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ABATING THE RISK OF ADEs THROUGH AUTOMATED MEDICATON CYCLE - - PowerPoint PPT Presentation

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ABATING THE RISK OF ADEs THROUGH AUTOMATED MEDICATON CYCLE MANAGEMENT Colleen Burch, RN P. Bruce Campbell, MD Francine Miranda, RN, BSN, FASHRM, HRM Tom Smith, R.Ph., MS Jim Webb, Panel Moderator INTRODUCTION INTRODUCTION 100,000

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SLIDE 1

ABATING THE RISK OF ADE’s THROUGH AUTOMATED MEDICATON CYCLE MANAGEMENT

Colleen Burch, RN

  • P. Bruce Campbell, MD

Francine Miranda, RN, BSN, FASHRM, HRM Tom Smith, R.Ph., MS Jim Webb, Panel Moderator

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SLIDE 2

INTRODUCTION INTRODUCTION

  • A word about timing
  • Enormous public

scrutiny

  • Pending legislation
  • Adverse drug events are

costly

– human terms – economic terms

  • ADEs are largely

preventable

20,000 40,000 60,000 80,000 100,000 Annual Deaths

Auto Accidents Adverse Medical Events AIDS Breast Cancer ADE's

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SLIDE 3

THE RISK MANAGER’S THE RISK MANAGER’S PERSPECTIVE PERSPECTIVE

The Organization’s Imperatives Francine Miranda, RN,FRM

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SLIDE 4

Lehigh Valley Hospital and Health Network

Background

  • Non-profit based in Allentown, PA

– Lehigh Valley Hospital – Muhlenberg Hospital – Lehigh Valley Health Services

  • Advanced regional resources include Level

1 trauma center, burn, kidney transport, perinatal/neonatal, cardiac and cancer center

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SLIDE 5

Lehigh Valley Hospital

Risk Management: What Is It? A systematic approach to the prevention of loss to protect and maintain the financial assets of the institution by preventing liability situations from occurring through proactive interventions.

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SLIDE 6
  • Medication errors
  • Falls with fractures
  • Misdiagnosis

Lehigh Valley Hospital

Liability Exposures - Where do ADE’s fall?

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SLIDE 7
  • What is your medication management

process?

  • Know the strengths and weaknesses of

your process

  • Know where to look for process issues

and be able to identify errors

Lehigh Valley Hospital

Medication Management Process

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SLIDE 8
  • Have a well defined system for process

improvement

  • Once you have the process ….

then look for the causes of breakdown

Lehigh Valley Hospital

Medication Management Process (continued)

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SLIDE 9
  • Physician Ordering
  • Transcription
  • Dispensing
  • Administration

Lehigh Valley Hospital

Medication Management Areas of Concern

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SLIDE 10
  • Order incomplete
  • Order illegible
  • Order written on

the wrong chart

  • Inappropriate drug

selection

  • Inappropriate/

unacceptable abbreviations

  • Route selection
  • Patient drug allergies

not identified

  • Decimal misplaced

Lehigh Valley Hospital

Physician Ordering Risks

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SLIDE 11
  • Order not transcribed
  • Order not completely

signed off

  • Incorrect

transcription onto MAR

  • Allergies not

transcribed

  • Incomplete order

not clarified

  • Transcription

illegible

Lehigh Valley Hospital

Transcription Risks

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SLIDE 12
  • Incorrect IV setting
  • Omitted/over-

looked

  • Extra/duplicated
  • Given without an
  • rder
  • Wrong time
  • Wrong drug
  • Wrong route
  • Wrong dosage

Lehigh Valley Hospital

Administration Risks

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SLIDE 13
  • Incorrect product

not obtained and delivered

  • Incorrectly labeled
  • Product not

delivered to the nursing unit

  • Delay in delivery
  • Product incorrectly

prepared in pharmacy

  • Miscalculation

Lehigh Valley Hospital

Dispensing Risks

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SLIDE 14
  • Do not make the process punitive
  • Cost of automation is a major

concern/obstacle

  • Know your administration’s view/ support
  • n medication errors
  • Have a core multi-disciplinary team work

towards reduction of errors

Lehigh Valley Hospital

Important Points to Remember

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SLIDE 15

THE PHYSICIAN’S THE PHYSICIAN’S PERSPECTIVE PERSPECTIVE

Medication Orders: Why Physicians Will Buy In

  • P. Bruce Campbell, MD
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SLIDE 16

Physicians and Medication Errors

  • How to reconcile “primum non nocere” and

>7,000 annual medication-related deaths?

– Unaware of frequency of medication errors – Unaware of costs of medication errors – Fatalistic attitude re. Medication errors – Competing demands for time and attention

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SLIDE 17

Physicians, Medication Errors, and Computers

  • Compelling demonstrations of decreased

medication errors and adverse drug events with computerized order entry

  • Physician usage crucial to realizing system

benefits

  • Physician reluctance to utilize computerized
  • rder entry no longer tenable
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SLIDE 18

Clinical Systems Implementation at an Urban Medical Center

  • May, 1990: “big bang” implementation of

RN documentation, results retrieval, order entry after two years of planning

  • May, 1990: clinical information system

implodes

  • May, 1992: system universally reviled
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SLIDE 19

Errors in implementation process

  • Administrative failure

– Articulation of commitment – Coherent expression of benefits and expectations – Adjudication of interdepartmental disputes

Clinical Systems Implementation at an Urban Medical Center

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SLIDE 20

Errors in implementation process

  • Errors of design: operationalization
  • Slavish dedication to deadlines
  • Involvement of physicians in design

and implementation

– Education, training, and participation insufficient

Clinical Systems Implementation at an Urban Medical Center

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SLIDE 21

Physician Order Entry at an Urban Medical Center

10 20 30 40 50 60 70 80 90

POE as Per Cent of Non-verbal Orders

7/93 7/94 7/95 7/96 7/97 7/98

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SLIDE 22

Successful Re-implementation

  • f Physician Order Entry
  • Secured senior hospital and clinical

commitment to the project

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SLIDE 23

Successful Re-implementation

  • f Physician Order Entry
  • “Super-users” adopt

the innovation unreservedly

  • Some will never adopt

the innovation unless forced

  • Majority need a prod

to adopt an innovation

10 20 30 40

Laggards Late Majority Early Majority Early Adopters Explorers

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SLIDE 24

Characteristics Critical to Adoption of an Innovation

  • Compatibility with values, experiences,

and needs of potential adopters

  • Relative advantage over the status quo
  • Observability
  • Feasibility
  • Complexity
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SLIDE 25

Physician Attitudes to Computers

  • No innate resistance to computer usage
  • No innate fears of a cultural revolution
  • Concerned solely with requirements for

additional time for order entry

  • Would invest additional 15-45 min. per

day to achieve an increase in quality or 10% reduction in costs

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SLIDE 26

Successful Re-implementation

  • f Physician Order Entry
  • Needs assessment to identify top MD

priorities for system development –7/10: more data –1/10: easier access –1/10: simplicity –1/10: pie-in-sky technology (VR)

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SLIDE 27
  • Demonstrated system benefits for

physicians (compatibility, observability)

– Pharmacy order execution: seconds vs. 90 minutes – Online heparin dosing:

  • Calculated dosing based on height,

weight, and coagulation status

Successful Re-implementation

  • f Physician Order Entry
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SLIDE 28

Online Heparin Dosing and Quality of Care

  • Conventional Dosing

– At 6 Hours: 20% Underdosed and 60% Overdosed – At 24 Hours: 50% Underdosed and 10% Overdosed (10% Therapeutic)

  • Protocol Dosing:

– At 6 Hours: 20% Underdosed, 5% Overdosed (75% Therapeutic) – At 24 Hours: 5% Underdosed, 5% Overdosed (90% Therapeutic)

0% 10% 75% 90%

0% 20% 40% 60% 80% 100% 6 H

  • u

r s 2 4 H

  • u

r s 6 H

  • u

r s 2 4 H

  • u

r s

Effect on Therapeutic Levels of Heparin Conventional Dosing vs. Protocol Dosing

Overdosed Therapeutic Underdosed

Conventional Protocol

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SLIDE 29

Successful Re-implementation

  • f Physician Order Entry
  • Identify and utilize system champions

– Opinion leaders most effective as majority mimics the behavior of role models – Therefore, tailor the tools to their needs (at least initially)

  • Cannot overeducate

– Repeated demonstrations of system capabilities and benefits – Train, train, train

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SLIDE 30

Clinical Systems Implementation

  • Physicians (must,will) adopt order entry
  • Physician utilization can either be

mandated or marketed

  • Physician involvement in system design

and implementation is crucial to success

– Ensures compatibility with values and needs – Ensures end users realize meaningful benefits

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SLIDE 31

THE PHARMACIST’S THE PHARMACIST’S PERSPECTIVE PERSPECTIVE

Filling, Dispensing, and Redeployment of Pharmacists Tom Smith, MS, R.Ph.

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SLIDE 32
  • 3 hospital system
  • 35 clinics
  • Primary facility

– 400 bed community hospital – Census remains high at 80% – Pre-automation pharmacy staff of 42

Moore Regional Hospital

Background

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SLIDE 33

Moore Regional

History of Medication Administration Systems

60’s

  • Decentralized medications
  • Centralized pharmacists
  • Errors > 20%
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SLIDE 34

70’s

  • Unit dose systems developed
  • Centralized medications
  • Centralized pharmacists
  • Errors reduced

Moore Regional

History of Medication Administration Systems

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SLIDE 35

80’s

  • Satellite pharmacies
  • Decentralized medications
  • Decentralized pharmacists
  • Unit-based cabinets
  • Faster turn-around times for

medications

Moore Regional

History of Medication Administration Systems

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SLIDE 36

90’s

  • Managed care
  • Reduced staffing
  • Closed satellites
  • Re-centralized medications
  • Emergence of automation

–Bar codes and bedside scans

Moore Regional

History of Medication Administration Systems

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SLIDE 37
  • Adhere to ASHP’s standards
  • Eliminate/control medication errors

– Implement proven bar-code technology – Implement justifiable automation

  • Robotics
  • Unit-based cabinet technology
  • Closed-loop systems

Moore Regional

Steps to Automation

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SLIDE 38
  • Re-deploy pharmacist to nursing units
  • Reduce inventory
  • Produce WIN/WIN for nursing and

pharmacy

  • Justify systems with “hard dollars”
  • Have a proven reliability

Moore Regional

Steps to Automation (continued)...

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SLIDE 39
  • Be innovative in drug distribution systems
  • Do it with fewer people
  • Reduce dollar drug expenditures
  • Increase the quality of our product

– Decrease errors – Be timely – Be patient-focused

Moore Regional

What Health Care is Being Asked to Do

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SLIDE 40
  • Decreased turn-around time
  • Reduced our inventory by 15%
  • Reduced staffing by 7 FTE’s
  • Increased services
  • Reduced missing/wrong doses by 96%
  • Realized error-free dispensing
  • Achieved system payback in 3 years

Moore Regional

What We Have Accomplished (so far…)

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SLIDE 41
  • Part of the healthcare team
  • Help decrease errors
  • Increased formulary adherence
  • Cost containment
  • Increased job satisfaction
  • Improved patient care

Moore Regional

Pharmacist Re-Deployment for Clinical Interventions

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SLIDE 42
  • Implement the final phase

– Scanning medications At the bedside – Paperless MAR – Close the loop

  • Increase pharmacist input into medication

selection, monitoring and education

Moore Regional

Future Steps

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SLIDE 43
  • Investigate “nurse server” model for drug

storage

  • Move toward physician order entry
  • Expand the use of robotics to our other

hospitals

Moore Regional

Future Steps (continued…)

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SLIDE 44

THE NURSE’S THE NURSE’S PERSPECTIVE PERSPECTIVE

Medication Administration - Where the Rubber Meets the Road Colleen Burch, RN

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SLIDE 45

Background

Providence Portland Medical Center (PPMC)

  • 420 beds
  • Very high managed care concentration
  • Part of Providence Health System
  • Pertinent Systems:

– Real-time patient documentation and automated medication administration at point-of-care – Integrated Pharmacy and Pharmacy robotics – Planning physician order entry implementation

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SLIDE 46
  • History of strong administrative support
  • ADE’s always reviewed for...

– patient safety – quality of care

  • Committed in early 1990’s

– point-of-care charting – focus on medication administration safety

PPMC

Patient Safety Initiatives

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SLIDE 47
  • Before implementing the system

– self-reported – suspect data represented “under reporting”

  • After implementing the system

– potential error caught BEFORE they occur – safety features alerts nurses to “missed doses”

PPMC

Reporting ADVERSE DRUG EVENTS

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SLIDE 48
  • Deployed in 1998

– distribution of medications – improved bar coding

  • Improved coordination

between departments

PPMC

Pharmacy Robotics - A Broader Safety Net

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SLIDE 49
  • Order development
  • Order entry and transcription
  • Processing and filling
  • Administration of medication

PPMC

Potential Points of Failure

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SLIDE 50
  • Order development

– Currently, physicians write orders in chart

  • Order entry and transcription

– Nurse or unit secretary directs order to Pharmacy

  • Processing and Filling

– Pharmacist verifies order – Medication profile generated – Robot fills request – Medications delivered to unit

PPMC

Our Medication Administration Process

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SLIDE 51
  • Nurse administers medication
  • Checks the 5 “Rights” - - patient, drug,

patient, drug, dose, route, time dose, route, time

  • Real-time Point-of-Care system

PPMC

Our Medication Administration Process

NDC 1234567890

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SLIDE 52

Medication Delivery: Medication Delivery:

  • Patient armband scanned (Right patient?)
  • Medication scanned into Point-of-Care device
  • Medication checked against real time

Medication Profile (Is there an order for this?)

  • System verifies against the order
  • If no discrepancies, medication is administered

and documented in real-time

PPMC

Our Medication Administration Process

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SLIDE 53
  • Check Medication Administration Profile

against original orders every 24 hours

  • “Overdue Medication” alert upon log-in
  • “Overdue Medication” list mid-shift and

end of shift

  • Allergy checking

PPMC

Additional Existing Safety Checks

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SLIDE 54
  • Nursing
  • Patients
  • Pharmacists
  • Physicians

PPMC

Reaction to Medication Loop System

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SLIDE 55
  • Administering the medication

– Point-of-care documentation w/ real-time MAR

  • Processing and filling

– Integrated orders, pharmacy, P-O-C documentation – Pharmacy robotics

  • Order entry & transcription / Order

Development

– Physician order entry with real-time alerts next

PPMC

Summary - Where We Are

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SLIDE 56
  • The ”Buck” stops here...
  • Embrace available technology to ensure

patient safety

  • Complete automation of the medication

administration process

PPMC

Advice from a Practicing Bedside Nurse

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SLIDE 57
  • Human error is possible by ANY

ANY health care team member

  • Patient safety is # 1
  • Systematic approach offers best return
  • Focus not on WHO

WHO but WHAT WHAT caused the error

PPMC

Summary - What are the Concerns?

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SLIDE 58

SUMMARY SUMMARY

  • Health care professionals want to solve this problem
  • Focus not on WHO but WHAT caused the error
  • Automation is not the panacea but can significantly

contribute to the solution

– requires accompanying process change

  • Introduce technology that can be made to be least

invasive with greatest impact

  • Physician usage crucial to realizing system benefits
  • Must ultimately address entire medication process
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SLIDE 59