n101y health information technology module medication safety patient safety error prevention
TRANSCRIPT
N101Y Health Information Technology
ModuleMedication Safety
Patient SafetyError Prevention
Patient Safety What is a culture of safety?
A Culture of Safety • IOM:• To Err is Human: Building
a Safer Health System (19919)
• Crossing the Quality Chasm – A New Health System for the 21st Century (2001)
• Medication Errors• Adverse Drug Events• Adverse Drug Reactions
• Assessing the Culture• Teamwork• Patient Involvement• Systems• Openness/Transparency• Accountability
Medication ErrorsTypes and when they occur
Types of Med Errors• Prescribing error • Omission error• Wrong time error• Unauthorized drug error• Improper dose error• Wrong dosage-form error
• Wrong drug-preparation error• Wrong administration-technique error• Deteriorated drug error• Monitoring error• Compliance error• Other medication error
American Society of Hospital Pharmacists. ASHP guidelineson preventing medication errors in hospitals. Am J HospPharm. 1993; 50:305–14.
When Med Errors Occur
• Ordering: wrong dose, wrong choice of drug,• Transcribing: wrong frequency of drug
administration, missed dose because medication is not transcribed,
• Dispensing: drug not sent in time to be administered at the time ordered, wrong drug, wrong dose,
• Administering: wrong dose of drug administered, wrong technique used to administer the drug, and
• Monitoring: not noting the effects of the given medication
Med Error DiscussionThink about medication administrationAs a student have you experienced• A near miss?• A medication error• Witnessing a near miss• Witness a medication error
• See table at http://www.psqh.com/sepoct05/barcodingrfid1.html for statistics.
From http://www.psqh.com/sepoct05/barcodingrfid1.html
Beyond the 5 Rights.
Preventing Medication Errors:
Technology and Equipment
Medication Administration Technology
ORDERING/TRANSCRIBING:• eMARs• ePrescriptions• CPOE (Computerized Provider Order Entry)• CDSS (Clinical Decision Support Systems)
Medication Administration Technology
DISPENSING:• Automated medication
dispensing devices (“Pyxis®”)ADMINISTERING:• BCMA (Bar Code Medication
Administration) • RFID • Smart Pumps
MONITORING:• Smart Rooms• EMR
EMR and Human Error
Elements in the EMR that reduce human error:• CPOE• Bar Code systems• CDSS• High Alert Medication Documentation• Point of Care Documentation• Mandatory Fields • Communication Tool• Med. Recon.
Potential for errors with technology
Errors with BMCA:
• Medication does not come packaged as bar-coded unit-dose product
• Pharmacy does not scan products arriving in pharmacy for readability
• Pharmacy applies correct label with bar code to wrong product
• Drugs not available in ready-to-use unit-doses for nurse (e.g., tablets not broken in half)
• Nurse fails to scan patient
• Nurse fails to scan medication• Bar code on patient and/or medication is
unreadable• Patient wristbands are not on patients
but other locations (e.g., clipboards, med rooms)
• Nurse overlooks alert displayed on computer screen
• Nurse overrides alert without investigating its cause
ERRORS WITH CPOE/EMR/eMAR/ePrescribing:• Mostly user interface issues:
o Wrong patient choseno Drop down menu issues (too many choices!)
• Software issuesIn 2010 computers at a major Midwest hospital chain :o EMR would switch to another patient record without the user
directing it to do soo electronic pharmacy orders weren't being delivered to nurses for
dispensing to patientshttp://www.huffingtonpost.com/2010/08/04/fda-obama-digital-medical_n_670036.html
Potential for errors with technology
Emerging Patient Safety Technologies
The present and the future
Other patient safety technologies
What is patient safety technology? 1. Used in direct hands-on care of the patient2. Documentation tools3. Meeting the needs of patients and families4. Supporting the staff caring for the patient and the
familySOME EXAMPLES:
o Bedside monitoringo CDSSo Communication Toolso Educational o Smart rooms
Potential for errorsOTHER TECHNOLOGIES:DISCUSSWhat are some other areas that might have potential for error• CDSS• Automated medication dispensing devices• Smart Pumps• Smart Rooms• Others?
The Nurse’s Role
• Participate or organize equipment fairs to evaluate technology and equipment before it is purchased at your facility
• Practice and learn to use new technology on challenging scenarios in a simulated setting
• Mentor and oversee temporary (agency) nurses and other personnel as they use your facility’s technology
• Become critical users of technology by identifying problems early and communicating them to vendors and in-house biomedical engineering staff
• Ensure that adverse events associated with medical devices are reported to the Food and Drug Administration MAUDE reporting system and/or ECRI’s Problem Reporting System
• Serve as a resource person on your unit for new technologies by being a SuperUser!
From: http://www.ncbi.nlm.nih.gov/books/NBK2686/
• Culture of safety
• Technology
• The future
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