5/19/2014
Technician Education Day
May 24, 2014 – Ft. Lauderdale, FL
7,000 are
medication
-related
deaths
The Pharmacy Technician’s Role
in Keeping Our Patients Safe
Antonia Zapantis, MS, PharmD, BCPS
Associate Professor, Nova Southeastern
University College of Pharmacy
1. IOM. To Err is Human. 1998. 2. IOM. Preventing Medication Errors: Quality Chasm Series. 2006.
Disclosure
Vasiliki Veronika
The presenter has no other financial or personal
relationships with commercial entities that may
have direct or indirect interest in the subject
matter of this presentation
Objectives
1
Define a medication error
2
Define cultures associated with safety
3
Discuss root cause analysis and its role
in medication error reduction
4
Discuss the process of Failure Mode
and Effects Analysis (FMEA)
5
Look-a-like/Sound-a-like (LASA)
Describe the role of technology in reducing
the occurrence of medication errors
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Vasiliki Veronika – The Superstar!
WHAT IS A MEDICATION ERROR?
Medication vs. Medical
Institute of Medicine (IOM)1,2
44,000-98,000 medical errors in US hospitals
result in death
~1.5 million preventable adverse events per
year
Preventable errors
• Est. cost between $17 to $29 billion per
year
• Avg. increased hospital cost of $4700$8,750 per admission
•
•
•
1. IOM. To Err is Human. 1998. 2. IOM. Preventing Medication Errors: Quality
Chasm Series 2006
“…any preventable event that may cause
or lead to inappropriate medication use or
patient harm, while the medication is in the
control of the health care professional,
patient, or consumer”
National Coordinating Council for Medication Error Reporting and
Prevention
Preventing Medication Errors:
Quality Chasm Series
•
A paradigm shift in the patient-provider relationship
•
•
•
•
Using information technologies to reduce medication
errors
•
•
Communicate more with patients at each point of healthcare
delivery
Pts or their surrogates should take more active role
Healthcare system needs to do a better job of educating pts
& of providing ways self-education
Potential error: A mistake in
prescribing, dispensing, or planned
medication administration that is
detected and corrected through
intervention (by a health care
provider or patient)
• “near miss”
In prescribing and dispensing medications
Improved labeling and packaging
IOM. Preventing Medication Errors: Quality Chasm Series. 2006.
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Classification
•
Prescribing
•
Dosage form
•
Omission
•
Administration technique
•
Compliance
•
Monitoring
•
Drug deterioration
•
Drug preparation
•
Unauthorized drug
usage
•
Timing
http://www.nyee.edu/images/lasa-example-017.jpg
Pharmacists Mutual Insurance
Company Claims (1989-2001)
Tall Man Lettering
HYDROXYZINE & HYDRALAZINE
vs.
hydrOXYzine & hydrALAzine
Wrong drug dispensed
50%
Wrong strength dispensed
25%
Wrong directions
9%
Failure to detect a prescribing
8%
error
Counseling
2%
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Ju
/
/
Look – a – Like / Sound – a - Like
Pick the
right one!
“Yas” vs. “Yaz”
http://www.hendricks.org/upload/images/Quality/
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Medication Safety:
The Swiss Cheese Effect
Coumadin 4 mg po qd
Sig: i tab po q day
Medication Safety:
Prescriber The Swiss Cheese Pharmacis
Effect
Nurse writes Pt’s allergy gives t fails to order for history is patient check medicatio
drug to not patient n to which obtained
which allergy patient is s/he is status
allergic
allergy
Flomax 0.4mg PO QD
Patient arrests & dies
Insulin SC NPH 15 u Am + 6 units pm
http://www.philblock.info/hitkb/_images/swiss_cheese_model2.jpg
A look through time at our culture…
Lipitor 10 mg po i qd
Punitive
Tequin tab 400 mg po qd
http://blogs.thenews.com.pk/blogs/wp-content/uploads/2011/12/corporal-punishment.jpg
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Punitive Culture “Name, shame and
blame”
www.ism
p.org





Individuals are fully and sometimes
solely accountable for the outcomes of
patients under their care
Necessary for disciplinary action in
order to maintain power and safety
Disciplinary action safety related to
severity of the undesirable outcome
“Bad practitioners” = Frequent or
harmful errors
Need to weed out these individuals for
safer healthcare environments
Lessons from Denver…
•
•
Treatment of congential syphilis in a one-day old infant
Order written for
ISMP
(Institute of Safe Medication Practices)
•
Non-profit organization
•
Publishes ISMP Medication Safety Alert
•
•
of specific error or system
ISMP’s Evaluation
•
•
“Benzathine penicillin G 150,000U IM”
•
•
•
•
Pharmacist misread order as 1,500,000 units
Label indicated that 2.5 mL = 1,500,000 units
Nurse expressed concern about number of
injections = 5 (max 0.5 mL per IM injection
Aspden P, et al. (ed). Preventing Medication Errors. 2007. National
Academies Press.
in neonate)
Distribute information to alert health care providers of
potential med errors or med errors which have occurred
in other institutions
Available to come to an institution for review
•
Identified >50 system failures
Focus on the multiple underlying system failures which
shape individual behavior and create the conditions
under which med errors occur
Providing optimal med safety requires that latent system
failure are recognized and corrected
We must look beyond blaming individuals!
Aspden P, et al. (ed). Preventing Medication Errors. 2007. National Academies Press.
Lessons from Denver…
•
•
•
•
•
•
Nurses gave slow IV push instead based on drug
reference book
Benzathine is insoluble & obstructs blood flow to lungs
After 1.8mL had been administered the infant became
unresponsive
3 nurses were indicted by a grand jury
for negligent homicide
2 agreed to legal sanctions before trial
1 plead not guilty & went to trial
Aspden P, et al. (ed). Preventing Medication Errors. 2007. National
Academies Press.
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A look through time at our culture…
A look through time at our culture…
PunitiveBlame-Free
www.pyxis.com
http://mcbrideandgroom.clarksrule.com/wp-content/uploads/2009/03/swing.jpg
Who Me?
Just Culture
“Amnesty for all”
Neither supports punitive nor blame-free cultures wholly
when errors occur
 Safety is valued in the organization
 Organization continually looks for risks that pose a
threat
 Careful thinking about risky behavioral choices
 Always thinking about the most reliable
ways to get the job done correctly

Purpose of a Non-Punitive Policy
Blame-free Culture

•
•
Even the most experienced, knowledgeable, vigilant, and
caring workers could make mistakes that could lead to
patient harm
Recognition that workers who made honest errors were
not truly blameworthy, nor was there much benefit for
punishment for unintentional acts
Not fully supportive of an industry wide
desire to become wholly blame-free
To encourage reporting of medication errors
as a means to assess and improve the
medication use process and provide a safe
environment for patient care without worries
of sanctions.
www.ismp.org
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Just Cause:
ERROR FOLLOW-UP
Different types of Error
• Unintentional &
unpredictable behavior
• Undesirable outcome,
either because a
planned action is not
completed as intended
or the wrong plan is
used to achieve an aim
• Drift into unsafe
habits, to lose
perception of the
risk attached to
everyday behaviors,
or mistakenly
believe the risk to
be justified
• Risk is understood &
intentional
Human error
At-risk behavior
Reckless behavior
•
“A Rose by Another Name…”
•
•
•
•
Incident report forms
Variance forms
Medication Errors Reporting Program (MERP)
Report
•
•
•
Errors
Near-misses
Hazardous conditions
http://www.phmic.com/SiteCollectionDocuments/Pharmacy%20Liability
%20Key%20Controls.pdf
Purpose of Error Reporting
Just Culture
Type of Behavior
Description
Suggested Response
Human Error
Unintentional acts
Console
At‐Risk
Short‐cuts
Coach
Reckless
Intentional
Substantial risk
Outside the norm
Discipline
•
•
•
•
To increase awareness of medication errors
To examine and evaluate the causes of medication
errors
To recommend strategies relative to system
modifications, practice standards and guidelines, and
changes in packaging, labeling, and product identity
Maintain systems to support and provide feedback to
reporters so that appropriate prevention
strategies can be developed in facilities
Reports Should Include…
•
•
Incident Report Forms
•
•
•
•
•
•
•
A description of the error or preventable adverse drug
reaction. What went wrong?
If this was this an actual medication error (reached the
patient) or are you expressing concern about a potential
error or writing about an error that was discovered
before it reached the patient?
The patient outcome
Where it occurred?
The generic & brand names of all products involved
The dosage form, concentration or strength, etc.
How was the error discovered/intercepted?
If the error was resolved?
Please state your recommendations for error prevention
www.ismp.org
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5/19/2014
Error Follow Up
•
Root Cause Analysis
Biggest complaint patients have regarding pharmacy
errors:
•
They are usually more upset about the response, or lack of
response they receive than with the actual error
•
•
•
Identifies the factors that underlie variation in
performance
Focuses primarily on the systems & processes, not
individual performance
End Result  Action Plan
•
•
Identifies the strategies to reduce risk of similar events
occurring in the future
Addresses responsibility for
implementation, oversight, pilot testing,
time lines, measurement strategies
www.ismp.org
Josie King Story
Sentinel Event
An unexpected occurrence that results
in unanticipated death or major,
permanent loss of function
*** “Sentinel Event” & “Medical Error” are not
synonymous; not all sentinel events occur because
of an error and not all errors result in sentinel
events***
Josie King Pediatric Patient Safety Program
www.josieking.org
Error with EPInephrine – Aug 2004
Dennis Quaid Twins
1 mL vial (10,000 units/mL) vs. 1 mL vial (10 units/mL)
•
•
16 yoa male w/ priapism

Inject 1:1,000,000 solution of epinephrine into penis =
Add 1:1,000 (1mg/mL) Epi to 1 L NS
•
Dr. thought 1:1,000 dilution was 1mg/L
•
Pt received 4mg of undiluted drug into penis
•
Cardiac Arrest & DIED


2006  Indiana
 6 neonates administered dose
 3 died
2007  California
 3 neonates administered dose
 No fatalities
2008  Texas
 17 neonates administered
doses
 2 died
2007
www.ismp.org
http://www.seamedical.com/images/Quaidtwins
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Questions that should only be
answered by the pharmacist
Heparin Babies
“Why does my medication
look different?”
 “Why are the directions
different than what my
doctor told me?”
 “I’m allergic to…
Can I take this
Medication?”

http://www.phmic.com/SiteCollectionDocuments/Pharmacy%20Liability%
http://www.ismp.org/images/acuteCareNewsletter/20060921a.jpg
http //www bd com/posiflush/products/images/posiflush heparin jpg
Avoiding drug mix-ups (ISMP)
Triple Check, Plus Two
Check each prescription 3 times
• When entering the
prescription/
order information
• When selecting
the bottle/vial
from the shelf
• While filling
the
medication/
order

Process 1
Process 2
Process 3


Repeat back all telephone orders, spell the drug name,
and ask for indication
Use magnifying lenses and place orders/prescriptions at
eye level under good light during transcription
Change the appearance of look-alike product names on
the computer, pharmacy shelf, product labels, and
medication records
 ex.
tAll mAn lettering
http://www.phmic.com/SiteCollectionDocuments/Pharmacy%20Liability
Triple Check, Plus Two
Plus two additional checks
• Check the
NDC/scan
• “Show and
Tell” before
dispensing
Process 1
Process 2
Avoiding drug mix-ups (ISMP)
To the patient,
nurse,
pharmacist



Affix name alert stickers in areas where look
or sound-a-likes are stored
Store look or sound a-likes in different
locations
Use at least 2 independent checks in the
dispensing process
 One person interprets and enters the rx
 The other person checks the label against
the original and product. Put the most
detail oriented person here
http://www.phmic.com/SiteCollectionDocuments/Pharmacy%20Liabilit
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Avoiding drug mix-ups (ISMP)



Verify the NDC code
Open the bottle in front of the patient to confirm
appearance and indication
Unit dose medication
“Approximately 45- 50% of medication errors
reported to the USP-ISMP Medication Error
Reporting Program (MERP) and FDA
MEDWatch Program are related to problems
with product labeling, packaging or
nomenclature.”
 In-patient
 Out-Patient?

(Done in Europe)
Limit use of abbreviations
Proulx SM. Managing Pharmaceuticals to Reduce Medication Errors . ISMP. 2003. Available at:
/
/
/
Why do errors occur?
http://www.jointcommission.org/NR/rdonlyres/969F94E2-6908-4A30-A1B4-EFE9BDB23D24/0/se_rc_medication_errors.jpg
FMEA: Process Steps
(What would
be the
consequences
of each
failure?)
Effects
Modes
(What could
go wrong?)
Causes
(Why would the
failures happen?)
http://www.jointcommission.org/NR/rdonlyres/969F94E2-6908-4A30-A1B4-EFE9BDB23D24/0/se_rc_medication_errors.jpg
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In-Patient Prescribing/Transcribing

Computerized Physician Order Entry (CPOE)
 Can
reduce medical errors by up to 70%
 1998 - only 1/3 of U.S. hospitals have CPOE
http://www.lifespan.org/imagesI/servi-tech-image-58718-cpoe1 o.jpg
CPOE
Some hospitals with CPOE:
Technology Initiatives
in Patient Safety
•
Brigham and Women’s Hospital
•
Ohio State University Medical Center
•
University of Virginia Health System
•
University Hospital of Arkansas
•
Medical College of Virginia Health System
•
University of Illinois at Chicago Medical Center
•
Vanderbilt University Medical Center
•
VA System
•
Cleveland Clinic Florida
•
Broward Health System
•
Memorial Health System
•
Jackson Memorial Hospital
http://www.codonics.com/Products/SLS/Large_Top.jpg
http://ww1.hdnux.com/photos/04/03/55/1063764/3/628x471.jpg
Technology Initiatives in
the Healthcare System
E-Prescribing/Transcribing

Prescribing
Monitoring
Transcribing/
Repackaging
Administration

BluefishRx*
Allscripts
 Pay for Themselves
 A study at University of
Rochester (NY) Medical
Center reported a
reduction in costs of
almost $394,000 per
year in the pilot study of
28 physicians in five
groups
 Earned back entire
investment in 16 months
*www.bluefishwireless.com
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Feb 2004 – FDA Bar Coding
Rule

In-Patient Dispensing
Pyxis® Automated Dispensing Cabinets (ADC)*
FDA estimates:
 50%
increase in the interception of medication
errors at the "dispensing and administration"
stages
 413,000
fewer adverse events over
the next 20 years
 $7.2
billion cost to the 6,000 hospitals
*www.pyxis.com
Out-Patient Dispensing
In-Patient Dispensing
ScriptPro® Prescription Dispensing System*
*www.scriptpro.com
http://www.mckesson.com/static_files/McKesson.com/MPT/Images/ROBOT-Rx/full_ROBOT-Rx_Carousel_4.jpg
Out-Patient Dispensing
In-Patient Dispensing
Baker Universal 2000*
Baker Cassettes*
Baker Cells*
*www.mckessonaps.com
http://jerryfahrni.com/wp-content/uploads/2009/05/vc1_frontangle.jpg
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Administration Point-of-Care
Considerations
Planning is key!
Takes a long time to plan
 Will not prevent all errors
 Has potential to create new types of
errors
 CPOE is time-consuming for ordering
practitioners
 Expensive! Upfront costs: $500K to
$15 million


Wireless or
OR Computer on
Wheels
Pharmacy
Computer
System
ADC
Administration Point-of-Care
Technician Education Day
May 24, 2014 – Ft. Lauderdale, FL
The Pharmacy Technician’s
Role in Keeping Our
Patients Safe
Antonia Zapantis, MS, PharmD, BCPS
Associate Professor
Nova Southeastern University College of Pharmacy
Monitoring: mHealth
http://blog.softwebsolutions.com/wp-content/uploads/2012/04/ipad-medical.jpghttp://www.mobilemarketingwatch.com/wordpress/wp-content/uploads/2011/01/Mobile-Healthcare-mHealth-News-Roundup.jpg
http://www.mocom2020.com/data/2009/03/mhealth-mocom2020com.jpg http://www.prlog.org/11414511-mhealth-is-in-high-demand.jpg
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