HOSPIPHAR LEC MEDICATION SAFETY
To Err Is Human: Building a Safer Health System
Institute of Medicine (IOM) Report indicating that pharmacists have been attempting to reduce medication risks in institutions. Highlighted the pervasive nature of injuries associated with both appropriate and inappropriate use of medications (reframing medical error as a chronic threat to public health
Medication Errors
Classification of Medication Errors
Crossing the Quality Chasm: A New Health System for the Twenty-first Century Century
IOM Highlighted the causes of medical error and called for fundamental changes to improve the quality of health care
Drug-related Problems (DRPs)
Events associated with drug therapies that cab or do hamper optimal health outcomes Include medication errors, adverse drug reactions, adverse drug events, and side effects
Medication Misadventures
Iatrogenic hazards associated wtih indicated drug therapy resulting in patient harm that can be attrivutable to error, immunologic response, or idiosyncratic response Cover medication errors, adverse drug reactions, and adverse drug events
Any error in medication process (prescribing, dispensing, administration), whether there are adverse consequences or not NOT all DRPs are m edication errors Medication errors MAY or MAY NOT cause adverse consequences Increase the risk of adverse consequences
Prescribing Errors Incorrect drug Incorrect dose Incorrect dosage form Incorrect quantity Incorrect route Incorrect concentration Incorrect rate of administration Incorrect instructions for use prescriptions or Illegible medication orders Transcription and/or Interpretation Errors Misinterpretation of abbreviations of spoken Misinterpretation prescriptions Illegible handwritten prescriptions Dispensing Errors Patient receives the wrong drug Correct drug for the wrong patient Wrong galenic form (tablet for patient who is NPO) Wrong dose Error in preparation or calculation Error in drug utilization review Administration Errors Wrong dose Omitted dose Additional dose Wrong administration time Incorrect handling of drugs during administration Wrong infusion rate Monitoring Errors Failure to review a prescribed regimen Failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy
Lacorte, Aries S. 3D-PH | PHAR 5
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Categories for Medication Errors
Adverse Drug Events (ADEs)
An injury, whther preventable or unpreventable, that may be caused by the use or lack of intended use of a drug
Side Effects
Expected, well-known reaction resulting in little or no change inpatient management NOT ADRs, THEY ARE ADEs ex: drowsiness or dry mouth in response to antihistamines
Adverse Drug Reactions (ADRs)
Types of ADRs 1. Allergic Reactions Immunnologic hypersensitivity o to drugs 2. Idiosyncratic Reactions o Abnormal responses to drugs that are peculiar to individuals 3. Sentinel Event o Unexpected occurrence involving actual or potential death or serious injury These events signal the need o for immediate investigation and response
DRPs that are unexpected, unintended, undesired, or excessive responses to a drug MAY or MAY NOT be a result of medication errors
Lacorte, Aries S. 3D-PH | PHAR 5
DRPs associated to Medication Errors
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Error of Commission Patient receives the correct drug in a way that does not result in optimal patient outcomes Patient receives incorrect drug which puts the patient at risk of negative outcomes Error of Omission failing to receive a Patient beneficial drug
Preventing Medication Errors (IOM) 1.
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Drug-related Morbidity Failure of a drug to achieve its intended health outcome due to unresolved drug-related problem Negative outcome associated with error Potential Injuries Mistakes in prescribing, dispensing, or medication administration that have the potential to cause an injury but did not, either by luck or because they were intecepted Latent Injuries A propensity or predisposition for harm during the process of care that actually does not result in patient injury
Errors that cause DRPs
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Involve the patient in the medication use process Consumer-oriented medication resources should be made availbale to support patient self-amangement of their medication use Health care providers should have access to patient informationnand decision-support tools and technologies to enable them to be more active in monitoring and interventing Medication labeling needs to be improved along with methods for communicating medication information to consumers Health information technology must be improved to support the medication use process Congressional funding should be increased to study safe and appropriate medication use and error prevention Health care payers and oversight organizations should be more active in promoting good medication use practices
Alerting Orders
Prescriptions which alert pharmacists that an ADR may have occurred Types of Alerting Orders 1. “Tracer” Drugs Commonly used to treat ADRs o Usually for doses of o antihistamines, epinephrine, corticosteroids 2. Abrupt discontinuation or decrease in drug dosage 3. Stat orders o For laboratory assessment of therapeutic drug levels
Lacorte, Aries S. 3D-PH | PHAR 5
High risk drugs for ADRs
Adrenergic agonists IV (epinephrine) Adrenergic antagonists IV (-olol drugs) Anesthetics (Ketamine) Antithrombotics (Warfarin, LMW heparin) Cardioplegic solutions Chemotherapeutic agents Hypertonic dextrose Dialysis solutions Epidural and intrathecal medications Hypoglycemic agents PO Inotropic agents (Digoxin, Milrinone) Insulin Methotrexate for non-oncologic use Sedatives (Midazolam) Narcotics/Opiates Neuromuscular blocking agents (Succinylcholine) Nitroprusside Oxytocin IV KCl and NaCl for injection Promethazine IV Radiocontrast agents Total parenteral nutrition (TPN)
Medication Reconciliation
Process of resolving discrepancies as patients transition across departments, locations, or other places Steps 1. Verification: most up-to-date list of medications 2. Clarification: medications and dosages are checked for appropriateness 3. Reconciliation: comparison of newly prescribed medications against what was prescribed previously 4. Transmission: therapy changes are communicated
Measures of Health Care Quality (by Donabedian)
Structures Measures of something that is reasonably associated with quality Easy to measure
Processes Actions reasonably associated with quality Outcomes Quality of system is assessed through impacts on health outcomes Health outcomes Dissatisfaction o Discomfort o o Disability Disease o Death o
Organizations that promote health care quality and patient safety 1.
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Institute of Medicine (IOM) Component of National Academy of Sciences Mission: “To serve as adviser to the nation to improve health” Institute for Healthcare Improvement (IHI) Not-for-profit organization Improving health care Goal: throughout the world National Quality Forum (NQF) Primary role: Improving health care quality measurement and reporting Endorses consensus-based national standards for measurement and public reporting of health care performance data The Leapfrog Group A voluntary program of employers who use employer purchasing power to discourage the health industry to make big leaps in health care safety, quality, and customer value Hospital Quality and Safety Survey: rate on four “leaps” of quality and safety practices Rewards Program: Hospital measures performance in five areas for effectiveness and affordability and rewards excellent hospitals
Lacorte, Aries S. 3D-PH | PHAR 5
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The Joint Commission (JCI) Assesses and accredits the quality of health systems 6. Centers for Medicare and Medicaid Services (CMS) Manages Medicare and Medicaid programs which contracts with a private Quality Improvement Organization (QIO) to monitor Medicare beneficiaries 7. Agency for Healthcare Research and Quality (AHRQ) Conducts and supports research in Quality improvement and o patient safety Outcomes and effectiveness of o care o Clinical practice and technology assessment Health care organization and o delivery systems 8. National Committee for Quality Assurance (NCQA) Manages Health Plan Employer Data and Information Set (HEDIS), which provide purchasers and consumers with information about quality of healthcare plans 9. American Society of Health-System Pharmacists (ASHP) Support health-system pharmacists in quality and safety through publishing, education, advocacy, and guidance documents 10. Pharmacy Quality Alliance (PQA) consortium of pharmacy A organizations that brings key stakeholders together to agree on strategies for measuring performance at pharmacy and pharmacist levels
Lacorte, Aries S. 3D-PH | PHAR 5
