incident management bulletin: medication errors

>www.dpw.state.pa.us >www.dhs.state.pa.us7/29/2021 1

Incident Management Bulletin:

Medication Errors

Failing to Provide Medication Management Missing/Theft of Medications

Course # - ID-2021-28

Course # ‐ ID‐2021‐28 1

Medication Errors ‐ Failing to Provide Medication Management ‐Missing/Theft of Medications


• Explain Medication Management and Medication Administration

• Review the 5 Rights of Medication Administration

• Clarify IM Bulletin policy and provide interpretation related to Medication Management incidents:

– Medication Error

– Neglect- Failure to Provide Medication Management

– Exploitation- Missing/Theft of Medications

Objectives:

Hello ‐My name is Rhonda Gengler, I’m the Chief Nursing Officer for the Office of Developmental Programs. Welcome to this webinar.

These are the objectives for today’s webinar:• Explain Medication Management and Medication Administration

• Review the 5 Rights of Medication Administration

• Clarify IM Bulletin policies and provide interpretations related to Medication Management incidents:

• Medication Errors• Neglect‐ Failure to Provide Medication Management• Exploitation‐Missing/Theft of Medications

Course # ‐ ID‐2021‐28 2



Medication Management

Medication Management

Treatment for Diagnosed

Health Conditions

Prescribed by Medical

Practitioners

Understanding the purpose and effects

Obtaining and Storing

Take as directed

Reduce side effects,

duplication, and drug

interactions

Medication Management is the process of overseeing the medications prescribed for an individual ‐ to ensure they are taken properly and achieving their planned, therapeutic outcome. It is processes and activities that are undertaken in order to ensure that the full range of medications that a person receives is appropriate.

Medication Management may include periodic review of medications to determine their necessity, to identify possible over medications, and to identify contraindicated medications. Obviously, many people play a role in this process. The health care practitioner will have certain responsibilities, caregivers will have certain responsibilities and Individuals will have certain responsibilities.

This slide shows some specific components in Medication Management that would be important for all of us who take medications. Medication Management is done by oneself or even with the support of non‐paid caregivers, such as a family or other household members along with the health care practitioner. How we obtain, store and take medications is based on the routines we develop or learn from others. We embed these practices within our Everyday Life.

In our private homes, we may store medications based on our individual preferences. Some may choose a medicine cabinet while other people may keep them in their kitchen or near their coffee pot, so they remember to take them in the morning. Some people may choose to take their medication directly from the prescription bottle and some will use a weekly or daily pill dispenser and fill it as needed.

However, in certain situations when an individual cannot self administer a medication, they will require support from others. In Pennsylvania, paid caregivers are permitted to administer medication if they fulfill the requirements of the Department of Human Services’ Medication Administration Training Course. This course has been developed to teach a standardized technique for medication administration.

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Medication Administration:

• Standardized practices for paid caregivers

• Ensures consistency and reduces errors

• Permitted by non-licensed professionals in certain settings

Medication Administration

Let’s review how Medication Administration is different from Medication Management.

Typically, in health care settings, administering medications must be done by a licensed professional. For our purposes, Medication Administration is completed by a paid caregiver. These can be either licensed professionals or unlicensed direct care workers. Remember, unlicensed direct care workers must successfully complete the Medication Administration Training Course in order to be qualified to administer medications. By allowing non‐licensed professionals to administer medications in the ODP service systems, this promotes an Everyday Life for individuals that are supported and are unable to self administer medications.

Medication Administration is based on a standardized process that helps to decrease the risk for medication errors and prevent harm from coming to the individual. This process also contains controls to ensure that medications are given in accordance with the healthcare practitioner’s orders.

Medication administration is not just about handing a person their pills or helping them to do what they would do or direct for themselves in the absence of a disability.

Medication administration is about:• Understanding and verifying the healthcare practitioners’ order • Knowing why the medication is prescribed and helping the Individual understand why

taking the medication is important for their health• Obtaining the medication, ensures it is correct, and storing the medication safely• Safely providing the medication at the correct time as prescribed• Understanding and monitoring the individual for side effects• Documenting the administration so others know which medications were administered• Effectively communicating with the healthcare practitioner and with other members of

the support team

Remember the goal of all this hard work is to prevent medication errors.

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A mistake in medication administration that includes but is not necessarily limited to the following:

• Wrong medication (an individual receives and takes medication which is intended for another person, discontinued, or inappropriately labeled

• Wrong dose (an individual receives the incorrect amount of medication);

• Wrong time (an individual receives medication dose at an incorrect time interval)

• Omission (missed dose) is when an individual does not receive a prescribed dose of medication, not including when an individual refuses to take medication.

Medication Errors

In the most general terms, a medication error is a mistake in the medication administration that includes but is not necessarily limited to the following: • Wrong medication ‐ an individual receives and takes medication which is intended for

another person, discontinued, or inappropriately labeled.• Wrong dose ‐ an individual receives the incorrect amount of a medication.• Wrong time ‐ an individual receives a medication dose at an incorrect time interval.• Omission ‐ a missed dose ‐ is when an individual does not receive a prescribed dose of a

medication. This does not include when an individual refuses a medication.

In a few slides we will review the changes in the IM Bulletin related to medication errors.

Course # ‐ ID‐2021‐28 5



Individual

Medication

Dose

Time

Route

Five Rights of Medication Administration

An important step in preventing medication errors is to ensure that all of the Rights of the Medication Administration are followed. There are 5 Medication Administration Rights: the right individual, the right medication, the right dose, the right time, and the right route. All of these rights must be in place and correct to safely administer the medication.

ODP requires these rights to be tracked and reported so that the causes of errors can be understood and therefore prevented from occurring again. Understanding errors helps providers implement new safety practices and guides ODP’s development of policies and regulations.

We will now review the three primary incident categories related to Medication Management. Incidents that occur in these categories can lead to serious harm to the individuals involved.

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#1 Medication Error definition changed

#2 Neglect-Failure to Provide Medication

Management

#3 Exploitation-Missing/Theft of Medications

IM Bulletin-Medication Management

Incident Management Bulletin 00‐21‐02 was published on March 1, 2021 and becomes effective July 1, 2021. As I just mentioned, the IM Bulletin contains three primary incident categories related to Medication Management. Incidents that occur in these categories can lead to serous harm to the individuals involved.

In the new bulletin there are changes to the definition of a Medication Error. This allows ODP to better collect data specific to all prescribed substances. In addition, two new primary and secondary incident categories have been introduced. All of the primary and secondary categories have definitions provided. We will discuss these in greater detail over the next few slides.

Course # ‐ ID‐2021‐28 7



Medication Error –

Any practice that does not comply with the “Rights of Medication Administration” as described in the ODP Medication Administration Training Course. A medication error occurring during a time when an unpaid caregiver is responsible for the administration of medication is not reportable. An individual’s refusal to take medication is not reportable as a medication error.

IM Bulletin- Medication Error

As defined in the IM Bulletin, a Medication Error is a practice that does not comply with the “Rights of Medication Administration” as described in the DHS Medication Administration Training Course.

A medication error occurring during the time when an unpaid caregiver is responsible for the administration of medication is not reportable. An individual’s refusal to take medication is not reportable as a medication error.

All medications, including over‐the‐counter medications, that are prescribed or ordered by a physician are now included in the definition. This includes over‐the‐counter products ‐for example: skin creams, shampoos, eye drops, and the like ‐ that do not contain a prescription medication but are prescribed and purchased as an over‐the‐counter medication are also included.

So what does this mean? Any medication or treatment product that is prescribed or ordered and not administered correctly as directed by the physician’s order, regardless of how it is obtained, is considered a medication error.

Let’s consider a few examples ‐ Today many medications are ordered by a physician but can be purchased over‐the‐counter. • If a paid caregiver fails to administer the individual their prescribed daily allergy

medication, regardless if it was purchased over‐the‐counter or by a prescription, this is a medication error.

• Another example is if an individual is prescribed a daily aspirin. This can be purchased over‐the‐counter. If the medication is not administered properly this is also considered a medication error.

Course # ‐ ID‐2021‐28 8



• Wrong Medication – Individual is given a medication that the individual is not prescribed or has been discontinued, or the individual was given medication that was supposed to be given for another reason.

• Wrong Dose – Individual is given too much or too little medication during a scheduled administration.

• Wrong Time – Individual is given medication too early or too late as defined by the range of allowable administration time.

• Wrong Route – Individual is given medication in a different way from the one specified on the label.

• Wrong Form – Individual is given medication in a different type from the one prescribed.

• Wrong Position – Individual is not placed correctly to receive the medication.

• Wrong Technique/Method – Medication is prepared for administration improperly.

• Omission – An administration of medication fails to occur.

• Wrong Person- An individual is given another individual’s medication.

IM Bulletin- Medication Error

ODP did not make changes to the nine secondary categories under Medication Error; however, we did provide definitions in the IM Bulletin that are consistent with what is taught in the DHS Medication Administration Training Course as seen on this slide.

Course # ‐ ID‐2021‐28 9



IM Bulletin- Neglect

Failure to Provide Medication Management – An event that may cause harm or lead to inappropriate medication use while the medication is in the control of the person(s) charged with administration.

Incidents of this nature include:– when harm occurs to the individual,

– the medication error occurs over more than one consecutive administration

– an individual receives medication intended for another individual.

Incidents of this type include, but are not limited to, a failure to:– administer medications via the correct route

– implement medication changes in a timely manner

– obtain medications from the pharmacy

Under the primary category of Neglect is a secondary category ‐ Failure to Provide Medication Management ‐ that allows ODP to capture incidents to better detect any negative outcomes that occur when the practices taught within the Medication Administration Training Course are not followed. This will allow for better data analysis in order to identify and strengthen areas for systemic improvement.

Let’s take a deeper look at this definition and I will provide some clarity regarding these important concepts.

Course # ‐ ID‐2021‐28 10





Incidents of this nature include:

• when harm occurs to the individual

• the medication error occurs over more than one consecutive administration

• or an individual receives medication intended for another individual.

This Photo by Unknown Author is licensed under CC BY-SA-NC

This secondary category was created to track instances when an incident occurs because an agency or agency staff are not maintaining medication administration best practices.

Due to the potential of harm to an individual when medication administration practices are not followed, ODP decided to make the Failure to Provide Medication Management under Neglect a separate and distinct category.

This was decided so that stronger oversight and controls can be put in place to ensure that the ODP Provider Network is effective in administering medications and that these activities are not placing individuals at risk.

Adding this secondary category to Neglect ensures that an investigation by a department‐certified investigator is completed, allowing the agency to create policies, procedures, and oversight practices that help to ensure incidents of this nature do not occur.

Course # ‐ ID‐2021‐28 11






• when harm occurs to the individual,


• an individual receives medication intended for another individual.

ODP is applying the concepts of consecutive administration in the broadest sense. Again, failure to receive medication as ordered by a health care practitioner is quite concerning and could have significant effects. Consecutive failures of any kind must be reported and addressed immediately to ensure individuals are free from any negative health impacts that can be associated with not taking a medication regularly as prescribed.

Examples of consecutive medication administration include:

• If an individual fails to receive a prescribed medication for multiple days in a row. For example, an individual was supposed to receive Kepra at 8 am yesterday, and then again at 8 am today, but they did not receive either dose.

• Another example, the individual fails to receive a prescribed medication multiple times in a day. For example, an individual is supposed to receive a Lorazepam three times a day. But at 8 am, and then again at 4pm, the dose of Lorazepam was missed, even though the individual received their noon medication correctly.

• Another example, if an individual fails to receive medications regardless of the specific medication more than once consecutively. An example is this: an individual misses their 8am dose of Kepra and their 12 noon dose of Lorazepam.

Course # ‐ ID‐2021‐28 12


It is a dangerous situation and has the potential to lead to serious consequences for the individual that received a medication intended and prescribed for someone else. Medications that are necessary and safe for one individual may be very harmful or even deadly to another individual. This may be due to a medication interaction or other factors such as individual's metabolism or health status.

Unfortunately, there have been numerous occurrences over the years where an individual supported by an ODP agency has accidently taken a medication that was prescribed for a housemate. For example, Harry’s 8 am medication is setting on the counter, the direct support worker steps into the living room to call Harry. While their back is turned, Frank enters the kitchen and takes the medication that was on the counter for Harry.

There have also been times when staff accidently administer a medication which was prescribed for one individual, but the medication was administered to a housemate. These types of errors can occur due to a variety of failures to follow the practices outlined in the Medication Administration Training Course including innocent distractions. As a result of these types of errors, some individuals have had to spend significant time in an ICU recovering and have had long lasting complications, while others have had fatal consequences.

By ensuring that the medication administration practices are adhered to as designed, it allows the ODP service system to safely administer medications and prevent harm to the individuals that we support. The bottom line is that handing someone another individual’s medication is like handing them a poison because one cannot predict how the individual may react.





• when harm occurs to the individual,


• an individual receives medication intended for another individual.

Course # ‐ ID‐2021‐28 13



Warfarin – aka Coumadin

Many people have heard of Coumadin which is a common blood thinner. Coumadin is also known as Warfarin which was first developed in 1948 at the Wisconsin Alumni Research Foundation through research and development of rodent or rat poisons.

This medication thinned the blood of the rodents to the point that the rodents died. It was then discovered that with very careful dosing and monitoring of this medication, it could be used to save human lives by preventing blood clots.

If an individual receives a dose of Coumadin that was meant for someone else, this is effectively giving the individual a dose of blood thinning poison, because it was prescribed specifically for the other individual.

Course # ‐ ID‐2021‐28 14



IM Bulletin

Failure to Provide Medication Management – An event that may cause harm or lead to inappropriate medication use while the medication is in the control of the person(s) charged with administration. Incidents of this nature include when harm occurs to the individual, the medication error occurs over more than one consecutive administration or an individual receives medication intended for another individual.




A failure to administer medications via the correct route not only is an error of the 5 Rights of Medication Administration, it also prevents the person from receiving the prescribed treatment.

This is especially important for things like creams and drops. Medications, like certain antibiotic drops, can be prescribed to treat infections of the ear as well as infections of the eyes. The medication box may state one route, but the healthcare practitioner must prescribe, and the pharmacy label should clearly state the intended route.

For example, Harry was ordered: Ofloxacin 0.3%, place 5 drops in the left ear twice a day. The direct care worker misreads the directions on the box and administers the medication into Harry’s left eye.

Confirming the right route prior to administrating a medication ensures that the individual is receiving the medication administered as prescribed and allows for the medication to be most effective.

Course # ‐ ID‐2021‐28 15



IM Bulletin





ODP has received many questions regarding the meaning of timely manner. Timely manner is a phrase that can be interpreted differently and there are many factors that come into play when determining if an individual is receiving their medication changes in a timely manner.

Certain medications should be given as soon as prescribed because they may be needed to treat a serious infection. Time is of the essence.

Some medication doses are adjusted based on the blood levels of the medication. Blood levels that are too high or too low can be a serious problem. A health care practitioner may need to make changes to the dosage of the medication based on the results of these blood levels.

A failure to implement medication changes in a timely manner can have serious consequences and lead to participant harm. To prevent this, agencies should discuss with the health care practitioner the appropriate timing for the medication dosage change and ensure that the change occurs.

By communicating with the health care practitioner, you are ensuring that you have a clear understanding of the prescriber's intent. Having these conversations on the front end at the time of the change can prevent incidents of failure to provide medication management.

Course # ‐ ID‐2021‐28 16



IM Bulletin





A Failure to Provide Medication Management by inappropriate planning to obtain prescribed medications from a pharmacy can have serious consequences. We often hear that “the pharmacy did not have the medication available”, “the medication is on back order”, or “the medication did not arrive in the mail”. This can lead to delays in medication administration and put individuals at harm.

Agencies may need to contact another pharmacy or contact the health care practitioner and communicate that they are having trouble obtaining the medication. Without prescribed medications an individual may have a seizure or high blood sugar or stroke. Do not assume that because the pharmacy said that they do not have the medication that it is okay to wait to fill the prescription.

Also, instituting practices and procedures that ensure that medication refills are obtained before the last pill is taken is certainly a best practice. The provider should pay close attention to when a prescription has no additional refills available. This will require that a new prescription is obtained from the health care practitioner. Ensuring that staff are communicating with each other and notifying others when the medication is running low, allows incidents of this nature to be prevented.

Course # ‐ ID‐2021‐28 17



Exploitation – An act or course of conduct by a person against an individual or an individual’s resources without informed consent or with consent obtained through misrepresentation, coercion, or threats of force, which results in monetary, personal, or other benefit, gain, or profit for the target, or monetary or personal loss to the individual. Exploitation should be reported regardless of the actual or perceived value of the loss.

Missing/Theft of Medications– Missing medications

without explanation or theft of medications.

IM Bulletin

As paid caregivers, you are trusted with managing and monitoring important medications that help ensure the individual’s physical and mental health and overall well‐being.

Medications prescribed for pain management or other health sustaining purposes may have the potential for abuse. As the nation continues to face the opioid epidemic, theft of controlled substances is increasing. Even medications without abuse potential may be subject to theft and misuse. It is imperative that providers have policies and procedures in place to ensure that medications are managed correctly, are accounted for, and are not subject to theft. Medications are the property of the individuals. When someone’s medications are stolen or go missing, this is as concerning as someone taking an individual’s funds. The individual could be harmed as a result of not receiving a dose of the medication that is missed or stolen.

We need to ensure that individuals we support are receiving their medication. We must all work together to ensure that the individuals we support are not the victims of missing medications, especially if they cannot report when they may have been given a certain substances last. As paid caregivers, we also need to ensure that reporting theft of medications to appropriate authorities is occurring.

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Safely assisting individuals with medication management and administration helps an individual remain healthy and safe, and helps protect their right to an Everyday Life in the community. These efforts strengthen our Home and Community‐Based Services for all Pennsylvanians.

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For additional technical assistance and resources:

• Contact your ODP Regional Office Nurse

• ODP-ID/A providers can also contact the IM Policy Mailbox at:

[email protected]

• ODP-BSASP providers can also contact BSASP directly at:

[email protected]

Resources

For additional technical assistance and resources, contact any of the resources listed.

Course # ‐ ID‐2021‐28 20


>www.dpw.state.pa.us >www.dhs.state.pa.us

Developed and produced by

Pennsylvania Department of Human ServicesOffice of Developmental Programs

in partnership with

Music courtesy of www.essasmusic.com

This webcast has been developed and produced by the Pennsylvania Department of Human Services, Office of Developmental Programs in partnership with The Columbus Organization.

Course # ‐ ID‐2021‐28 21


incident management bulletin: medication errors

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