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7/30/2017
1
Preventing
Medication Errors in
PracticeMargo Karriker, PharmD, FSVHP, DICVP
University of California, Davis
University of California Veterinary Medical Center – San Diego
5th Annual UCI Conti Symposium on Veterinary Continuing Education
August 6th, 2017
To make no mistakes is not in
the power of man; but from
their errors and mistakes the
wise and good learn wisdom
for the future.
Plutarch
Objectives
• Recognize errors happen
• Examine error prevention initiatives in veterinary medicine
• Compare initiatives in human medicine
• Identify error prevention opportunities for your practice
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How many of us have a
medication error reporting and
prevention/medication safety
program?
Healthcare in the United States is not as safe as it should be –
and can be… (Institute of Medicine. November 1999)
Healthcare in the United States is not as safe as it should be –
and can be… (Institute of Medicine. November 1999)
Four strategies for improvement:
• Establish a national focus to create leadership, research, tools,
and protocols to enhance the knowledge base about safety.
• Identify and learn from errors by developing a nationwide
public mandatory reporting system and encourage
organizations to participate in voluntary reporting.
• Raise performance standards and expectations for
improvement in safety through oversight organizations.
• Implement safety systems in organizations to ensure safe
practices at the delivery level.
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Institute of Safe Medication
Practices501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use
• Began in 1975, with a ongoing column in Hospital Pharmacy that increases understanding and educates healthcare professionals and others about medication error prevention
• Voluntary consumer and practitioner reporting program
• Med-ERRS (Medical Error Recognition and Revision Strategies) works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design.
• Newsletters, educational programs and patient-safety tools
Source: www.ismp.org
Institute of Safe Medication
Practices
Source: https://www.ismp.org/newsletters/acutecare
Institute of Safe Medication
Practices
Source: https://www.ismp.org/Tools/highalertmedications.pdf
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Safety-minded culture
Punitive culture
Blame-free culture
Just culture
Source: Acute Care. ISMP Medication
Safety Alert.
http://www.ismp.org/newsletters/acutec
are/articles/20060907.asp
Safety-minded culture: Just
culture
Human error
At risk behavior
Reckless behavior
Safety-minded culture: Just
culture
Human error
At risk behavior
Reckless behavior
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Safety-minded culture: Just
culture
Human error
At risk behavior
Reckless behavior
Safety-minded culture: Just
culture
Human error
At risk behavior
Reckless behavior
ACTION IN VETERINARY MEDICINE
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Action in Veterinary Medicine:
FDA CVM
Source:
https://www.fda.gov/AnimalVeterinary/SafetyHealth/ProductSafetyInformation/
Action in Veterinary Medicine:
FDA CVM• FDA CVM’s role in
error prevention
• Evaluation of drug
names
• Review of drug labels
and packaging design
• Review of adverse
drug event reports
• Educational outreach
Source: https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm325222.htm
Action in Veterinary Medicine:
FDA CVM
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Action in Veterinary Medicine:
AAHA
Source:
https://ams.aaha.org/eweb/images/AAHAnet/phoenix2009procee
dings
Action in Veterinary Medicine:
AAHA• Client disclosure
• T:
• Truth and Transparency
• E
• Empathizing
• A
• Apology and Accountability
• M
• Management
Action in Veterinary Medicine:
AAHA
• Standard - PC57
• The practice utilizes a written protocol that defines what
constitutes an adverse/sentinel event and how such events are
addressed.
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Action in Veterinary Medicine:
AVMA• FAQs
• Prescription writing
best practices
• Guidelines for
veterinary
prescription drugs
Source: https://www.avma.org/KB/Resources/Reference/Pages/Pharmacy
LESSONS FROM HUMAN MEDICINE
The challenge
• May 2000
• Results of the ISMP “Medication Safety Self Assessment”
• Specific medication safety objectives were included in the CEO’s
strategic plan in only twelve percent of hospitals.
• About 50% of respondents did not feel that their leadership:
• Demonstrated a commitment to patient safety
• Encouraged practitioner error reporting
• Supported the use of system enhancements, like technology, that
were likely to reduce errors
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How many of us include
medication safety objectives
and goals in our strategic plan?
Pathways for Medication Safety
Strategic Planning
• Medication safety should be a critical component of a
strategic plan for all hospitals.
• Why is this important?
• Why should every hospital devote significant resources to
medication safety?
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Why is strategic planning
important?• Moves focus to long term goals
• Balances immediate/short-term patient needs with long-term
goals of the organization
• Safe medication use requires careful planning. Cannot be
achieved if all resources are spent meeting immediate needs.
• Errors involving medications comprise the largest single cause of
medical errors in hospitals
Why should we devote significant
resources to medication safety?• Two serious errors
occurred for every 100 admissions
• Length of stay increased
• $1000s of extra costs
• Preventable errors cost $ millions
• Malpractice/liability
• Marketing/bad PR
• Higher employee turnover
• Decreased operational efficiency
The implementation process
Involve key people
Review Materials
Map a Strategy for the Future
Select Change Projects
Implement a Strategic
Plan
Monitor Performance
Source: www.medpathways.info. Pathways for
Medication Safety. AHA/HRET/ISMP. 2002
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Creating a Model Strategic Plan
Creating a Model Strategic Plan
Create, communicate, and demonstrate a leadership-driven
culture of safety.
• Professional organizations
• Regulatory agencies
• Hospital leadership
• Peer leadership
• Consider a dedicated staff position focused on medication
safety
• Revise mission statement to include an emphasis on safety
• Create continuous safety training and provide feedback
Creating a Model Strategic Plan
Improve error detection, reporting and use of the information
to improve medication safety
Evaluate where technology can help reduce the risk of errors
• Every member of the staff
• Create a method to capture error reports efficiently
• Establish a feedback mechanism to keep everyone informed
• When adopting new technologies, consider safety issues
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Creating a Model Strategic PlanImprove error detection, reporting and use of the information
to improve medication safety
Evaluate where technology can help reduce the risk of errors
Source: https://www.usatoday.com/story/tech/columnist/2017/07/28/doctors-using-
virtual-reality-breathe-new-life-into-technology. July 28th 2017
Creating a Model Strategic Plan
Reduce the risk of errors with high-alert medications
prescribed and administered.
• Create and maintain and list of medications
• Establish the procedures required when these drugs are used
Creating a Model Strategic Plan
Establish a blame-free environment for reporting errors.
“I just don’t want to get anyone in trouble…”
• Survey staff about anxiety and fear about making and
reporting errors
• Consider anonymous reporting
• Link safety competence tenets to employee evaluations, not
frequency/pattern of reported errors
• Focus on systematic solutions to frequent causes of error
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Creating a Model Strategic Plan
Involve the community in medication safety initiatives.
• Communicate safety initiatives to clients
• Host client education training
Creating a Model Strategic Plan
Involve the community in medication safety initiatives.
• Rate of errors increased
• Incorrect dose
• Wrong medication taken/given
• Took/gave medication twice
• Cardiovascular drugs
• Analgesics
• Hormones and hormone antagonists
• Sedative/hypnotics/antipsychotics
Source: Hodges, N. L., Spiller, H. A., Casavant, M. J., Chounthirath, T., & Smith, G. A. (2017). Non-health care facility medication errors resulting in serious medical outcomes. Clinical toxicology, , 1-8.
Our program
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Medication Error Statistics
• Data collected from September 15, 2011 – February 25, 2016
• 657 total entries
• 603 entries evaluated
Inpatient
Outpatient
Potential
By Service
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
Pe
rce
nt
Service
Outpatient
Inpatient
Errors Reach Patient
68%
29%
3%
Inpatient
Reached
Patient
Did Not
Reach
Patient
Unknown 83%
16%
1%
Outpatient
Reached
Patient
Did Not
Reach
Patient
Unknown
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Cause Harm/ Change in
Treatment
• Inpatient
• 13% classified as
causing harm
• Of errors that reached
patients, 28% required
change in treatment
• Outpatient
• 11% classified as
causing harm
• Of errors that reached
patients, 9% required
change in treatment
Medication/Medication Class
0
20
40
60
80
100
120
140
High Alert Medications
• Inpatient
• 509 entries
• 42 unknown drug
involved
• 201 High Alert Meds
• Outpatient
• 81 entries
• 3 unknown drug
involved
• 9 High Alert Meds
39% - 48%
involving High
Alert
Medications
11% - 15%
involving High
Alert
Medications
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Inpatient Error Causes
Human
Communication
Labeling
Unknown
Other
Staff Education
• What is a medication error?
• Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in the control of the health care professional,
patient, or consumer.
How to report
• Easy to access
• Minimal time
investment
• Focuses on root
cause
• Non-punitive
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What should be reported
• Nothing is too trivial
• Near-misses should be reported
• Even if it didn’t reach the patient
• Anything that is unintended
• Even if no harm was caused
How we’re using the data
• Focus on improved
patient care
• Consistent,
constructive
feedback
• Need buy-in from
everyone
Summary
• Prioritize error reporting and prevention
• Include error prevention goals in your strategic plan
• Create a blame-free culture of medication safety
• Implement a continuous, sustainable error prevention
program
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Resources
• Institute of Safe Medication Practices
• www.ismp.org
• FDA Center for Veterinary Medicine: Consumer Updates
• https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm3252
22.htm
• Pathways for Medication Safety: Institute for Healthcare
Improvement
• http://www.ihi.org
QUESTIONS?
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