E VERYONE M AKES M ISTAKES : M EDICATION S AFETY IN P HARMACY - - PowerPoint PPT Presentation

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E VERYONE M AKES M ISTAKES : M EDICATION S AFETY IN P HARMACY - - PowerPoint PPT Presentation

Jun 25, 2023 389 likes •716 views

E VERYONE M AKES M ISTAKES : M EDICATION S AFETY IN P HARMACY PRACTICE Breanne Piazik, PharmD, MPH, BCPS O BJECTIVES Identify medication errors Describe common factors that may contribute to medication errors Identify strategies for

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EVERYONE MAKES MISTAKES: MEDICATION SAFETY IN PHARMACY

PRACTICE

Breanne Piazik, PharmD, MPH, BCPS

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OBJECTIVES

 Identify medication errors  Describe common factors that may contribute to

medication errors

 Identify strategies for preventing errors  Describe how to respond to a medication error

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STATEMENT OF DISCLOSURE

 I have no conflicts of interest.

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WHAT IS A MEDICATION ERROR?

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WHAT IS A MEDICATION ERROR?

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.

About Medication Errors. (2015, January 30). Retrieved from https://www.nccmerp.org/about-medication-errors

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IS THIS A MED ERROR?

 Patient received ketamine drip that was 10 times

the prescribed concentration

 Patient developed hives after amoxicillin

administration

 Azithromycin was reconstituted incorrectly, but

was caught before it was dispensed to the patient

 Patient received a dose of diltiazem IR 240 mg

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CATEGORIZING MEDICATION ERRORS

 Where it happens in the process  Prescribing/monitoring  Storing/dispensing/preparing  Administering  Outcome to the patient  Was there harm?  If there was harm, was it temporary?  Did we need to intervene?

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CATEGORIZE THE EVENT

 Patient received ketamine drip that was 10 times

the prescribed concentration

 Patient developed hives after amoxicillin

administration

 Azithromycin was reconstituted incorrectly, but

was caught before it was dispensed to the patient

 Patient received a dose of diltiazem IR 240 mg

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HOW DO MEDICATION ERRORS HAPPEN?

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HOW DO MEDICATION ERRORS HAPPEN?

Look Alike Sound Alike Medications

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https://www.ismp.org/sites/default/files/attachments/2017-11/tallmanletters.pdf

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HOW DO MEDICATION ERRORS HAPPEN?

Communication

 Abbreviations/slang  tPA vs. TPN vs. TXA1  levo…  Accents  15 vs. 50  Handwriting2

  • 1. ISMP. (2015, Sep.) FDA Adviser-ERR: Avoide using the error-prone abbreviation, TPA. Retrieved from https://www.ismp.org/alerts/fda-advise-

err-avoid-using-error-prone-abbreviation-tpa.

  • 2. ISMP. (2015, Dec.) Health alert! Avandia, not Coumadin. Community/Ambulatory Care ISMP Medication Safety Alert! 14(12). Retrieved from

https://www.ismp.org/communityambulatory/medication-safety-alert-december-2015.

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HOW DO MEDICATION ERRORS HAPPEN?

Staffing

 Staffing patterns  Are enough staff scheduled during the busiest times

  • f the day?

 Call outs  Are call outs covered?  Can certain tasks be postponed/delayed?  Training  Are staff competent to perform the tasks that are

asked of them?

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HOW DO MEDICATION ERRORS HAPPEN?

Lack of knowledge

 Patient information  Allergy information  Medication list  Pharmacies used  Problem/condition list  Lab values  Medication information  Dosing  Administration  Monitoring

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HOW DO MEDICATION ERRORS HAPPEN?

Distractions

 Phone calls  Interruptions  Drive-thru

System problems

 System defaults  Shortcuts and hotkeys  Dose warnings

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HOW DO MEDICATION ERRORS HAPPEN?

 Human error  Confirmation Bias: search for and focus on

information that supports what someone already believes, while ignoring facts that go against those beliefs1

Psychology Today (2019). What is Bias? Retrieved from https://www.psychologytoday.com/us/basics/bias

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HOW DO MEDICATION ERRORS HAPPEN? SWISS CHEESE MODEL

 Created by James Reason based on analysis of

aviation errors

 Human error is inevitable  Systems resemble stacked layers of Swiss cheese  Active error: committed by individuals  Latent error: flaws in system  “Error waiting to happen”

  • AHRQ. (2019, Jan.) Patient Safety Primer: Systems Approach. Retrieve from https://psnet.ahrq.gov/primers/primer/21.
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The Swiss cheese model [online image]. (2019).Retrieved from https://www.cmpa- acpm.ca/serve/docs/ela/goodpracticesguide/pages/patient_safety/Systems/systems _thinking_2-e.html

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SWISS CHEESE EXAMPLES?

 Patient received ketamine drip that was 10 times

the prescribed concentration

 Azithromycin was reconstituted incorrectly, but

was caught before it was dispensed to the patient

 Patient received a dose of diltiazem IR 240 mg

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WHAT CAN WE DO TO PREVENT ERRORS?

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ROOT CAUSE ANALYSIS

 Way to identify underlying

causes of an event

 Usually involves a team  Goal is to identify both

active and latent errors

 What happened?  Why did it happen?  What can be done to

prevent it from happening again?

American Society for Quality. (2019). What is root cause analysis (RCA)? Retrieved from https://asq.org/quality-resources/root-cause-analysis The cause mapping method of root cause analysis. (2019). Retrieved from https://www.thinkreliability.com/cause- mapping/what-is-root-cause-analysis/.

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ROOT CAUSES

Error: Patient received ketamine drip that was 10 times the prescribed concentration Active errors:

 Incorrect product selection during dispensing  Preparation with incorrect product

Latent errors:

 Staffing  Time pressure- nurse was waiting for medication  Multiple ketamine concentrations available

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ROOT CAUSES

Error: Patient received a dose of diltiazem 240 mg IR Active errors:

 Incorrect product selection during prescribing  Medication list was not updated  Incorrect product verified for inpatient

administration Latent errors:

 No dose warning fired  Displayed in medical record as a prescription

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WHAT CAN WE DO TO PREVENT ERRORS?

 Open and honest reporting of errors  Completely analyze errors to identify root causes  Change processes to mitigate root causes  Checklists  Warnings  Education  Maximize visual differences  Change storage locations  Hard stops

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WHAT CAN WE DO TO PREVENT ERRORS? JUST CULTURE

 Shift from punitive culture  System of shared accountability  Organizations are accountable for their systems

 Learning system constantly looking to improve

 Individuals are accountable for their behavior

 Human error  At-risk behavior  Reckless behavior

Just Culture: Training for Managers. (2012). Plano, TX: Outcome Engenuity, LLC.

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JUST CULTURE INVESTIGATION

 What happened?  What normally happens?  What is supposed to happen?  Policy/procedure  Why did it happen?  What is the organization going to do to manage

the risk?

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WHAT DO WE DO WHEN WE DISCOVER AN ERROR?

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WHAT DO WE DO WHEN WE DISCOVER AN

ERROR?

 Respond  Ensure the patient is alright  Intervene if necessary  Notify the prescriber/patient  Report  CQI rules  Prevent  Change process as necessary as identified by error

investigation

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IN SUMMARY

 Be honest and open about errors  Mistakes happen; everyone is human  Report errors so others can learn  Report errors so the system can improve  Report errors for the patients’ sake  Report errors because it is the right thing to do

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Questions?