Medication Safety- Technology Audrey B. Johnson, MSM, SSGB, Bpharm

2016 Annual meeting

Disclosure:

2016 Annual meeting Information being presented solely based on Industry data, publications, and professional experience. No Financial Sponsorship has been provided for this presentation.

Presenter is a Pharmacy professional and has no endorsements, industry relationships, or sponsorships for this session.

Objective:Objective 1Discuss the past, present and future use of technology to assist in reduction of medication errors

Objective 2Describe effective error reduction strategies to prevent patient harm caused by medication errors

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Wednesday- 4pm

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2016 Annual meeting

Saturday- 2 days later

2016 Annual meeting3pm Status---ER Intubation

8pm Status--- ICU

Case Study 1:

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52yr Female with CP quadriplegic

Found Non-responsive with Pinpoint PupilsTime noted as 12:30amParamedics Called-transported to HospitalUpon arrival vitals unstable- Respiratory Rate shallowBody Temperature-Heart Rate-Pulse decreasing **No further details to discuss**2 identified drugs in patient system (Benzo& Opioids)Medication profile review revealed identified drugs NOT listed

the past, present and future use of technology to assist in reduction of medication errors

2016 Annual meeting

Medication Error Trending Report

2016 Annual meetingError Reports in FAERS by type of reporter (Healthcare Professional [HCP] or consumer) since the year 2004 until the end of 2013 www.fda.gov

YearConsumersPhysicianPharmacist Other HealthTotal HP200474,64792,70520,32045,951158,9762005105,172106,15021,49243,585171,2272006126,915113,11621,46849,652184,2362007174,015120,70021,31660,184202,2002008226,265153,64127,02788,239268,9072009273,033177,92429,213110,777317,9142010403,843229,39436,447161,213427,0542011492,118278,31148,283197,694524,2882012562,474352,84754,496228,098635,4412013664,842381,80867,528265,995715,331

Where do Medication Errors Occur?

Medication Safety Technology :Order Entry-ScreeningCPOEDrug Screening FunctionalitiesDosing ToolsSupportive TechnologyBar CodingEMRAutomated Dispensing UnitsAdministration DevicesInfusion Pumps

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IT systems potential to save up to $88 billion over 10 years in costs in the USA, with increasing adoptionPrevention of medication errors has is a high priority worldwideEvidence supports that systems that use information technology (IT) reduces errorCPOE- computerized physician order entry Automated dispensing cabinetsBar-coded bedside medication administrationEMR- Electronic medication reconciliationHospitals with automated notes and records, order entry, and clinical decision support have fewer complications, lower mortality rates, and lower costs

CPOE Computerized Physician Order Entry Computerized Physician Order Entry (CPOE) systems are a type of health information technology that facilitate the process of ordering medications, tests, and procedures and can reduce the rate of medical errors and enhance patient safety. CPOE systems integrate basic patient medical information, current medication orders, and recent clinical treatment guidelines to alert clinicians of orders that may result in adverse effects and patient harm. CPOE systems incorporate basic patient information such as drug allergies, medical technology, electronic patient records, laboratory reports, pharmacy prescription, and pertinent information from other sources

Efficiency of CPOE Pharmacy Turnaround times before and after CPOE implementationBefore CPOE590 44minsAfter CPOE 960 7.3mins 83.4% improvement

medication safety impact of CPOECPOE provides physicians with standardized lists and templates for entering orders Reduce the likelihood of inappropriate therapy or incomplete informationReduce potential delays to the order processing and adverse drug events. Reduces the necessity of other providers to interpret handwritten orders, which may be very difficult to read, misread, and contain inappropriate abbreviations. Provides clinical decision support features to help physicians input appropriate and safe orders

Legibility Benefit of CPOE

fda Bar Code Rule

2016 Annual meeting FDA is working to reduce medication errors: Bar code label rule

FDA proposed a New rule after a Public meeting in July 2002-requiringBar codes on certain drug and biological product labels- similar to that used in supermarkets

FDA's final rule on bar code labeling was published on Feb. 26, 2004

Bar Code rule took effect on April 26, 2004

www.Federalregister.gov

Other Benefits of Bar Code Technology Generated a new production efficiencies for activities such as reporting, record keeping, purchasing, and inventory controls An average sized hospital could save as many as 397 hours of pharmacist resources and 5,694 hours of nursing resources annually The average annualized gains of these potential efficiencies are between $376.3 million and $602.0 million (at 7 percent), or $359.0 million and $574.2 million (at 3 percent).

Medication Safety Technology:Order Entry-ScreeningSafety StopsRequired DataAlertsHard Stops/PrecautionsOverrides/Alert Fatigue*Drug Monitoring ScreeningDosing parameters Drug Profile Screening*

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Medication Safety Technology:

Automated Dispensing UnitsAutomated Compounding UnitsSafety ParametersUtilization controlsValidation TestingDigital Tracking/Monitoring RoboticsPackingsCountingIV Compounding

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Medication Safety Technologies:

Administration DevicesPumpsIVIntrathecalSafety ParametersUtilization controlsValidation TestingDigital Tracking/Monitoring

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Does Technology Error?

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What should the content count be? 3What is the content count? 8How can this occur ??

What happens when the 4hr trained Med Tech does med-pass??

Automation DevicesADC and ACD platform linked to the pharmacy computerPharmacist can review each new medication order and screen it for safety before the drug can be removed from the cabinet ADC and ACDs have BAR CODE safety for utilizationKey Functionality Support: Proper InterfacingParameter SettingsAdministrative SettingSafety SettingUser TrainingMonitoring-Tracking64B16-28.607 Automated Pharmacy System 64B16-28.608 Automated Filling Systems within a Pharmacy

Case Review 2:

2016 Annual meetingJacquelyn, who was 9 at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.

Carol Ley slept in her daughter's hospital room that night. When she woke up in the middle of the night and checked on her, Jacquelyn was barely breathing. "I called her name, but she wouldn't respond," she says. "I shook her and called for help." The morphine pump hadn't been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn's body. She survived the overdose, but it was a close call. "If three more hours had gone by, I don't think Jacquelyn would have survived," Ley says. "Fortunately, I woke up."

Infusion Pump Safety:

2016 Annual meeting Key bounce

Key bounce results from pressing once on a pumps number key and getting an unintended repeat of that same number. (example 88 vs 8) Softly or partially pressed for a timeProgramming a pump from an odd angle. Errors also have resulted from accidentally hitting a number key twice Intentionally hitting the key twice because the corresponding number did not appear immediately on the screen

Medication Safety Technologies:Supportive TechnologyScreenings MechanismsLab Order Data AccessSimulation Based Training

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Assessment Question 1:

Which technology system was introduced by FDA in response to medication errors? Bar Code TechnologyCPOEEMRADC

Describe effectiveerror reduction strategies to prevent patient harm caused by medication errors

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reduction strategies

2016 Annual meeting (effective-supportive-realistic program) >2 days and < 2 monthsTraining & Competency Assessment*

Checklist of standard functionality skills Comprehensive training Assessment of knowledge Annual review of skills (under utilization will impact proficiency)

reduction strategies

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Procedures and Process*Standardized procedures and process

Validation-TestingCalibrationMaintenanceUpgrades-UpdatesSystem Quality Validations

Case Study 2:

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2 yr. old patient scheduled to receive final Chemo dose after long bout with cancer *spinal malignancyUnlicensed pharmacy technician mistakenly mixed a chemo orderworking in cramped quarters and rushed for timeRPH gave final approval to the mixture-after seeing a spent bag of 0.9% saline next to the mixed solution

Patient codes and died

Emily Jerry

Root Cause Analysis: (RCA)

2016 Annual meeting What happened? (Facts)Pharmacy technician mistakenly mixed the chemo with 23% Saline rather than the intended 0.9% Saline; Pharmacist verified without checking

Why did it happen? (*explanations provided)pharmacy understaffed, distracted, working in cramped quarters, rushed for time

*Emotionally distracted: Technician* Hurried-Trusting: Pharmacist

Workflow Design & Procedures

Key Success Competency Training & Assessment

Monitoring- Quality Assurance Process

reduction strategies

2016 Annual meeting Workflow Design

Task Alignments

Time Allocations

Interruptions

Constraints

Resources/Tools

reduction strategies

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Evaluating Volume

Staffing

Continuous Quality Improvement CAPARoot Cause AnalysisFMEA

Risk Mitigation Strategies

Assessment Question 2:Which of the following is a key component in utilization of technology for medication safety?Current systemsProceduresTrainingStaffingAll of the above

References:

2016 Annual meeting Advocating for Safe Pediatric Medication Labeling; Christopher Jerry; Pppmag.com/March 2012- (IV Safety)FDA.govFAERS.govCDC.govROOT CAUSE ANALYSIS WORKBOOK FOR COMMUNITY/AMBULATORY PHARMACY; ISMP.govAndrew M. Steele, MD, MPH, MSc; Mical DeBrow, PhD, RN Efficiency Gains with Computerized Provider Order Entry ; federalregister.gov/articles/2004Med-Errs.comJournal of Pharmacy Research Vol.5 Issue 10.October 2012 NIH.govQualitysafety.bmj.com/ on May 14, 2016 - Published by group.bmj.com

Thank you for your Attention and Safe Practice .