npr reports, rules and medication safety by steven botwinski, r.ph., yvonne kimura, pharm.d. hao...
TRANSCRIPT
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NPR REPORTS, RULES AND MEDICATION SAFETY
bySteven Botwinski, R.Ph., Yvonne Kimura, Pharm.D.
Hao Luu, ProgrammerBruce Matthias, R.Ph.
The IN Group, Inc.February 18, 2009
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Goals:
• Demonstrate how rules, NPR reports and customer defined screens can be used to aid in regulatory compliance
• Demonstrate how NPR reports can be used to increase the efficiency of clinical monitoring
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JCAHO National Patient Safety Goal 2008
Goal 3E: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
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Anticoagulation monitoring
• Anticoagulation protocol Baseline INR required (order entry- pharmacist) Administration current INR (eMAR-nurse) Clinical progress (daily rounds-pharmacist) Performance measures (pharmacy director)
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Anticoagulation monitoring - Order entry
• Baseline INR required prior to starting warfarin
• Pharmacy rule for pop up screen to warn the pharmacist that no baseline INR has been ordered within 24 hours
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Anticoagulation monitoring - Medication administration
• The medication should not be administered if the most recent (within 24 hours) INR is outside the acceptable range.
• eMAR rule to warn the nurse that the INR is outside the safe range
Display INR value Require action and response
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Anticoagulation monitoring - Clinical monitoring
• Pharmacist monitoring patient progress Patient response to therapy Potential drug interactions Monitoring all anticoagulants
• Use scheduled NPR report Screen patients Pertinent data (lab trends, other meds)
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Anticoagulation monitoring - Performance measures
• Administrative report for all anticoagulant use Degree of compliance Institutional performance trends Detail for follow-up as needed
• Use NPR report Run for specific date range Use data from PHA, LAB, NUR, OE Include heparin, enoxaparin, argatroban and warfarin) for baseline labs and changing renal function if applicable
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Black Box Warnings
Types of Black Box Warnings • Intervention required at order entry• Informational for nursing• Intervention required during therapy• Can be a combination of the above
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Black Box Warnings - Intervention at order entry
• PHA order entry
• Rule with pop-up screen
• Data used from other modules to prevent over flagging (example: female, childbearing age, pregnant? Yes, No, or information missing)
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Black Box Warnings - Informational for nursing
• Information in entirety can be placed in special instructions to be viewed by nurse in eMAR
Advantage: no need for external printer or separate routine
Disadvantage: requires extra keystroke to seen entire text or RN may not notice it is there
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Black Box Warnings - Intervention at administration
• Information in entirety can be placed in Rx comments to be viewed by nurse in eMAR
Full text seen on Acknowledge
Drawback: requres extra key stroke to view full text on first screen of eMAR
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Black Box Warnings - Intervention at administration
• Information in entirety can be placed in admin criteria to be viewed by nurse in eMAR
Will pop-up automatically for viewing in eMAR with each administration and on acknowledge (example: use for quinolones)
Other potential uses: look-alike, sound-alike
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Vaccine Administration
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Vaccine Administration
Vaccine administration requirements • Record lot number and expiration• Provide patient with current vaccine information sheet (VIS)
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Vaccine Administration
• Create a CDS for eMAR Administration query to record lot number and expiration Prompt “Vaccine Information Sheet Given? Automatic launch to CDC website to obtain current VIS (www.immunize.org/vis)
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www.immunize.org/vis/
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www.cdc.gov/vaccines/pubs/vis/default.htm
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Neonatal Dose Verification and Documentation Witness
• Dose verification and preparation verification by a second nurse
• Alleviate need to create a separate pediatric drug formulary
• Audit trail for policy adherence / accountability
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Neonatal Dose Verification and Documentation Witness
eMAR cosignature as part of the prescription audit trail is a great solution…. BUT
eMAR cosignature has been an all or none phenomena once set up in the drug dictionary…. UNITIL NOW
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Neonatal Dose Verification and Documentation Witness
Set up eMAR rule • If patient age is <30 days, require a cosignature for verification of dose and preparation• Include the cosignature as part of the Rx audit trail• Attach the eMAR rule at the global Customer Defined Parameter level
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