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MEDICATION SAFETY
Meeting HFAP Accreditation Standards for Pharmacy Services and Medication Use
Part One
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HFAP Chapter 25 keeps you in compliance with the Medicare Conditions of Participation
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Medication Safety Series
1. Prescribing challenges
2. Procurement in an era of drug shortages – keeping it safe
3. Preparation and dispensing – includes sterile preparation
4. Administration of medications – timing, unit dose, bedside medication verification
5. Monitoring of therapy, Medication Use Evaluations
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Prescribing Challenges - Objectives Describe the optimal environment for
safe prescribing List the necessary tools for enhancing
the knowledge of medications Discuss the advantages and
disadvantages of computerized physician order entry (CPOE)
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The Problem
The Institute of Medicine Report revealed that errors in medical care are responsible for many deaths
Many health care providers are not aware of their responsibilities
Medication errors responsible for numerous adverse outcomes, including death
This results in high cost (emotional and financial)
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Who are the participants?
Physicians Nurses Pharmacists Respiratory Therapists Patients The casual observers who can alert the
care providers about opportunities for errors
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RESPONSIBILITIES
Physicians Nurses Pharmacists Respiratory Therapists
Prescribing X X
Preparation X X X X
Dispensing X X X X
Administration X X X X
Monitoring X X X X
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Regulatory Standards
HFAP – Chapter 25 CMS Conditions of Participation 482.25
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The Medication Use Process Components Prescribing Procurement Preparation Dispensing Administration Monitoring
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Where Do Errors Occur?
Prescribing 39%Transcribing 11%Dispensing 12%Administering 38%
Where Do Errors Occur?
Prescribing 39%Transcribing 11%Dispensing 12%Administering 38%
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PRESCRIBING25.01.12, 25.01.13
Is a collaborative effort There is an increasing body of
knowledge– New therapeutic entities– Drug interactions– Allergies database– Food-drug interactions– Post-marketing data
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PRESCRIBING Physician (and other prescribers)
responsibilities:– Diagnosis
– Drug and dosing choices
– Medication reconciliation Pharmacist responsibilities (25.01.15, 25.01.16)
– Drug information
– Protocol-based management of patient medications
– Review of physician orders
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Training, Memory and Best Efforts As Safety System Tools
1980: medical school graduates needed to really know 60 drugs well
2000: this number was estimated at 600 drugs
2012: add another 100-200 drugs Drug-drug interactions increase
exponentially with these numbers
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Training, Memory and Best Efforts As Safety System Tools
DDI = drug-drug interaction
Karas S. Ann Emerg Med 1981; 10:627-630
Medications Potential DDIs
2 11
4 66
8 2828
16 120120
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HIGH ALERT MEDICATIONS25.01.01, 25.01.20
Adrenergic agonists Intravenous adrenergic antagonists Amiodarone/Amrinone Benzodiazepines (especially
midazolam) Intravenous calcium Chemotherapeutic agents
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THE ABBREVIATION PROBLEM U ug q.d. qod SC TIW
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Medication Prescribing ProcessComponents: Communication
Written Prescription Orders Medication Ordering Systems Electronic Order Transmission Dosage Calculations Verbal Orders Medication reconciliation
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Written Medication Orders: Illegible Handwriting 16% of physicians have illegible handwriting.1 Common cause of prescribing errors.2, 3, 4 Delays medication administration.5
Interrupts workflow. 5
Prevalent and expensive claim in malpractice cases.3
1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8; 3. Cabral JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm 1993; 50: 305-14; 5. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Illegible Handwriting: Error Prevention Prescribers’ Obligation Write/Print More Carefully Computers Verbal Communications
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Written Medication Orders: Complete Information Patient’s Name Patient-Specific Data Generic and Brand Name Drug Strength Dosage Form Amount Directions for Use Purpose Refills
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Written Medication Orders: Patient-Specific Information Age Weight Renal and Hepatic Function Concurrent Disease States Laboratory Test Results Concurrent Medications Allergies Medical/Surgical/Family History Pregnancy/Lactation Status
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Written Medication Orders: Do Not Use Abbreviations Drug names “QD” or “OD” for the word daily Letter “U” for unit “µg” for microgram (use mcg) “QOD” for every other day “sc” or “sq” for subcutaneous “a/” or “&” for and “cc” for cubic centimeter “D/C” for discontinue or discharge
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. Jones EH. Clev Clin J Med 1997; 64: 355-9.
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Written Medication Orders: Decimals Avoid whenever possible1
– Use 500 mg for 0.5 g– Use 125 mcg for 0.125 mg
Never leave a decimal point “naked” 1, 2, 3
– Haldol .5 mg Haldol 0.5 mg
Never use a terminal zero– -Colchicine 1 mg not 1.0 mg
Space between name and dose1,3
– Inderal40 mg Inderal 40 mg
1. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
2. Jones EH. Clev Clin J Med 1997; 64: 355-9.3. Cohen MR. Am Pharm 1992; NS32; 32-3.
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Written Medication Orders: Drug Names
“Look-Alike” or “Sound-Alike” Drug Names
“Confirmation Bias” Addition of Suffixes
– Example Adalat CC 30 mg vs. Adalat 30 mg
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.Cohen MR. Am Pharm 1992; NS32: 21-2.
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Look-alike And Sound-alike Drug Names
USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.
Zyrtec®Zantac®
Prilosec®Plendil®
Neoral®Nizoral®
Lomotil®Lamisil®
Fosamax®Flomax®
Cardura®Cardene®
LorazepamAlprazolam
Accutane®Accupril®
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Medication Prescribing Process: Computerized Prescriber Order Entry (CPOE)
– Computer with 3 Interacting Databases• Drug History• Drug Information/Guidelines Database• Patient-Specific Information
– Avoids• Illegible Prescriptions or orders• Improper Terminology• Ambiguous Orders• Incomplete Information
Schiff GD. JAMA 1998; 279: 1024-9.
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Computerized Physician Order Entry (CPOE)
Provides Decision Support Warns of Drug Interactions
– Drug-Drug– Drug-Allergy– Drug-Food
Checks Dosing Reduces Transcription Error Reduces number of lost orders Reduces duplicative diagnostic testing Recommends cost effective, therapeutic
alternatives
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CPOE Advantages
Automate ordering process Reduces Order Errors
– Standardized, legible complete orders
– Alerts Data collected on variances in practice
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Improved Quality
CPOE allows for physician reminders of best practice or evidence-based guidelines
Indiana University study– Pneumococcal vaccine in eligible patients
0.8% 36.0%
– Heparin prophylaxis18.9% 32%
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CPOE Disadvantages
Errors still possible Alerts Multiple steps Access
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Dosage Calculations
Recognized cause of medication errors Use patient-specific information
– height– weight – age– body system function
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Dosage Calculations: Error Prevention
Avoid calculations Cross-checking
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23. ISMP Medication Safety Alert 1996; 1 (15).
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Verbal Orders: Error Prevention Avoid when possible Enunciate slowly and distinctly State numbers like pilots
(i.e., “one-five mg” for 15 mg) Spell out difficult drug names Specify concentrations
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Conflict Resolution
Communication is essential No one is right all the time Take the time to listen Beware of instilling an atmosphere of
fear Interdisciplinary collaboration
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Patient Education
Educate patients about their medications Purpose of each medication Name of drug, dose, how to take, etc. Provide patients with understandable written
instructions Lack of involving patients in check systems Inform patients about potential for error with
drugs known to be problematic
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PRESCRIBING REVIEW
Right indication Right drug choice Correct dosage Absence of contraindications
– Allergies– Drug interactions (food, other drugs)– Pregnancy and lactation
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HIGH ALERT MEDICATIONS
Insulin Lidocaine Intravenous magnesium sulfate Opiate narcotics Neuromuscular blocking agents Intravenous potassium Intravenous sodium chloride (high
concentration)
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PROBLEMS
Lack of knowledge of proper dose Outdated information Illegible handwriting Incomplete orders Use of the apothecary system Order on the wrong chart Nameless prescription
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PROBLEMS
Ordering a total course of therapy instead of daily doses
Lack of knowledge about proper routes of administration
Ability to bypass controls in automated systems
Verbal orders poorly communicated
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SOLUTIONS
Clear handwriting (Print) Avoid abbreviations when errors could
occur Prescriber order entry Avoid verbal orders Double check doses Review cases of polypharmacy
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SUMMARY
Prescribing inappropriately can result in serious medication errors.
Major advances have been made in improving prescribing safety
Technology is our friend Interdisciplinary interactions go a long
way toward preventing errors
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NEXT SESSION
Medication procurement in an era of medication shortages
Compounding pharmacies – friend or foe?