Medication Error Reporting Program (MERP)

Update

April 2010*********************************************

Overview and presentation of our readiness

• Opening PowerPoint completed and under review by Quality Management

• Pharmacy has complied data and highlight success story of Hospital-wide medication error reduction efforts

• Vulnerabilities identified• Pharmacy Performance Improvement Plan

Opening PowerPoint presentation

Part 1 – Hospital demographics, affiliations, services, goals (18 slides)

Part 2 – MUSS (SFGH MERP Committee), reporting structure, MUSS activities related to MERP (5 slides)

Part 3 – Technology implemented that impacted medication safety (1 slide)

Part 4 – Success stories related to the technology (4 slides)

Part 5 – INLP impact on medication safety (3 slides)

4

San Francisco General Hospital and Trauma Center

)

A California Public Hospital

• SFGH is one of 19 public hospitals in CA• Today, just 6% of hospitals that

– Provide nearly half of the hospital care to the state’s uninsured

– Operate almost 60% of CA’s trauma centers– Operate almost 45% of the burn centers– Serve 2.5 million patients per year

• During the economic crisis, the need for services is growing

SFGH is for everyone

• Only Trauma Center in San Francisco• Care for 100,000 patients per year• Provides 20% of all inpatient care in SF• Only Psychiatric Emergency &

Rehabilitation Services • Referral Center for “Healthy San Francisco,”

the health access program for the uninsured

University of California, San Francisco (UCSF)

• SFGH has partnered with UCSF for over 130 years through our teaching and research affiliation.

• Over 160 UCSF Principal Investigators conduct research at SFGH with an annual budget of $143M

• Over 1,300 UCSF employees on campus.

Clinical training at SFGHUniversity of California, San Francisco

Schools of Nursing, Pharmacy, Dentistry, and Medicine350 3rd or 4th Year Medical Students, 800 Residents, 60 Clinical Fellows32% of intern/resident training in 17 academic departments35% medical student clinical training

California State University System, Community colleges, private universities and colleges place approximately 200 clinical nursing students for rotations at SFGH.

SFGH PATIENT DIVERSITY FY 2008-2009

Under 1813%

18-2411%

25-4434%

45-6433%

Over 649%

Male51%

Female49%

Age

Race

SexN=98,698

White24%

Afric-Amer18%

Hispanic32%

Nat Amer0%

Asian/PI21%

Oth/Unk5%

Dedicated interpreter staff at SFGH provide services in over 20 languages:

SpanishCantoneseMandarinRussianVietnameseTagalogCambodian

ThaiArabicAmharic (Ethiopia)PortuguesePolishBurmese

…and more

Top 10 Discharge DiagnosesFY 2008 - 2009

1. Schizophrenia2. Normal Delivery3. Pneumonia Organism4. Congestive Heart Failure5. Chest Pain6. Alcohol Withdrawal7. Leg Cellulitis8. Shortness of Breath9. HIV Disease10. Obstructive Chronic Bronchitis with Exacerbation

SFGH ServicesFY 2008-2009

Outpatient: 529,098 visits

Inpatient: 15,405 admissions 103,313 patient days

Skilled Nursing: average census 30 LOS 34 days

Acute Care for the Elderly(ACE)

• Special dedicated unit for post-op, medical, surgical and rehab patients

• Trained inter-disciplinary team emphasizes socialization, exercise, discharge planning, reducing pharmaceutical dependence

• Only ACE unit in California• Currently 35 beds on two units

San Francisco Behavioral Health CenterFY 2008-2009

Mental Health Skilled Nursing Facility Average daily census of 57

Mental Health Rehabilitation Center Average daily census of 45

Adult Residential Care FacilityAverage daily census is 41

Surgical Services

Ten operating rooms6,872 procedures performed - of which 48% were emergency1,118,100 surgical minutes

Baby Friendly HospitalFY 2008-2009

SFGH named by World Health Organization as Baby Friendly in May 2007Only Baby Friendly hospital in San Francisco1 of 63 hospitals in U.S.1,334 babies were born at SFGH1,966 women received prenatal care, 25% high-risk

Trauma and EmergencyFY 2008-2009

Over 53,000 Emergency Room visits

15% are admittedOver 7,200 Psychiatric Emergency encounters

26% are admitted

SFGH receives 29% of all ambulance traffic in San Francisco3,559 adults and children are treated for injuries requiring thetrauma activation.

SFGH Goals FY 2008-2009

• Promote patient safety• Enhance clinical care• Promote staff retention & recruitment• Maintain hospital infrastructure• Comply with all regulatory standards &

attain specialty certifications• Maintain services during hospital rebuild

VIEW FROM 23RD STREET

Performance Improvement and Patient Safety Reporting Pathway

Committees Involved in Medication Management

• Pharmacy and Therapeutics Committee– Medication Use and Safety (MUSS)– Formulary Review Subcommittee (FRS)– Pain Management Subcommittee– Nutrition Subcommittee– Antibiotic Review Subcommittee– Procedural Sedation Committee– Clinical Laboratory/Therapeutics Committee

• Performance Improvement Patient Safety Committee (PIPS)• Nursing Quality Improvement Coordinating Council (NQICC)

– CALNOC – Integrated Nursing Leadership Program (INLP)

• Joint Nursing Pharmacy Committee

Medication Use and Safety Subcommittee (MUSS)

Membership comprised of:Medical Staff, Nursing, Pharmacy, Respiratory Care Services, Radiology, Quality Management, Risk Management

Duties/Responsibilities:

• Oversees the Hospital’s MERP• Review adverse drug events and medication unusual occurrences• Develops and maintains medication management policies• Discusses medication management safety processes including

opportunities for improvement.• Develops safety strategies including staff education• Review pre-printed physician order forms that contain medication

orders.

MUSS Committee activities – ADR summary

REPORTED ADR BY QUARTER

020406080

100120140160180

2006

-120

06-2

2006

-320

06-4

2007

-120

07-2

2007

-320

07-4

2008

-120

08-2

2008

-320

08-4

2009

-120

09-2

2009

-320

09-4

# OF ADR

QU

AR

TER

MUSS Committee activities – Med Error Review summary

Total # of Med Error UO's by quarter (2007-2009 total = 1816)

125

170139

119 107 109 107

175148

199222

196

0

50

100

150

200

250

1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr

2007 2008 2009

# of

UO

s

MUSS Committee activities – Med Error Review summary (con’t)

Total Ordering Errors (Total UOs Reported = 161)

1215

20

810 10

5

12 12

17

2119

0

5

10

15

20

25

1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr

2007 2008 2009

# of

err

ors

Total Preparation Errors (Total UO's Reported = 428)

1428 27

153

11

26

52 54

73

48

77

0102030405060708090

1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr

2007 2008 2009

# of

err

ors

Total Administration Errors (Total UO's Reported = 1452)

105121

100 97 89 8497

139 132

168 180

140

020406080

100120140160180200

1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr

2007 2008 2009

# of

err

ors

Total Communication Errors (Total UO's Reported = 788)

61

90

60

47 4839

45

74 70

8779

88

0102030405060708090

100

1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr

2007 2008 2009#

of e

rror

s

Technology implemented at SFGH that impacted Medication Errors

1. Invision/Lifetime Clinical Record (LCR)• Medication Reconciliation• Laboratory values & reports • Allergies & Clinical Alerts

2. Siemens Rx system Patient profiles in Omnicell ADMs

3. Medication Administration Check & Communication (MAK)

4. Omnicell-Automated Dispensing Machines (ADMs)

Invision/LCR - Medication Reconciliation

• Electronic System

28

Medication Administration Check & Communicate Medication Administration Check & Communicate (MAK) (MAK) –– Electronic Medication RecordElectronic Medication Record

Integrated in the Siemens Pharmacy system to facilitate electronic medication administration process using wireless technologies.Project Aim:

Increase patient safety Decrease medication errors by 50% utilizing the electronic medication administration (MAK) program

Computerized documentation achieves the following:Elimination of all transcriptionPharmacy-entered orders are visible in real timeElectronic communication between Nursing & Pharmacy in MAK, reduces phone callsDrug information libraryLab dataHigh alert medications require 2 nurse logonsSpecific drugs require data entry: pain score, pulse, BP, glucoseReminders for pain reassessmentsInjection site charting

MAK Outcomes Study on 5C

• Medication Administration Accuracy Errors were reduced on Unit 5C after introduction of MAK in September 2008

• Error rate was 57% lower than the average error rate on comparison non-MAK units at SFGH

9.1

2.3

11.9

1.3

0

2

4

6

8

10

12

4D 5A 5D 6A % 5C %

% Errors Before% Errors After

Overall Error Rate: Before and After MAK Implementation

2008 Q4 – 2009 Q42007 Q1-2008 Q3

MAK Outcomes Study on 5C

844

2184

316524

0

500

1000

1500

2000

2500

4D 5A 5D 6A 5C

Number Observed Dosesbefore MAKNumber Observed Dosesafter MAK

0.875

0.15

0.6

00

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

4D 5A 5D 6A % 5C %

% Wrong Dose Before% Wrong Dose After

0.825

0.2

0.4

00

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

4D 5A 5D 6A % 5C %

% Extra Dose Before% Extra Dose After

2.6

1

2.4

0.3

0

0.5

1

1.5

2

2.5

3

4D 5A 5D 6A % 5C %

% Omission Before% Omission After

CALNOC – Collaborative Alliance for Nursing Outcomes

• Voluntary quality outcomes monitoring benchmarked anonymously to other like-sized California hospitals.

• Indicators:Medication Administration Accuracy Study (Med Pass) Study: Observe 100 medication passes for the following:

-Patient Identification-Allergies-Patient Teaching-Distraction during Med Pass-Compares to MD Order, Med Admin Record (MAR) & Omnicell-Hand Hygiene-Charting

• All nursing areas of SFGH conduct Medication Administration Accuracy Studies

Administration –Omitted Administrations

Reasons for Omitted Medication Administrations (N=35 patients)

Patient Refused15%

Patient nauseated14%

NPO15%

No reason charted11%

Held per MD Order11%

Dose Administered11%

Not indicated per clinical parameters

11%

IV Site Used3% Pt Off Unit

9%

Integrated Nurse Leadership Program (INLP) Integrated Nurse Leadership Program (INLP) in Medin Med--SurgSurg• The Integrated Nurse Leadership Program (INLP) is funded by the Gordon and Betty

Moore Foundation and is directed and administered by the Center for the Health Professions at the University of California, San Francisco.

• INLP aim is to transform the hospital work environment and improve nurse-related patient outcomes through developing nurses’ professionalism, while enhancing their capacity to create and lead sustainable systems change.

• SFGH the INLP focus has been on Medication Safety including this unit projects:– 4B - Decrease high alert medication errors that could be prevented by 2 RN checks

by 50% in 2009. – 4D - Reduce medication errors related to antibiotics to 80% by Jan 2009.– 5A - Increase and sustain number of medication administration without interruptions

to 90% by June 30, 2009.– 5C - Maintain 95% compliance of “No Interruptions during Preparation and

Administration of Medications Using the New MAK System” by February 2009. – 5D - Decrease medication error related to heparin SQ and IV administration by 100%

and decrease interruptions during medication administration by 90% in six months. – 6A - To conduct 100% allergy screening with every medication administration by

June 30, 2009.

Potential vulnerabilities

• Policy and Procedures – Revision to be completed by April 23, 2010.

• Timely review of UO – Aim is 100% reviewed and addressed by April 23, 2010

• Collation of all medication errors – Have ME, ADR data but need more order entry errors

• Omitted dose – Clinical pharmacists start reviewing charts for omitted dose on April 19, 2010

2010 Pharmacy Performance Improvement Plan

1. 100% of medication orders are entered in the correct patient’s profile by April 2010

2. Reduce interruption by 50% during order entry by encouraging the use of RN-Pharmacy Communication form by Oct 2010

3. 90% of orders will have a 30 minutes turn around time by July 2010

4. Implement pop-up alert window in Omnicell to assist nurses prior to administration for all high-alert meds by July 2010

2010 Pharmacy Performance Improvement Plan (con’t)

5. 100% of units with clinical pharmacist assignment Verify pharmacy profile, MAR and MD orders for discrepancies starting May 2010

6. Implement medication alerts for 100% of MAK units for high alert meds by Sept 2010

7. Implement Omnicell biometrics feature sign-on in 50% of inpatient nursing units by Dec 2010

8. Implement TallMan lettering in Omnicell for 100% of ISMP medication list by April 2010

9. Increase order entry error data reporting by 50% by June 2010