identified risks. Findings were assessed based on high, moderate or low risk as previously defined.

A. Prescribing 1.0 ‘Do Not Use’ Abbreviations (A.1.3) The abbreviations, symbols, and dose designations found in the ISMP ‘Do Not Use Abbreviations’ listing have been identified as being frequently misinterpreted and involved in harmful medication errors. The abbreviations should not be used when communicating medical information. This includes internal communications, telephone/verbal prescriptions, computer generated labels, labels for drug storage bins, medication administration records, and pharmacy and prescriber computer order entry screens. Accreditation Canada specifies that ‘Do Not Use Abbreviations’ should be eliminated in the organization. IH has an approved list of ‘Do Not Use’ abbreviations and is referenced in IH Policy PHB0100 Safe Communication of Medication Orders. The list was posted on all nursing units; physician orders include the list at the top of the page; yellow chart dividers with the ‘Do Not Use’ abbreviation list imprinted on it have recently been inserted into charts.


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Internal Audit found all sites and all units had some of the ‘Do Not Use’ abbreviations on Physician Orders, MAR, nursing notes, pharmacy medication labels, and the computer generated MAR.

2.0 Best Possible Medication History (A.1.1) Obtaining the Best Possible Medication History (BPMH) is a collaborative process between physicians, pharmacy and nursing with all disciplines sharing responsibility and accountability for their part in this process. The medication history is recorded in the patient chart which allows physicians and staff to determine which medications need to be continued, changed, or discontinued during the hospital stay. Additionally, new medications may be ordered. The BPMH is used in the Medication Reconciliation process. Medication Reconciliation attempts to reconcile all previous medications the patient may/or may not be taking against all new medications the physician may order for the patient while in hospital. The Medication Reconciliation process is intended to enhance patient safety by decreasing the risk of adverse drug events. On arrival at the hospital, the patient is interviewed by staff in an effort to gather a complete and accurate list of all medications the patient is taking at home, including over the counter medications (OTC) and herbal supplements. Staff access Medinet, BC Pharmanet’s information system, to obtain a list of medications the patient has been prescribed in the past 120 days. IH Clinical Practice Standard and Procedure: Acute Care Best Possible Medication History (February 2012) provides guidelines on how to complete the BMPH and the Medication Reconciliation process. The BMPH is a Required Organizational Practice (ACQP, 2012). Internal Audit noted that completion of the BPMH and subsequent Medication Reconciliation varied significantly between sites and within individual units at each site. Most sites and individual units had evidence of the BPMH on the patient chart; however, the majority were not completed or signed. Overall, there was limited evidence of the Medication Reconciliation process being completed. There were no specific responsibilities assigned to each of the disciplines (physicians, nursing, and pharmacy) for each part of the process, and no regular monitoring or feedback to ensure accountability for completion of their responsibilities. Staff interviewed identified that they were often confused as to the process itself and their related responsibilities. Education related to the BPMH and the Medication Reconciliation process was inconsistent and not clearly explained.


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3.0 Physician Verbal/Telephone Orders (A.1.6) Accreditation Canada and IH Policy PHB0100 – Safe Communication of Medication Orders defines the policy for verbal and telephone orders. Internal Audit noted that many sample charts audited across all units audited had verbal orders of a non-emergent nature. Verbal and telephone orders were not signed off by the physician within 48 hours as required by policy.

Recommendation 2: The Health Authority Medical Advisory Committee should ensure that all physicians are aware of, and comply with, the IH policy Safe Communication of Medication Orders (PHB0100).

B. Dispensing 1.0 Unlocked Medication Carts (C.2.3) The safe storage of medication is critical to ensure access is limited to authorized individuals. Uncontrolled access offers opportunity for drug diversion and presents a high risk to patient and public safety. The ISMP VJH Report and IH Pharmacy Policy PHK0600 state that controlled substances are to be securely stored in medication carts between dose administrations. Internal Audit found unlocked and unattended medication carts in many hallways. Several carts had controlled substances such as such as morphine, morphine-filled syringes, and Tylenol with codeine. One cart had keys to the narcotic cabinet in the top drawer of the unlocked medication cart. One site’s carts automatically locked after three minutes, while another site’s carts automatically locked after 15 minutes.

2.0 Pre-Pouring Medications (C.3.4) The practice of pre-pouring medications involves dispensing and preparation of all of the medications a patient requires for the entire shift at one time. This usually involves removing the medication from the unit dose or blister packages and placing the medications into unlabeled medication cups. The unlabeled medication cups filled with medications are then stored in the medication carts. Internal Audit | Medication Management Practices Audit

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The College of Registered Nurses of BC (CRNBC) states that this practice can, ‘blur the accountability for ensuring the seven rights and/or increase the possibility of errors’. The ISMP VJH Report 6 recommended that the practice of pre-pouring medications be eliminated. Internal Audit found three sites were engaged in the practice of pre-pouring medications.

3.0 Use of a Single Syringe of Narcotic for Multiple Doses (C.4.4) The practice of using a single syringe of narcotic for use in multiple doses is a high risk practice. This practice provides the opportunity for a significant or fatal medication error or drug diversion, increased likelihood of contamination, and decreased stability of the medication. IH Policy PHK0600 – Controlled Substances requires controlled substances to be kept securely locked, and the use of narcotic syringes for multiple doses is permitted only in specialty care areas specified by policy. Internal Audit noted that three sites prepared single syringes of narcotics for multiple doses, a practice that is in contravention of policy for medical-surgical units. The narcotic syringes were stored in unlocked medication carts. Unsecured storage of narcotics represents a risk of theft and to public safety. Some of the morphine filled syringes were outdated indicating that narcotics were not wasted at the end of each shift as required by policy.

4.0 Destruction of Controlled (Narcotic) Substances (C.4.5) The prescribed dose of a narcotic may require that only a portion of the narcotic vial or pill be administered. The unused amount of narcotic must be ‘wasted’ prior to administration. The wasted narcotic must be witnessed by another licensed personnel and documented as described by the policy. Witnessing and documentation of wastage is necessary to ensure the correct dose of medication has been administered, allows for the accurate tracking of inventory; and complies with the requirements under the Canadian Controlled Drugs and Substances Act S.C. 1996, c. 19. Additionally, IH Policy PHK0600 – Controlled Substances specifies the policy for wasting narcotics. Internal Audit found that six of the eight sites did not waste narcotics according to policy. Some staff was not sure how to record wastage in Pyxis® or how to resolve narcotic

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ISMP Report to Vernon Jubilee Hospital. Supplemental Medication System Safety Report: Identified Vulnerabilities and Recommendations. April 8, 2010, pg.17


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discrepancies. Staff requested others witness narcotic wastage after the medication was given and the narcotic ampoule discarded. Controlled substances must be wasted in appropriate biohazard containers containing an adsorbent material to denature it and render it impossible to be used illicitly. At many sites, wasted narcotic substances were disposed of into sharps containers without adsorbent material added. 5.0 Borrowing Medications (C.3.3) Borrowing medication from a ‘profiled’ patient for use on a ‘non-profiled patient’ is a safety risk as it bypasses the safety checks that occur in Pharmacy during the dispensing process. Limited staffing resources and Connex technology issues have increased the time it takes Pharmacy to enter the patient medication information into Meditech and have the medication available in Pyxis®. Internal Audit found that at five of the eight sites, medications were frequently borrowed in Pyxis® from electronically ‘profiled’ patients for use on ‘non-profiled’ patients.

C.

Administering 1.0 High Alert Medications (D.1.2) High alert medications are those medications with a narrow margin of safety and thus require independent double checks prior to administration. High alert medications have been implicated in medication errors and may cause severe patient harm. Accreditation Canada 7 requires healthcare organizations to define and list high risk/high alert medications. Internal Audit found IH High Alert Medications Bulletin (June 2009) prominently posted on the units. Some information noted on the bulletins conflicted with IH Clinical Practice Standard and Procedure: High Alert Medication Management (Oct 2011) 8. One site had a site-specific policy that was not consistent with the IH policy. Internal Audit found that most sites did not know which medications required an independent double check and/or second practitioner verification. Some staff was not aware that subcutaneous Insulin required an independent double check. Fentanyl patches were not double checked as required.

7

Accreditation Canada Qmentum Program Version 4, 2012, Managing Medications Section 2.5 and Section 18.5

8

IH Pharmacy Practice Manual, Clinical Practice Standard and Procedure. High-Alert Medication Management – Nursing Draft for Consultation – February 2010, Last update: Oct. 4, 2011


22

2.0 Patient ID Band Check (D.2.2) Correct patient identification is the first, and most basic, patient safety practice. It is a requirement that a patient is correctly identified and that their identity is positively confirmed prior to receiving any treatments or interventions, including medications. Two unique identifiers (name and date of birth) must be used to unequivocally identify the patient. Two unique patient identifiers must be recorded on a patient ID band and the patient must have an ID band on at all times. Two unique patient identifiers must be on all patient records, including the MAR. Prior to administering medication, the patient identity must be confirmed by comparing two unique patient identifiers on the patient ID band to the patient identification information on the MAR. IH Policy AH1500 – Facility Identification Banding for Emergency Patients outlines the requirements to provide an identification band on the patient. Including all inpatients in this policy may be advisable. Internal Audit found that at all sites, the patient ID band was not checked (nor was the patient asked to state their name and date of birth) prior to medication administration. The patient identification was never compared to the patient identification information on the MAR.

3.0 Patient Allergy Band Check (D.2.3) Obtaining the allergy and adverse drug reaction information is a critical requirement to ensure that patients are protected from receiving medication that will cause harm. Accreditation Canada requires healthcare organizations to have in place a policy related to recording patient allergies and adverse drug reactions in the patient medication history. The IH CPSP for Allergy/Adverse Drug Reaction Documentation (Electronic Print-out & Document Services Form #82634) (draft November 2010) was implemented concurrently with the Connex upgrade of the Meditech software. Internal Audit found the Allergy/Adverse Drug Reaction form on the charts; however, many patient charts did not have the form completed. The MAR did have allergy/adverse drug reactions noted when known. Staff did not check the patient allergy band prior to medication administration. During the medication administration process, patients were not asked about allergies and the MAR was not taken to the bedside to confirm or exclude allergies.


23

4.0 Opening of Unit Dose Medication at the Bedside (D.3.3) The unit dose system consists of individually packaged single dose medications with the name and dose of the medication printed on the package. The unit dose system increases patient safety by ensuring the correct medication and dose is taken directly to the patient prior to administration. Pharmacy has invested a significant amount of resources to implement the unit dose system throughout most of the region. For safety, the unopened unit dose medication package must be taken to the patient bedside and compared to the MAR at the time of medication administration. This practice confirms the medication, the dose and the route of administration against the information on the MAR. Internal Audit observed that the unit dose medication packages were not taken unopened directly to the patient bedside for administration. The unit dose packages were opened and put into unlabeled medication cups during medication preparation, usually in the medication room or on the medication cart. This practice defeats the intended purpose of the unit dose system by circumventing the safety measures inherent in the unit dose method.

5.0 Labeling of Medications from Multi-Dose Packages and Multi-Dose Injectables (D.3.4) Medication is often available in multi-dose blister packs, containers, or vials. During medication preparation, the required number of pills are removed and placed in a labeled medication cup. Injectable medications must be drawn into a labeled syringe. IH CPSP: Medication Management: Acute Care Nursing (July, 2012) requires that all syringes and medication cups be labeled with the medication name and dose. This provides for accurate identification of the medication up to the point of administration to the patient 9. Internal Audit observed that at all sites medications were poured into medication cups and were not labeled. Syringes were not labeled with the exception of syringes containing narcotics, and those that came pre-labeled from the manufacturer. Unlabeled medication cups on one unit were found filled to overflowing inside the drawers of the medication carts.

9

ISMP Supplemental Medication System Safety Report April 2010. Page 18


24

6.0 Labeling of all Syringes Containing Medications (D.3.5) Internal Audit found, that with the exception of syringes containing narcotics, or those coming pre-labeled from a manufacturer, syringes containing medications were rarely labeled with the name and dose of the medication. At one site Heparin and Insulin filled syringes were unlabeled and left unattended at the bedside.

7.0 Documentation of Medication on the MAR (D.7.1) If the documentation occurs prior to medication administration, it may appear that the patient received the medication when, in fact, they did not. The patient may not receive the intended medication if there are interruptions in care, in the event of an emergency situation, or if the patient refused the medication. Conversely, not documenting the medication as soon as possible after administration increases the risk that the patient may receive the medication twice because it is not recorded on the MAR that the patient has already received the medication. Internal Audit observed that five of the eight sites documented medication administration prior to the medication being administered to the patient.

8.0 Patient and Family Teaching (D.9.1) Teaching patients about the medication benefits and potential adverse effects, how to use the medication and the consequences of non-adherence to the medication regimen encourages patient participation in their own care. This practice engages the patient as an active partner in safe medication practices. Internal Audit found that at six sites, staff did not consistently inform the patient about the medication they received. Staff were noted to refer to the purpose of the medication (e.g. for their blood pressure) but did not state the name of the medication.

D. Support of Practice 1.0 Orientation and Continuing Education (E.1.1) Accreditation Canada requires that staff have access to internal or external training to the medication use process and information about adverse drug events so that they are knowledgeable about the medication, medication management and safety practices. Internal Audit | Medication Management Practices Audit

25

Educational strategies aimed to improve medication safety and avert unnecessary medication errors should enhance understanding, technical competence and safety around the medication administration process. Internal Audit found that orientation and continuing education related to medication administration practices varies across the health authority. Staff orientation to medication practices was provided by nurse educators or preceptors on the unit. At some sites, Pharmacy may provide a one hour session on the use of Pyxis®. There was no formal competency evaluation on medication management practices, medication safety, or Pyxis®. Ongoing education consisted of bulletins posted in the medication room or on the inpatient units related to various medication administration practices and policies. Bulletins observed included Safe Medication Practice Bulletin: High Alert Medications (March 2012) and Do Not Use Abbreviations (November 2011). The ISMP VJH Report recommended that a functional assessment and ongoing education sessions on medication safety be developed.

Recommendation 3: The Acute Services Leadership Team, with assistance from the Professional Practice Office and Pharmacy, should develop a Safe Medication Management Practices education program for initial orientation of medical, nursing, and pharmacy staff and require annual competency validation.

2.0 Medication Reference Material (E.1.3) Lack of medication knowledge is a continuous risk, and there is a need for staff to continually gain more knowledge about current and new medications. With many thousands of medications currently available in today’s practice environment, it is impossible for staff to know the purpose, dose, and side effects of all medications they may potentially administer. Information can be provided through current nursing or pharmacy reference manuals or via on-line access. Medication reference materials should be readily available on nursing units to allow staff to easily access information on medications. Internal Audit noted that sites had various medication and nursing reference manuals from 2005 to 2012. Most sites had a Compendium of Pharmaceutical and Specialties (CPS) but that reference source is complex and does not specifically focus on information helpful to nursing staff. Some staff used Wikipedia or Google for medication Internal Audit | Medication Management Practices Audit

26

information. These latter resources are not appropriate in professional practice. Other staff used Lexicomp, an information source on Pyxis®. Staff stated they would like to use this reference, but it creates a line-up at the Pyxis® station. Accessing information electronically was challenging as there were limited computers available and demand for computer access was high. Online access to IH InsideNet medication information is not straightforward and requires persistence to retrieve the information. Staff stated that information was difficult to find it and took too long to access, so they did not make use of the resource available.

Recommendation 4: Pharmacy should ensure staff have easy access to current medication related resources on the IH InsideNet.

E. Medication Safety 1.0 Incident Reporting and Overall Quality and Safety (F.1.2) Error reporting strategies are critical to the implementation of effective system-level approaches to reduce medication errors. Internal Audit found that most staff was not aware that the PSLS Incident Reporting system is used to identify areas of risk and develop strategies for risk reduction.

2.0 Review PSLS Incidents and Identify Trends (F.1.3) To be effective, medication error reporting needs to be ongoing and part of a continuous quality improvement process. All reported incidents are reviewed by Quality and Safety staff with follow-up by unit managers and others as required. Quarterly reports are prepared and submitted to the site for trend analysis. Internal Audit found that although the Nursing Managers and/or the Pharmacist was designated as the ‘handler’ for investigation and follow-up of PSLS reported events, trend analysis was rarely performed. Constraints on time and competing priorities make this activity very difficult to complete.


27

3.0 Feedback Provided Reported Patient Safety Learning Events (F.1.4) All medication adverse events and near misses must be reported in the PSLS and followed up by the ‘handler’. The ‘handler’ is usually the manager or the team leader. When an incident is entered into PSLS, staff receive automatic confirmation that the report was submitted, along with a report number. However, staff interviewed stated they often did not recall the details of the incident because they do not receive a copy of the report. The majority of staff interviewed stated they did not receive feedback on a consistent basis after reporting an incident. Some staff enter ‘anonymous’ as the person who reported the event and therefore it is not possible for the ‘handler’ to provide feedback.

Recommendation 5: The Acute Services Leadership Team should: •

ensure PSLS incident trending is completed at each site; and,

•

continue to educate staff as to the linkages between incident reporting and overall quality improvement and patient safety.

F. Environment of Care 1.0 Distractions during the Medication Administration Process (G.1.1) Distractions and interruptions during the process of delivering care can have a significant impact on medication safety. In a culture of safety, the organization identifies medication management as a high risk and error-prone activity. The environment should be structured to ensure interruptions are limited. All health care team members should have a sense of mutual respect for the activity. Team members should work collaboratively to assist one another with noncritical tasks to avoid interrupting a nurse engaged in medication preparation activities. At seven of the sites reviewed, there were multiple distractions observed while the staff were preparing and administering medications. Interruptions included: telephone calls, other staff, patients, family members, emergency codes, falls, navigating through hallways congested with equipment, and patients on cell phones. In the medication room, staff engaged in social chatter and other non-medication related conversations.


28

The medication rooms were noisy and congested. Many were located next to the noise and congestion at the nursing station. With the exception of one site, there were no doors on the medication preparation areas. One site taped-off an area on the floor around the Pyxis® machine and designated it as a ‘Quiet Zone,’ also known as a ‘No Interruption Zone’. 2.0 Confidentially of Patient Information (G.3.1) IH Policy AR0400 – Privacy and Management of Confidential Information specifies the standards for privacy and management of confidential information within IH. Internal Audit observed that MAR binders were frequently left open on top of the medication carts in the hallway. Some nursing units had whiteboards with patient identifiers that could be seen by patients and the public. One site had medical and staff records stored in a room behind an unlocked door.

3.0

Medication Storage Areas (G.2.1)

To promote a calm and efficient environment for medication preparation, the medication area should be clean and orderly. Optimizing the physical environment promotes accurate medication preparation and provides a safer workplace minimizing the risk to patients and employees. Four sites had crowded and cluttered medication preparation areas. Cupboards contained various items that were not relevant in the medication administration process. There was limited counter space for medication preparation.

Recommendation 6: The Acute Services Leadership Team should request Transformation, Innovation and Change to conduct a Lean review of nursing medication rooms and Pyxis® areas.

4.0 Night Time Lighting (G.2.3) The ISMP VJH Report identified improper lighting as a contributor to some medication errors. When there is insufficient lighting at the bedside, it is difficult for staff to check patient ID and medication information.


29

Internal Audit noted that night-time lighting on many units was not optimal. Lighting was provided through over-bed lights, hallway lights and flashlights, including personal cell phones. Some medication carts had lights but the battery was not always charged.

5.0 Storage of Equipment in Hallway (G.2.4) Equipment in the hallway poses a safety hazard to staff and patients. Patients experiencing the side effects of many medications may be unstable while on their feet or experience dizziness. Clutter in the hallways and patient rooms pose a risk of falls to patients and staff. Five of the sites visited had cluttered hallways. Items included patient beds, wheel chairs, blood pressure cuff stands, dirty linen hampers, clean linen carts, beds, chairs, over-bed tables and carts.

Recommendation 7: Capital Planning should utilize the CSA standards for Canadian Health Care Facilities (Z8000-11) for new space or renovated patient care areas to minimize interruptions and provide sufficient work areas, lighting and storage for the medication management process.

6.0 Sharps Containers (G.2.5) Sharps containers are used to safely dispose of used needles, syringes, and wasted narcotics. The top of sharps containers should be structured so that it is challenging to access discarded contents. Placing absorbent beads in the sharps container denatures wasted narcotics and reduces the potential for wasted narcotics being diverted from the sharps container. Six of the sites had sharps containers with open mouth tops that could be accessed. Not all of the containers had the adsorbent material. Housekeeping is currently upgrading the sharps containers across IH to ensure that the containers have additional safety features.


30

LEADING PRACTICES AND IMPROVEMENT OPPORTUNITIES Internal Audit identified several leading practices in the medication management process both within IH as well as through discussions with Pharmacy staff at Alberta Health Services. These leading practices included: 1. Pyxis® Automated Medication Dispensing Cabinets Currently, not all patient care areas within IH are equipped with Pyxis® automated medication dispensing cabinets. Pyxis® dispensing cabinets increase patient safety by allowing access only to specific medications ordered for the individual patient, decreasing time to administer first dose, providing allergy and drug interaction warnings, and automating recording of narcotic waste. 2. Intravenous (IV) Admixtures Pharmacy at KGH and RIH provide a comprehensive IV admixture service. At these sites, IV medications are delivered to nursing units in pre-mixed syringes or IV minibags. IV admixture services increase patient safety by ensuring that the reconstitution of IV medications is performed by clinicians knowledgeable about this process and under the sterile conditions of a laminar air flow hood. On many nursing units staff were observed reconstituting IV medications in the medication preparation area, or in the hallway. The environment was not sterile and some staff were not certain about the concentration and type of diluents required. Additionally, there were multiple distractions while this activity was taking place. 3. Clinical Pharmacy Services The availability of clinical pharmacists on the patient care units is beneficial as it provides the opportunity for the pharmacist to review patient medications and suggest changes or revisions to improve care and increase safety. Clinical pharmacists serve as a valuable resource to nursing staff on the units. 4. Pharmacy Hours When the pharmacy is closed, the nursing staff are responsible for processing the medication orders and obtaining the medication from the night cupboard or through Pyxis® ‘over-ride’. These practices by-passes the safety checks inherent in the pharmacy order entry and dispensing process.


31

Recommendation 8: Pharmacy should develop a business case to: •

continue the implementation of Pyxis® automated medication dispensing cabinets in all patient care areas

•

support the expansion of IV admixture services to each acute care site;

•

provide additional clinical pharmacists on patient care units; and,

•

increase Pharmacy operating hours to support improved patient care and reduce the time the automated dispensing cabinets are on ‘over-ride’.

5. Multi-Disciplinary Medication Safety Committee The ISMP VJH Report recommended that a multidisciplinary medication safety team be established for all disciplines to outline expectations for safe practices, the basic principles of medication safety, system safeguards (e.g. double checks for high alert medications), safe practices for communication of medication orders, and standardized communication processes 10. While Internal Audit noted the existence of these committees at some sites, not all committees were active. A regional multidisciplinary safety team would be able to standardize medication management practices throughout the region.

Recommendation 9: The Pharmacy and Therapeutics Committee should establish a regional multidisciplinary Medication Management and Safety working group consisting of Medical Staff, Nursing, Pharmacy, and Quality to implement recognized improvement strategies that support safe medication practices and minimize risk to patients.

6. Ongoing Observational Practice Reviews Infection Control, Medical Device Reprocessing (MDR), Surgical Services, Dietary and Housekeeping have developed strategies to perform ongoing observational practice. PRH currently performs ad hoc narcotic practices reviews.

10

ISMP VJH Report, 2010. Page 24.


32

Given the significance of the risks identified in the sample of medical/surgical units tested and the high occurrence of medication related PSLS events, there is a need for an ongoing medication management quality assurance program across all acute care areas.

Recommendation 10: The Acute Services Leadership Team should implement an on-going quality assurance program to monitor compliance with medication related standards and policies.

7. Narcotic and Controlled Substances Risks Internal Audit noted many situations where current controls over narcotic and other controlled substances may not be sufficient to prevent employee diversion. Although the availability of the Pyxis® automated medication cabinets in many areas has reduced the risk as compared to the traditional locked cabinets, theft can still occur. Further, narcotics and controlled substances were noted in unlocked medication carts and other areas. Internal Audit was advised that staff access to Pyxis® is granted for 1-6 Pyxis® machines, or for Pyxis® machines throughout the health service area. In addition, access is not always deleted when it is no longer required, such as a staff resignation. Given the inherent risk of theft of narcotics and controlled substances as well as the requirement by Health Canada to securely control these medications, further controls should be considered.

Recommendation 11: The Pharmacy Leadership Team should: •

strengthen controls for Pyxis® user access;

•

require completion of the online Pyxis® education and competency training program prior to granting Pyxis® user access; and,

•

conduct a narcotic and controlled substances diversion risk assessment and enhance controls to address identified risks.


33

8. Computer Physician Order Entry (CPOE) and Barcode Medication Administration (BCMA) The use of Computer Physician Order Entry and Barcode Medication Administration is considered a leading practice to reduce medication errors and adverse drug events. CPOE and BCMA are in place at SOGH. CPOE requires that all patient care orders are entered electronically by the prescriber and transcription is not necessary. BMCA confirms staff identification, patient identification and medication verification and records the medication administration electronically on the electronic MAR (eMAR). In a study published in the New England Journal of Medicine (2010), 14,041 medication administrations were observed and 3,082 order transcriptions were reviewed. Observers noted 776 errors in medication administration on units that did not use the bar-code eMAR (11.5% error rate) versus 495 such errors on units that did use it (6.8% error rate). This represents a 41.4% relative reduction in errors. The rate of potential adverse drug events fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% reduction. Transcription errors occurred at a rate of 6.1% on units that did not use the barcode eMAR but were completely eliminated on units that did use it 11. The use of the CPOE and BCMA, when used correctly can reduce, although not entirely eliminate, errors in order entry and medication administration. Internal Audit conducted an audit of the SOGH’s medication management practices (Project # 12-000-I) in July 2012. Using the same methodology and the same standard risk-based audit tool developed by Internal Audit, the audit findings (Appendix 3) showed: •

SOGH was compliant with 73% of the items audited; and,

•

CPOE eliminates the use of ‘Do Not Use’ abbreviations and illegible handwriting.

According to the SOGH eMAR Measuring and Monitoring Report (July 2011- July 2012):

11

•

76% of the medications supplied have barcodes applied, allowing for barcode scanning;

•

71% of the time positive patient identification was verified with barcode scanning; and,

Poon, E.G., et al. Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine. 2010. 362:1698-1707.


34

•

986 potential medication errors were known to be prevented with the use of BCMA.

Recommendation 12: The Health Informatics Strategy Council should consider the IH-wide implementation of Computer Physician Order Entry and Barcode Medication Administration as a long term initiative.

ACKNOWLEDGEMENTS The assistance and co-operation of the clinical and management staff involved in this audit made it possible to identify areas for practice improvement that will increase patient safety in the medication management process.

Givonna De Bruin, CA, CIA Corporate Director, Internal Audit


35

GLOSSARY OF ABBREVIATIONS ACQP ................................... Accreditation Canada Qmentum Program BCMA ................................... Barcode Medication Administration BPMH ................................... Best possible medication history CLNPBC ............................... College of Licensed Practical Nurses of British Columbia CMH ..................................... Cariboo Memorial Hospital CRNBC ................................. College of Registered Nurses of British Columbia CPOE .................................. Computer Physician Order Entry CPS ..................................... Compendium of Pharmaceuticals and Specialties CRNBC ................................. College of Registered Nurses of British Columbia EKH ..................................... East Kootenay Regional Hospital eMAR ................................... Electronic Medication Administration Record ID ..................................... Identification IMIT ..................................... Information Management and Information Technology IH ..................................... Interior Health IHCPSP ................................ Interior Health Clinical Practice Standard and Procedure ISMP ..................................... Institute of Safe Medication Practices IV ..................................... Intravenous KBH ..................................... Kootenay Boundary Hospital KGH ..................................... Kelowna General Hospital LPN ..................................... Licensed Practical Nurse MAR ..................................... Medication Administration Record MDR .................................... Medical Device Reprocessing OTC ..................................... Over the counter medications PRH ..................................... Penticton Regional Hospital PSLS .................................... Patient Safety Learning System ROPs .................................... Required Operating Procedures RIH ..................................... Royal Inland Hospital RN ..................................... Registered Nurse SLH ..................................... Shuswap Lake Hospital SOGH ................................... South Okanagan General Hospital VJH ..................................... Vernon Jubilee Hospital


36

APPENDIX 1: SITE SPECIFIC FINDINGS Site specific finding are presented for the two tertiary hospitals, four regional hospitals and two community hospitals.

TERTIARY HOSPITALS Kelowna General Hospital •

KGH met the practice standard for 56% of the audited items.

•

BPMH and medication reconciliation were completed on 83% of the patients on the surgical units and 58% on the medical units.

•

There is a robust Pharmacy IV admixture service which supports patient safety and safe medication practices.

•

Pharmacy had concerns over the non-formulary ‘trial’ medications that were provided in Psychiatry.

•

High alert medications were not double-checked consistently.

•

Medications were stored on top of the Pyxis® cabinet, counter and medication cart.

•

Nursing staff use a ‘dot and circle’ notation to document medications poured and administered. Staff were assigned to ‘Teams’ and any team member could give medication for any patients on the team. This approach may result in confusion of responsibilities and contribute to medication errors.

•

White boards displaying patient information was visible to patients and the public.

Royal Inland Hospital •

RIH met the practice standard for 56% of the audited items.

•

BPMH and medication reconciliation were complete on 41% of patients.

•

Some MAR binders had pre-printed orders photocopied from the patient chart. This practice should be reviewed to ensure that the most current pre-printed order is used in medication administration.

•

The 6th floor and 7N did not use medication carts. Staff obtained the medication from the Pyxis® cabinet and transported it to the wall cabinet in the hallway.


37

•

Some medications were stored in hallway wall cabinets on 7N. Medications were stored on the Pyxis® cabinet and top of medication carts.

•

Staff on the Pyxis® units were inconsistent with recording wastage of controlled substances.

•


REGIONAL HOSPITALS East Kootenay Regional Hospital •

EKH met the practice standard for 61% of the audited items.

•

BPMH and medication reconciliation were completed on all patients on the surgical unit, and on 68% of the patients on the medical units.

•

The site did not have Pyxis® cabinets but used medication carts.

•

Syringes were not labeled with the name and dose of the medication.

Kootenay Boundary Regional Hospital •

KBH met the practice standard for 53% of the audited items.

•

BMPH and medication reconciliation were completed for 40% of the patients.

•

Pyxis® cabinets were located in separate rooms with door lock access.

•

The surgical unit used a three day MAR instead of the one day MAR.

•

Physician orders were not consistently checked every 24 hours.

•

Destruction of controlled substances was not compliant with policy.

•


•

Limited IV admixture services require nursing staff to reconstitute a high number of IV medications on the unit.

Penticton Regional Hospital •

PRH met the practice standard for 54% of the audited items.

•

BPMH were completed on 6% of the charts. Internal Audit | Medication Management Practices Audit

38

•

Pyxis® cabinets were located in the hallway and did not have sufficient surrounding counter space for preparation.

•

Small fridges located by the Pyxis® cabinet were too high and made it difficult for staff to access medications in the fridge. This represents a medication safety risk and an Occupational Health and Safety Risk.

•

Staff pre-pour medications for the entire shift and store medications in the medication cart.

•

Syringes filled with narcotics were found in unlocked medication carts.

•

Destruction of controlled substances was not compliant with policy.

•

Site-specific policy for independent double-checks was inconsistent with IH policy and ACQP requirements.

Vernon Jubilee Hospital •

Staff at VJH met the practice standard for 60% of the audited items.

•

The BPMH was not consistently found on the chart and of those on the chart, medication reconciliation was completed for only a few patients. Pharmacy stated the delay of implementing the BPMH was due to the effort focused on opening the site’s new patient care tower.

•

The Pyxis® machines had a 1 machine to 30 patients ratio compared to the recommended standard of 1 machine to 20 patients.

COMMUNITY HOSPITALS Cariboo Memorial Hospital •

CMH met the practice standard for 60% of the audited items.

•

Staff were consistently completing the BPMH and medication reconciliation.

•

The site did not have locking medication carts and used utility carts.

•

One Pyxis® cabinet was used for medical/surgical patients, as well as for the nursery, compromising Infection Control practices.

•

Controlled drugs were not wasted according to policy; some outdated narcotic filled syringes were found on the medication carts. Internal Audit | Medication Management Practices Audit

39

Shuswap Lake Hospital •

SLH met the practice standard for 50% of the items audited.

•

BPMH and medication reconciliation were completed for only one patient out of a total of 25 patients.

•

This site does not have Pyxis® cabinets. Medication carts with patient specific cassettes are stocked by Pharmacy every 24 hours.

•


•

Medication carts were left unlocked and unattended in the hallway. One of these carts had the keys to narcotic cabinet in the top drawer.

•

Patient charts had a photocopy of a Staff Signature Log dated November 2010. Some charts had additional names of staff hand written on the form. This practice should be reviewed to ensure that only staff involved with patient care has signed the Log.

•

Monitoring of pain control was noted on one of six charts audited.


40

APPENDIX 2: COMPILED SITE AUDIT FINDINGS A. Prescribing

Reference

KGH

RIH

VJH PRH EKRH KBH CMH SLH

2

2

2

2

2

2

1

3

1

1

1

1

1

1

1

1

3

3

3

3

3

3

3

3

1

1

1

1

1

1

1

1

1

1

1

1

2

1

2

2

2

2

2

2

2

2

1.0 Com m unicating Medication Orders and Medication Inform ation A.1.1 The Best Possible Medication History (Medication Reconciliation) occurs on admit, transfer, discharge - begin w ith Pharmacy Medication Reconciliation Record A.1.2 Ensure physicians order sheet has been labeled w ith 2 unique patient identifiers (name, DOB, PHN) A.1.3 Implement a list of DO NOT USE abbreviations as identified by ISMP (Canada) A.1.4 The prescriber shall authorize the use of Pre-printed Orders and must individualize each medication order to the particular patient's needs. A.1.5 Allergy and Adverse Drug Event information is displayed on the MAR.

IH CPSP MM 4.1 ACQP Required Operating Procedure IH CPSP MM 4.3.1 ACQP MM 10.2 IH CPSP MM 4.3.2

IHA CPSP Allergy/ADR Documentation 6.2 1 ACQP MM 10.6 & 10.7 A.1.6 Physician verbal/telephone orders are not valid except in emergency PHB0100 Safe situations and these orders and must be signed off by physician Communication of 2 w ithin 48 hours. Medication Orders Reference B. Transcribing KGH

RIH


1.0 Patient Identification on Medication Adm inistration Record All MARs must be dated and identified w ith the patient’s full name, IH CPSP MM 4.4.3 date of birth, age and gender. 2.0 Physician Order Verification Process and Medication Adm inistration Record B.1.1

B.2.1

Check all orders on the Physician Orders at least once every 24 hours to verify they are correct and present on the MAR. C. Dispensing

IH CPSP MM 4.7 Reference

1

1

1

1

1

2

1

1

1

1

1

1

1

2

1

2

KGH

RIH

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

3

2

1

1

1

1

2

1

1

2

1

1

1

3

1

1

3

3

3

3

1

n/a

3

3

1

1

1

1

n/a

1

1

n/a

1

1

1

1

n/a

1

1

n/a

2

1

2

2

2

2

1

1

1

1

1

3

1

2

3

1


1.0 Minim izes the Num ber of Medications and Stock Drugs C.1.1

Limit the availability of Heparin products and remove high dose formats. (> 50,000 units total drug quantity) (10,000 units/mL in 5mL and 25,000 units in 2 mL) C.1.2 Limit the availability of Narcotic (opiod) products and remove highpotency high-dose formats. (Hydromorphone >2mg/mL and Morphine>15mg/mL) C.1.3 Remove concentrated electrolytes. (Potassium Chloride, Potassium Phosphate, Sodium Chloride > 0.9%). 2.0 Storage and Selection

ACQP MM 3.5

C.2.1

IH CPSP MM 4.9

C.2.2

C.2.3

Medications w ill be stored in either Automated Dispensing Cabinets (Pyxis®), draw ers in medication carts, cassettes, refrigerators or in designated w ard stock areas. Patient-specific items are not stored in a bin on the top of the medication cart, or in the medication room. The medication carts in the hallw ays are not left unlocked, unattended, or w ith draw ers open.

ACQP MM 3.6

ACQP MM 7.2

ISMP April 2010 Supplemental Recommendations ISMP April 2010 Supplemental Recommendations

3.0 Autom ated Dispensing Cabinets (Pyxis) C.3.1

C.3.2 C.3.3 C.3.4

Critical override w ill be enabled by Pharmacy at the close of business IH PP Pyxis 2.5 and w ill be disabled w hen Pharmacy reopens for business. NonACQP MM 14.0 Pyxis unit use Night Cupboard. All fridge items for the unit must be documented using the Pyxis. IH PP Pyxis 3.1.2 Medications w ill not be sent or borrow ed from another unit using the IH PP Pyxis 2.8 Pyxis machine. Only medications that are due to be administered w ill be removed, IH PP Pyxis 3.1.2 e.g. medications w ill not be removed for an entire shift. (Eliminate the practice of pre-pouring medications.)


41

Appendix 2: Compiled Site Findings (continued) C.4.0 Storage and Securem ent of Controlled Substances C.4.1 C.4.2

C.4.3

C.4.4

All controlled drugs must be physically secured and locked at all times or in an Automated Dispensing Cabinet. Pyxis Units. Count is done prior to dose w ithdraw al. Count discrepancies w ill be reconciled as they occur and checked at the end of each shift. Non-Pyxis Units. Results of each count are transferred to the register. Differences betw een the count and the running inventory totals must be immediately resolved. Do not prepare and use a single syringe of narcotic medication for more than one dose of medication.

IH CPSP MM 4.10 PHK0600 p.7 IH CPSP MM 4.9 IH PP Pyxis 4.0 PHK0600 p.7 PHK0600 p.8

ISMP April 2010 Supplemental Recommendations C.4.5 Destruction or w aste of any controlled substances must be recorded IH CPSP MM 4.12.5 (Pyxis or manual register) and w itnessed by tw o licensed healthcare PHK0600 p.8 professionals. D. Adm inistering Reference

1

1

1

3

1

1

3

1

1

1

2

3

n/a

1

1

n/a

1

2

1

1

1

1

1

1

1

1

3

3

1

1

3

1

3

3

3

3

1

3

3

1

KGH

RIH

1

1

1

1

1

1

1

2

3

3

1

3

3

3

2

2

1

1

1

1

1

1

1

1

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1


1.0 High Alert Medications and Allergy/ADR D.1.1 D.1.2

A nurse must review the Allergy/ADR information prior to medication administration. High Alert Medications require an independent double check and documentation of second practitioner verification e.g. Heparin, Insulin, Opioids

IHA CPSP Allergy/ADR Documentation 1.6 ACQP MM 2.5 ISMP April 2010 Supplemental Recommendations

2.0 Right Patient D.2.1

Prior to administration, check 2 unique identifiers to positively identify IH CPSP MM 4.12.4 the right patient's MAR. (Pt ID check #1) PHK0600 ACQP MM 18.3 ISMP April 2010 D.2.2 The MAR must be taken to the patient’s location for medication administration. Compare 2 unique patient identifiers (name and date of Supplemental birth) name on MAR to the identifiers on the Patient ID band. (Pt ID Recommendations check #2) D.2.3 Check MAR for allergies and for presence of an Allergy band on the IH CPSP MM 4.12.4 patient. ACQP MM 10.6 & 10.7 3.0 Right Medication and Right Dose D.3.1 The MAR or Physician’s order must be used to ensure the correct IH CPSP MM 4.9.1 medication is being selected and dispensed. (Med Check #1) PHK0600 D.3.2

Compare the name of the medication and the dose of the medication on the medication package to the entry on the MAR (Med Check #2)

D.3.3

IHCPSP MM 4.12.4

The unit dose medication must be taken to the patient’s bedside in the original packaging and opened at the bedside. Compare the name and dose of the medication to the MAR. (Med Check #3) D.3.4 Medications that are dispensed from multi-dose blister pack or injectables, must be immediately labeled w ith name of drug, dose and route of administration prior to taking to the bedside. D.3.5 All syringes containing medications must be labeled appropriately w ith name of drug and dose. 4.0 Right Tim e

IH CPSP MM 4.12.1 ACQP MM 7.4 & 7.5

3

3

3

3

3

3

3

3


3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

D.4.1

Prior to medication administration review the MAR for the right scheduled time for medication administration. 5.0 Right Route

IH CPSP MM 4.12.4

1

1

1

1

1

1

1

1

D.5.1

Review the MAR and note that the route of administration is appropriate for the medication and patient condition. 6.0 Right Reason

IH CPSP MM 4.12.4

1

1

3

1

1

1

1

1

D.6.1

Take into consideration: medication history, allergies, height, w eight, lab values, age, and diagnosis. 7.0 Right Docum entation

IH CPSP MM 4.12.4

1

1

1

1

1

1

1

2

D.7.1

IH CPSP MM 4.12.4

3

2

1

1

2

3

1

2

1

1

1

1

1

1

1

2

D.7.2

Document the administration of the medication on the MAR as soon as possible after giving medication. The nurse must document their printed name, full signature, initials and professional designation on the Staff Identification Record or Signature Log on each patient chart.


IH CPSP MM 5.0


42

Appendix 2: Compiled Site Findings (continued) 8.0 Right Monitoring D.8.1 Perform monitoring as appropriate to patient care needs and document in the Nursing Notes. 9.0 Patient and Family Teaching

IH CPSP MM 4.12.4

D.9.1 Inform the patient about each medication’s name and its purpose prior IH CPSP MM 4.12.4 to administering. ACPQ MM 16.5 Reference E. Support Safe Medication Practices

2

1

1

1

1

2

1

2

2

1

2

2

2

2

1

2

KGH RIH VJH PRH EKRH KBH CMH SLH

1.0 Orientation and Continuing Education E.1.1

E.1.2 E.1.3

Staff receive orientation and continuing education on medication ACQP MM 1.7 management and medication safety. Training covers safety issues such as 'Do Not Use' abbreviations, 'look-alike, sound-alike', high alert medications and independent double checks, and safe communication of medication information (e.g. bulletins, new Rx policies). Staff receive orientation and continuing education on infusion pumps. ACQP MM 19.4 Medication reference materials are readily available e.g.. Nurse Consult, Lexicomp, current drug manuals.

2

1

2

2

2

2

2

2

1

1

1

1

1

1

1

1

IH CPSP MM 2.0 IH CPSP MM 4.12.3

1

2

2

1

1

3

1

2

ISMP April 2010 Supplemental Recommendations

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

2.0 Access to Pharmacist E.2.0

Staff have access to pharmacist on-call during the hours that in hours pharmacy is closed.

3.0 Consistent Scope of Practice E.3.0

Staff are aw are of the difference in scope of practice betw een RN CRNBC and LPN in regard to medication practices. CRNBC and CLPNBC state CLPNBC that LPNs "may independently administer medication - any route ACQP MM 18.0 except intravenous - to stable patients w ith predictable outcomes".

F. Medication Safety

Reference

KGH RIH VJH PRH EKRH KBH CMH SLH

1.0 Medication Errors and Event Reporting F.1.1

F.1.2

F.1.3 F.1.4

All medication events or medication good catch/near misses should be completed on the Patient Safety Event Form in the Patient Safety Learning System (PSLS). Staff receive ongoing education about the need to report all incidents and near misses and how this information is used in the hospital quality and safety program. A handler is assigned to review all PSLS incidents on the unit/area and identify trends in medication administration. There is a process to provide regular feedback to all staff including Nursing, Pharmacy and Physicians about adverse drug events, hazardous situations, and risk reduction strategies. (e.g. feedback about Rx incident on unit, Rx safety).

IH CPSP MM 6.0 ACQP 21.4 ISMP April 2010 Supplemental Recommendations

1

1

2

1

2

1

1

2

2

2

2

2

2

2

2

2

2

2

2

2

1

2

1

2

2

2

2

2

2

2

2

2

ACQP MM 21.9


43

Appendix 2: Compiled Site Findings (continued) G. Environm ent of Care

KGH

RIH

ISMP April 2010 Supplemental Recommendations

3

3

1

3

3

3

3

3

ACQP MM 6.1

2

2

1

2

1

1

2

1

1

1

1

1

2

n/a

2

1

2

2

1

1

2

1

2

2

2

2

2

2

1

1

2

1

1

2

1

2

2

2

2

1

IHA AR0400

3

3

3

3

3

1

1

3

IH Adult Parenteral Therapy Manual IH Emergency Response Plan

1

1

1

1

1

1

1

1

Reference


1.0 Distractions and Interruptions G.1.1 Distractions and interruptions during the medication management process are minimized. 2.0 Physical Environm ent G.2.1 Medication storage and preparation areas are clean and orderly.

G.2.2 There are sufficient numbers of medication carts to properly support ISMP April 2010 the medication administration process. Supplemental Recommendations G.2.3 The available lighting options for night-time care is sufficient for safe ISMP April 2010 medication administration. Supplemental Recommendations G.2.4 All items and equipment in patient care area and hallw ays are stored ISMP April 2010 in a manner that does not pose a hazard to patients, staff, or visitors. Supplemental Recommendations G.2.5 Sharps containers are conveniently located and are of the type that Internal Audit Question removal of used sharps is impossible. 3.0 Patient Confidentiality G.3.1 Confidentiality of patient information is protected. 4.0 Em ergency Response G.4.1 Staff are aw are of Emergency Codes and Anaphylaxis and Allergy Reaction Guidelines.

1 = Practice meets standard

32

32

34

31

33

29

34

27

2 = Practice does not meet standard - action required

12

14

12

11

12

14

11

17

3 = Practice does not meet standard - urgent action required

13

11

11

15

9

12

12

10

Number of Audit Items

57

57

57

57

54

55

57

54

Overall

KGH

RIH

56% 23% 21%

56%

56% 60% 54%

Practice meets standard Practice does not meet standard - action required Practice does not meet standard - urgent action required

VJH PRH

EKH KBH CMH SLH 61%

53% 60% 50%

21%

25% 21% 19%

22%

25% 19% 31%

23%

19% 19% 26%

17%

22% 21% 19%


44

APPENDIX 3: SOGH SUMMARY FINDINGS SOGH uses CPOE for order entry and BCMA for medication administration. Consequently, medication management practices were reviewed separately from the rest of the IH acute care sites which do not have CPOE and BCMA in place. The following is a brief summary of the audit findings: A. Prescribing •

BPMH is performed by Pharmacy on patients admitted to the Emergency Department. BPMH is in transition with Connex implementation.

•

eMARS met the requirement for MARs to be dated and identified with the patient’s full name, date of birth, age and gender; but printed MARs used for transfer did not have all of the information recorded.

C. Dispensing •

Medication carts were left unlocked an unattended in the hall. Automatic lock-out is set to five minutes.

•

Critical override is left on 24/7. This is related to pharmacy staffing issues and pharmacy covering both residential care and clinical pharmacy. Pharmacy order entry is completed in the morning prior to medication distribution. Risk is somewhat mitigated by use of BCMA.

•

Documentation of fridge items in Pyxis® is a challenge because the medication fridge is located quite a distance down the hall from the Pyxis® automated dispensing cabinet.

D. Administering •

Double checking high alert medications is a challenge in the current electronic system. Work is underway to resolve this issue.

•

The SOGH medication administration process is accomplished through the use Barcode Medication Administration. The current BCMA process involves (1) verify the nurse (2) verify the medication (3) verify the patient. o

Correct use of BCMA can eliminate all medication errors due to incorrect patient identification. However, in order to accommodate emergency situations, it is possible to administer the medication without using the barcode scanner. This ‘choice’ is sometimes used as a ‘work-around’ by nursing staff when administering medications.

o

SOGH eMAR Measuring and Monitoring Report shows an average 71% positive patient identification by barcode scanning. Conversely, this indicates that 30% of


45

the time, patients are not scanned for positive identification prior to medication administration. •

The eMAR Monitoring and Measuring Report indicates a large number of unacknowledged allergy warnings due to system sensitivities which may not be indicative of true allergies. The nurse excercises clinical judgement prior to proceeding with medication administration in the face of an allergy warning. Work is underway to reduce these ‘nuisance warnings’. o

The staff were not observed to physically check patient allergy bands.

F. Medication Safety •

Staff receive limited feedback on PSLS events. The eMAR Measuring and Monitoring Report is an excellent tool to monitor effectiveness of BCMA. This report is not reviewed regularly by management and risk reduction strategies are not identified or implemented.

G. Environment of Care o

The Pyxis® Automated Dispensing Cabinet is located in a breezeway across from a patient bathroom.

o

Several wheelchairs were stored in the breezeway blocking access to the small sink.

o

There was no counter space for medication preparation beside the Pyxis®.

o

Ward stock is in a separate room beside the nursing station.

o

The medication fridge is located in the nursing report room quite a distance down the hall from the Pyxis®.

o

One medication storage area had carpet on the floors.


46

Interior Health Medication Management Audit

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