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1 IN LONG TERM CARE BY: SAUL GREENBERGER, L.N.H.A. FOUNDER, PHARMSCRIPT PHARMACY Managing Medication Errors Managing Medication Errors: Saul Greenberger Med Errors- Outline Types of Errors Contributing Factors Why is LTC more prone? Pharmacy – A Key Component A parallel industry How can they be avoided? Quality Improvement Criminalization- An alarming trend Managing Medication Errors: Saul Greenberger Med Error - Definition Any preventable event that may cause or lead to inappropriate medication use or patient harm National Coordinating Council for Medication Error Reporting and Prevention Managing Medication Errors: Saul Greenberger

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Page 1: Managing Medication Errors · Managing Medication Errors: Saul Greenberger Minimize Distractions Impossible to AVOID but can be CONTROLLED Cell Phones Other interruptions Restart

1

IN LONG TERM CARE

B Y : S A U L G R E E N B E R G E R , L . N . H . A . F O U N D E R , P H A R M S C R I P T P H A R M A C Y

Managing Medication Errors

Managing Medication Errors: Saul Greenberger

Med Errors- Outline

Types of Errors

Contributing Factors

Why is LTC more prone?

Pharmacy – A Key Component

A parallel industry

How can they be avoided?

Quality Improvement

Criminalization- An alarming trend

Managing Medication Errors: Saul Greenberger

Med Error - Definition

Any preventable event that may cause or lead to inappropriate medication use or patient harm

National Coordinating Council for

Medication Error Reporting and Prevention

Managing Medication Errors: Saul Greenberger

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Timeline of “Preventable Events”

Pre-Admission

Admission

Medication Administration

On-Going Resident Stay

Managing Medication Errors: Saul Greenberger

MECHANICAL VS. HUMAN

Types of Errors

Managing Medication Errors: Saul Greenberger

Human Error - Definition

Human error is any human action or lack thereof

that exceeds the tolerances defined by the system with

which the human interacts.

D.K. Lorenzo, A Manager’s Guide

to Reducing Human Errors

Managing Medication Errors: Saul Greenberger

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Unintentional errors

Actions committed or omitted with no prior thought

misreading an order

bumping the wrong switch

forgetting to properly set the dose on an X-ray device

usually thought of as accidents

Managing Medication Errors: Saul Greenberger

Intentional errors

Actions deliberately committed or omitted because staff believe their actions are correct or better than

the prescribed actions

Shortcuts

“Improved” methods

Don’t always result in harm

Managing Medication Errors: Saul Greenberger

Developed by James Reason , University of Manchester

A series of events which must occur in a specific order and manner for an accident to occur

Holes are opportunities for failure

Each slice is another layer of the system

The Swiss Cheese Organizational Model

Managing Medication Errors: Saul Greenberger

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WHAT MAKES THEM HAPPEN?

Contributing Factors

Managing Medication Errors: Saul Greenberger

Performance Shaping Factors (PSF)

Anything that affects staffs’ performance of a task

Managing Medication Errors: Saul Greenberger

External

Stressors

Internal

Internal PSFs

Individual skills, abilities, attitudes and other characteristics staff bring to the job

Experience

Knowledge of standards

Intelligence

Motivation/work attitude

Personality

Emotional state

Physical condition/health

Managing Medication Errors: Saul Greenberger

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External PSFs

Influence the environment in which tasks are performed

Facility Layout

Temperature, lighting, noise

Shift rotation/Staffing levels

Procedures: written or not written

Frequency/repetitiveness

Managing Medication Errors: Saul Greenberger

Stressors

Heavy task load

Threats of failure or loss of job

Degrading or meaningless work

Long, uneventful vigilance periods

Distractions

Fatigue

Lack of rewards, recognition or benefits

Managing Medication Errors: Saul Greenberger

EVEN MORE ERRORS

Long Term Care

Managing Medication Errors: Saul Greenberger

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Concerning Statistics

Managing Medication Errors: Saul Greenberger

•7,000 yearly deaths due to sloppy handwriting •106,000 yearly deaths from adverse drug reaction •Only 6% of ALL adverse drug reactions are properly identified •800,000 preventable drug-related errors occur in long-term care settings

Concerning Statistics (Cont.)

Managing Medication Errors: Saul Greenberger

Why is LTC More Error Prone?

Managing Medication Errors: Saul Greenberger

Unusually Complex

Environment

Rx/Resident Existing

Compromised Health

Many Residents per

Unit

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Additional Factors

Transition from one care setting to another

Prescribing or transcription errors

Medicare Part D

Time Constraints/ Understaffed

Inadequate pharmacological knowledge

Failure to comply or lack of procedures

Managing Medication Errors: Saul Greenberger

A KEY COMPONENT

PHARMACY

Managing Medication Errors: Saul Greenberger

The Fill Process - Oversimplified

Managing Medication Errors: Saul Greenberger

Code Fill Bag

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8

Managing Medication Errors: Saul Greenberger

Pharmacy Step 1 - Code

PROCEDURE: Receive fax Enter data RPH1 Check Print Label

QUALITY ASSURANCE : Missing Orders Skips Transcription Allergies

Pharmacy Step 2 - Fill

PROCEDURE: Pre-Pack Affix Label RPH2 Check

QUALITY ASSURANCE: Mismatch Skips

Pharmacy Step 3 - Bag

Managing Medication Errors: Saul Greenberger

PROCEDURE

• Package Totes • Create Manifests • On Time Delivery

QUALITY ASSURANCE • Mixed Totes • Skips

Page 9: Managing Medication Errors · Managing Medication Errors: Saul Greenberger Minimize Distractions Impossible to AVOID but can be CONTROLLED Cell Phones Other interruptions Restart

9

ERRORS FROM ANOTHER PERSPECTIVE

A Parallel Industry

Managing Medication Errors: Saul Greenberger

Managing Medication Errors: Saul Greenberger

Transportation Facts Odds of fatal accident

Managing Medication Errors: Saul Greenberger

Airline = 1/ 7,000,000

Train = 1/ 1,000,000

Driving = 1/14,000

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10

General Odds of Death

Cardiovascular disease: 1 in 2

Smoking : 1 in 600

Bicycle accident: 1 in 88,000

Tornado: 1 in 450,000

Lightning: 1 in 1.9 million

Bee sting: 1 in 5.5 million

Managing Medication Errors: Saul Greenberger

Managing Medication Errors: Saul Greenberger

Airline Strengths

Minimized distractions

Checklist centered/ Verbalization

Set up to avoid work fatigue

Unprecedented training routines

Thorough investigation after even MINOR accident

Managing Medication Errors: Saul Greenberger

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11

Delta Flight 1141 : August 31, 1988

Managing Medication Errors: Saul Greenberger

APPLIED LEARNING

How Can We Control Med Errors?

Managing Medication Errors: Saul Greenberger

Minimize Distractions

Impossible to AVOID but can be CONTROLLED

Cell Phones

Other interruptions

Restart individual med pass if interrupted

Managing Medication Errors: Saul Greenberger

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12

Checklists

Managing Medication Errors: Saul Greenberger

Keep them brief

Easy to understand

Make them available

Wide range of scenarios

Verbalizing

Work Fatigue

Shortage of staff

Pool of per diem staff

Look out for signs of extreme fatigue

Keep an eye out for talent

Managing Medication Errors: Saul Greenberger

Training

Re-examine orientation procedures

On-going competency exams

Perform routine drills

Real life testing

Managing Medication Errors: Saul Greenberger

Page 13: Managing Medication Errors · Managing Medication Errors: Saul Greenberger Minimize Distractions Impossible to AVOID but can be CONTROLLED Cell Phones Other interruptions Restart

13

Investigate

Internal poc’s

Take A/I reports more seriously

Look for systemic breakdowns

Identify training weaknesses

Share lessons with other facilities

Managing Medication Errors: Saul Greenberger

Managing Medication Errors: Saul Greenberger

Managing Medication Errors: Saul Greenberger

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14

FROM TEXTBOOK TO PRACTICE

Quality Improvement

Managing Medication Errors: Saul Greenberger

Managing Medication Errors: Saul Greenberger

Six Sigma

Identifying and removing the causes of defects (errors)

Minimizing variability

Uses Quality Management methods

Infrastructure of experts within organization

Managing Medication Errors: Saul Greenberger

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15

Quality Management Tools

Managing Medication Errors: Saul Greenberger

QM 5 Whys

Pareto Analysis

Pick Chart

Check Sheet

Five Whys

Managing Medication Errors: Saul Greenberger

Check Sheet

Managing Medication Errors: Saul Greenberger

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Pareto Analysis

Managing Medication Errors: Saul Greenberger

Pick Chart

Managing Medication Errors: Saul Greenberger

National Quality Forum (NQF)

Setting priorities and goals for performance improvement

Creating standards for measuring and reporting

Education and outreach

Managing Medication Errors: Saul Greenberger

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17

Measuring

Managing Medication Errors: Saul Greenberger

Cornerstone of any quality improvement program

•Can’t change what you can’t measure •Gives true scope of any problem area •Lets you know when you’ve reached the goal •Lets you compare to others

Managing Medication Errors: Saul Greenberger

“Vulnerable Adult Abuse”

Any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult.

Washington State Office of the Attorney General

Managing Medication Errors: Saul Greenberger

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Who is a Vulnerable Adult ?

One who is unable to independently provide for their own basic necessities of life by virtue of:

Age

Physical injury

Disability

Disease

Emotional or developmental disorders

Managing Medication Errors: Saul Greenberger

Death of Michael Jackson

Managing Medication Errors: Saul Greenberger

June 25, 2009

WHAT TO TAKE HOME

Summary & Conclusion

Managing Medication Errors: Saul Greenberger


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