medication error reporting program (merp) update april ... · opening powerpoint presentation part...
TRANSCRIPT
Medication Error Reporting Program (MERP)
Update
April 2010*********************************************
Overview and presentation of our readiness
• Opening PowerPoint completed and under review by Quality Management
• Pharmacy has complied data and highlight success story of Hospital-wide medication error reduction efforts
• Vulnerabilities identified• Pharmacy Performance Improvement Plan
Opening PowerPoint presentation
Part 1 – Hospital demographics, affiliations, services, goals (18 slides)
Part 2 – MUSS (SFGH MERP Committee), reporting structure, MUSS activities related to MERP (5 slides)
Part 3 – Technology implemented that impacted medication safety (1 slide)
Part 4 – Success stories related to the technology (4 slides)
Part 5 – INLP impact on medication safety (3 slides)
4
San Francisco General Hospital and Trauma Center
)
A California Public Hospital
• SFGH is one of 19 public hospitals in CA• Today, just 6% of hospitals that
– Provide nearly half of the hospital care to the state’s uninsured
– Operate almost 60% of CA’s trauma centers– Operate almost 45% of the burn centers– Serve 2.5 million patients per year
• During the economic crisis, the need for services is growing
SFGH is for everyone
• Only Trauma Center in San Francisco• Care for 100,000 patients per year• Provides 20% of all inpatient care in SF• Only Psychiatric Emergency &
Rehabilitation Services • Referral Center for “Healthy San Francisco,”
the health access program for the uninsured
University of California, San Francisco (UCSF)
• SFGH has partnered with UCSF for over 130 years through our teaching and research affiliation.
• Over 160 UCSF Principal Investigators conduct research at SFGH with an annual budget of $143M
• Over 1,300 UCSF employees on campus.
Clinical training at SFGHUniversity of California, San Francisco
Schools of Nursing, Pharmacy, Dentistry, and Medicine350 3rd or 4th Year Medical Students, 800 Residents, 60 Clinical Fellows32% of intern/resident training in 17 academic departments35% medical student clinical training
California State University System, Community colleges, private universities and colleges place approximately 200 clinical nursing students for rotations at SFGH.
SFGH PATIENT DIVERSITY FY 2008-2009
Under 1813%
18-2411%
25-4434%
45-6433%
Over 649%
Male51%
Female49%
Age
Race
SexN=98,698
White24%
Afric-Amer18%
Hispanic32%
Nat Amer0%
Asian/PI21%
Oth/Unk5%
Dedicated interpreter staff at SFGH provide services in over 20 languages:
SpanishCantoneseMandarinRussianVietnameseTagalogCambodian
ThaiArabicAmharic (Ethiopia)PortuguesePolishBurmese
…and more
Top 10 Discharge DiagnosesFY 2008 - 2009
1. Schizophrenia2. Normal Delivery3. Pneumonia Organism4. Congestive Heart Failure5. Chest Pain6. Alcohol Withdrawal7. Leg Cellulitis8. Shortness of Breath9. HIV Disease10. Obstructive Chronic Bronchitis with Exacerbation
SFGH ServicesFY 2008-2009
Outpatient: 529,098 visits
Inpatient: 15,405 admissions 103,313 patient days
Skilled Nursing: average census 30 LOS 34 days
Acute Care for the Elderly(ACE)
• Special dedicated unit for post-op, medical, surgical and rehab patients
• Trained inter-disciplinary team emphasizes socialization, exercise, discharge planning, reducing pharmaceutical dependence
• Only ACE unit in California• Currently 35 beds on two units
San Francisco Behavioral Health CenterFY 2008-2009
Mental Health Skilled Nursing Facility Average daily census of 57
Mental Health Rehabilitation Center Average daily census of 45
Adult Residential Care FacilityAverage daily census is 41
Surgical Services
Ten operating rooms6,872 procedures performed - of which 48% were emergency1,118,100 surgical minutes
Baby Friendly HospitalFY 2008-2009
SFGH named by World Health Organization as Baby Friendly in May 2007Only Baby Friendly hospital in San Francisco1 of 63 hospitals in U.S.1,334 babies were born at SFGH1,966 women received prenatal care, 25% high-risk
Trauma and EmergencyFY 2008-2009
Over 53,000 Emergency Room visits
15% are admittedOver 7,200 Psychiatric Emergency encounters
26% are admitted
SFGH receives 29% of all ambulance traffic in San Francisco3,559 adults and children are treated for injuries requiring thetrauma activation.
SFGH Goals FY 2008-2009
• Promote patient safety• Enhance clinical care• Promote staff retention & recruitment• Maintain hospital infrastructure• Comply with all regulatory standards &
attain specialty certifications• Maintain services during hospital rebuild
VIEW FROM 23RD STREET
Performance Improvement and Patient Safety Reporting Pathway
Committees Involved in Medication Management
• Pharmacy and Therapeutics Committee– Medication Use and Safety (MUSS)– Formulary Review Subcommittee (FRS)– Pain Management Subcommittee– Nutrition Subcommittee– Antibiotic Review Subcommittee– Procedural Sedation Committee– Clinical Laboratory/Therapeutics Committee
• Performance Improvement Patient Safety Committee (PIPS)• Nursing Quality Improvement Coordinating Council (NQICC)
– CALNOC – Integrated Nursing Leadership Program (INLP)
• Joint Nursing Pharmacy Committee
Medication Use and Safety Subcommittee (MUSS)
Membership comprised of:Medical Staff, Nursing, Pharmacy, Respiratory Care Services, Radiology, Quality Management, Risk Management
Duties/Responsibilities:
• Oversees the Hospital’s MERP• Review adverse drug events and medication unusual occurrences• Develops and maintains medication management policies• Discusses medication management safety processes including
opportunities for improvement.• Develops safety strategies including staff education• Review pre-printed physician order forms that contain medication
orders.
MUSS Committee activities – ADR summary
REPORTED ADR BY QUARTER
020406080
100120140160180
2006
-120
06-2
2006
-320
06-4
2007
-120
07-2
2007
-320
07-4
2008
-120
08-2
2008
-320
08-4
2009
-120
09-2
2009
-320
09-4
# OF ADR
QU
AR
TER
MUSS Committee activities – Med Error Review summary
Total # of Med Error UO's by quarter (2007-2009 total = 1816)
125
170139
119 107 109 107
175148
199222
196
0
50
100
150
200
250
1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr
2007 2008 2009
# of
UO
s
MUSS Committee activities – Med Error Review summary (con’t)
Total Ordering Errors (Total UOs Reported = 161)
1215
20
810 10
5
12 12
17
2119
0
5
10
15
20
25
1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr
2007 2008 2009
# of
err
ors
Total Preparation Errors (Total UO's Reported = 428)
1428 27
153
11
26
52 54
73
48
77
0102030405060708090
1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr
2007 2008 2009
# of
err
ors
Total Administration Errors (Total UO's Reported = 1452)
105121
100 97 89 8497
139 132
168 180
140
020406080
100120140160180200
1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr
2007 2008 2009
# of
err
ors
Total Communication Errors (Total UO's Reported = 788)
61
90
60
47 4839
45
74 70
8779
88
0102030405060708090
100
1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr
2007 2008 2009#
of e
rror
s
Technology implemented at SFGH that impacted Medication Errors
1. Invision/Lifetime Clinical Record (LCR)• Medication Reconciliation• Laboratory values & reports • Allergies & Clinical Alerts
2. Siemens Rx system Patient profiles in Omnicell ADMs
3. Medication Administration Check & Communication (MAK)
4. Omnicell-Automated Dispensing Machines (ADMs)
Invision/LCR - Medication Reconciliation
• Electronic System
28
Medication Administration Check & Communicate Medication Administration Check & Communicate (MAK) (MAK) –– Electronic Medication RecordElectronic Medication Record
Integrated in the Siemens Pharmacy system to facilitate electronic medication administration process using wireless technologies.Project Aim:
Increase patient safety Decrease medication errors by 50% utilizing the electronic medication administration (MAK) program
Computerized documentation achieves the following:Elimination of all transcriptionPharmacy-entered orders are visible in real timeElectronic communication between Nursing & Pharmacy in MAK, reduces phone callsDrug information libraryLab dataHigh alert medications require 2 nurse logonsSpecific drugs require data entry: pain score, pulse, BP, glucoseReminders for pain reassessmentsInjection site charting
MAK Outcomes Study on 5C
• Medication Administration Accuracy Errors were reduced on Unit 5C after introduction of MAK in September 2008
• Error rate was 57% lower than the average error rate on comparison non-MAK units at SFGH
9.1
2.3
11.9
1.3
0
2
4
6
8
10
12
4D 5A 5D 6A % 5C %
% Errors Before% Errors After
Overall Error Rate: Before and After MAK Implementation
2008 Q4 – 2009 Q42007 Q1-2008 Q3
MAK Outcomes Study on 5C
844
2184
316524
0
500
1000
1500
2000
2500
4D 5A 5D 6A 5C
Number Observed Dosesbefore MAKNumber Observed Dosesafter MAK
0.875
0.15
0.6
00
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
4D 5A 5D 6A % 5C %
% Wrong Dose Before% Wrong Dose After
0.825
0.2
0.4
00
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
4D 5A 5D 6A % 5C %
% Extra Dose Before% Extra Dose After
2.6
1
2.4
0.3
0
0.5
1
1.5
2
2.5
3
4D 5A 5D 6A % 5C %
% Omission Before% Omission After
CALNOC – Collaborative Alliance for Nursing Outcomes
• Voluntary quality outcomes monitoring benchmarked anonymously to other like-sized California hospitals.
• Indicators:Medication Administration Accuracy Study (Med Pass) Study: Observe 100 medication passes for the following:
-Patient Identification-Allergies-Patient Teaching-Distraction during Med Pass-Compares to MD Order, Med Admin Record (MAR) & Omnicell-Hand Hygiene-Charting
• All nursing areas of SFGH conduct Medication Administration Accuracy Studies
Administration –Omitted Administrations
Reasons for Omitted Medication Administrations (N=35 patients)
Patient Refused15%
Patient nauseated14%
NPO15%
No reason charted11%
Held per MD Order11%
Dose Administered11%
Not indicated per clinical parameters
11%
IV Site Used3% Pt Off Unit
9%
Integrated Nurse Leadership Program (INLP) Integrated Nurse Leadership Program (INLP) in Medin Med--SurgSurg• The Integrated Nurse Leadership Program (INLP) is funded by the Gordon and Betty
Moore Foundation and is directed and administered by the Center for the Health Professions at the University of California, San Francisco.
• INLP aim is to transform the hospital work environment and improve nurse-related patient outcomes through developing nurses’ professionalism, while enhancing their capacity to create and lead sustainable systems change.
• SFGH the INLP focus has been on Medication Safety including this unit projects:– 4B - Decrease high alert medication errors that could be prevented by 2 RN checks
by 50% in 2009. – 4D - Reduce medication errors related to antibiotics to 80% by Jan 2009.– 5A - Increase and sustain number of medication administration without interruptions
to 90% by June 30, 2009.– 5C - Maintain 95% compliance of “No Interruptions during Preparation and
Administration of Medications Using the New MAK System” by February 2009. – 5D - Decrease medication error related to heparin SQ and IV administration by 100%
and decrease interruptions during medication administration by 90% in six months. – 6A - To conduct 100% allergy screening with every medication administration by
June 30, 2009.
Potential vulnerabilities
• Policy and Procedures – Revision to be completed by April 23, 2010.
• Timely review of UO – Aim is 100% reviewed and addressed by April 23, 2010
• Collation of all medication errors – Have ME, ADR data but need more order entry errors
• Omitted dose – Clinical pharmacists start reviewing charts for omitted dose on April 19, 2010
2010 Pharmacy Performance Improvement Plan
1. 100% of medication orders are entered in the correct patient’s profile by April 2010
2. Reduce interruption by 50% during order entry by encouraging the use of RN-Pharmacy Communication form by Oct 2010
3. 90% of orders will have a 30 minutes turn around time by July 2010
4. Implement pop-up alert window in Omnicell to assist nurses prior to administration for all high-alert meds by July 2010
2010 Pharmacy Performance Improvement Plan (con’t)
5. 100% of units with clinical pharmacist assignment Verify pharmacy profile, MAR and MD orders for discrepancies starting May 2010
6. Implement medication alerts for 100% of MAK units for high alert meds by Sept 2010
7. Implement Omnicell biometrics feature sign-on in 50% of inpatient nursing units by Dec 2010
8. Implement TallMan lettering in Omnicell for 100% of ISMP medication list by April 2010
9. Increase order entry error data reporting by 50% by June 2010