EVALUATING AND REDUCING THE RISK AND COST OF MEDICATION ERRORS - - PowerPoint PPT Presentation

EVALUATING AND REDUCING THE RISK AND COST OF MEDICATION ERRORS RELATED TO INCOMPLETE MEDICATION HISTORIES

Haley Monolopolus, Pharm. D. PGY-1 Pharmacy Practice Resident Providence Alaska Medical Center, Anchorage, AK

IRB status: approved

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DISCLOSURE

 Presenter: Haley Monolopolus

 Conflict of interest: none  Sponsorship: no funding received to support research

 The research presented is subject to different interpretation  This presentation is educational in nature and abides by non- commercial guidelines

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LEARNING OBJECTIVES

1. Explain the goal of medication history and define undocumented intentional discrepancies and unintentional discrepancies 2. Identify potential barriers to completing medication histories for patients admitted to the hospital 3. Give examples of medication error categories based on the National Coordinating Council for Medication Error Reporting and Prevention Index

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PROVIDENCE ALASKA MEDICAL CENTER

Anchorage, AK  Largest hospital in the state

 402 beds  62 emergency department beds

 Tertiary, non-profit, community medical center  Transition of care services

 2.4 FTE medication history technicians:

 Coverage: M-F 0900-1930, Sa/Su: 1000-1830

 Decentralized pharmacists, pharmacy residents, pharmacy students

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PRE-TEST ASSESSMENT

1. Which of the following is an example of an undocumented intentional discrepancy?

a) Hospitalist adds lisinopril 10 mg daily to the home medication list since the patient was taking it prior to admission. b) Hospitalist omitted ordering lisinopril 10 mg daily, by mistake. c) Hospitalist holds lisinopril 10 mg daily due to AKI, without documenting in the EHR. d) Hospitalist holds lisinopril 10 mg daily due to AKI and documents the change in the EHR.

2. All of the following are potential barriers to completing medication histories for patients admitted to the hospital EXCEPT:

a) Lack of appropriate documentation b) Standardized process required by Joint Commission c) Staffing capabilities d) Receiving documentation from outpatient pharmacies

3. What NCC MERP error category would the following scenario be classified as?: The physician unintentionally omits ordering allopurinol 100 mg daily from the home medication list and patient does not receive the medication

a) A b) B c) C d) D

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BACKGROUND

 The Joint Commission identified medication reconciliation as a National Safety Goal in 2005  Despite a formal process being mandated by accreditation

• rganizations, a large percentage of patients have unintentional

medication discrepancies on their home medication list  Currently, there is no universal, standardized prioritization scheme for completing medication histories  At PAMC our goal is to complete medication histories within 24 hours of admission

 If unable to complete within 48 hours, work is stopped unless continuation is requested by a physician and/or pharmacist

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BACKGROUND

 Goals of medication reconciliation

 Prevent ADRs at all interfaces of care (admission, transfer, discharge)  Confirm undocumented intentional discrepancies  Eliminate unintentional discrepancies

 Undocumented intentional discrepancies

 Prescriber intentionally adds /changes/discontinues a medication without clearly documenting in the patient’s medical record

 Unintentional discrepancies

 Prescriber unintentionally adds/changes/omits a medication the patient was taking prior to admission

 Potential barriers to completing medication history

 Direct admissions, staffing capabilities, patient altered/unreliable, complex home medication lists, lack of documentation, receiving documents from pharmacies/other sources

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STUDY OBJECTIVES

 Primary Objective

 Evaluate the number, type, severity, cost, and risk of errors

• ccurring when medication histories are not completed within 48

hours of admission

 Secondary Objectives

 Evaluate current process of completing medication histories and identify prioritization scheme to capture higher risk patients  Evaluate number/types of changes made to previously completed medication histories for patients with “simple medication histories”

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METHODS

SIMPLE MEDICATION GROUP

History completed any time during admission which meets any of the following:  <5 prescription medications  Only OTC medications

48 HOUR HIGH RISK GROUP History completed after 48 hours of admission which meets any of the following:

 >5 prescription medications  Anticoagulants, anti-epileptics, insulin, transplant medications, and/or COPD medications

• Data analyzed for patients having medication histories completed

between June 1st, 2019 and December 31st, 2019

• Cost evaluated for medications incorrectly administered based on an

inaccurate medication history

• Medication errors and risk assessed using the NCC MERP Index

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METHODS

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RESULTS – Patient Groups

SIMPLE GROUP Total patients = 345  <3 Rx medications, including no medications = 238 patients (69%)

 < 3 Rx medications = 142 patients  No medications = 96 patients

 3-4 Rx medications = 82 patients (24%)  Only OTC medications = 25 patients (7%)

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RESULTS – Patient Groups

HIGH RISK GROUP Total patients = 84  > 5 Rx medications ONLY = 35 patients (42%)  High risk medications ONLY = 2 patients (2%)  > 5 Rx medications AND high risk medication = 47 patients (65%)

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RESULTS – Errors

SIMPLE GROUP HIGH RISK GROUP Total Patients 345 84 Patients with Error Present

• n List

194 (46%) 77 (92%) Total Errors

• Wrong drug/dose/freq
• Missing drug

425 463 134 errors (31.5%) 273 errors (59%) 291 errors (68.5%) 190 errors (41%) Errors per Patient ~2 ~6

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RESULTS – Wrong Drug

SIMPLE GROUP  Wrong drug actually administered

 6 medications (4.4%)  30 total doses

 Total unnecessary Cost

 Rx = $59.22  Patient = $1,143.50

Medication Number

• f Doses

PRN (Y/N) Aspirin 81 mg 2 N Budesonide-formoterol 160-4.5 mcg 6 N Clonazepam 1 mg 10 Y Lisinopril 20 mg 1 N Metoprolol succinate 50 mg 6 N Omeprazole 40 mg 5 N

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RESULTS – Missing Drug

SIMPLE GROUP  Missing drug actually omitted

 81 medications (27.1%)  510 total doses Prescription Medications OTC/non-formulary Medications Number of Medications 34 (43%) 47 (57%) Number of Doses 160 (31.6%) 347 (68.4%)

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RESULTS – Wrong Drug

HIGH RISK GROUP  Wrong drug actually administered

 76 medications (27.8%)  556 total doses

 Total unnecessary Cost

 Rx = $214.16  Patient = $16,584.17

Medication: HIGHLIGHTS Number

• f Doses

PRN (Y/N) Amitriptyline 100 mg 18 N Pantoprazole 40 mg

20 N

Carvedilol 3.125 mg

8 N

Apixaban 5 mg

10 N

SMX-TMP 800-160 mg

4 N

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RESULTS – Missing Drug

HIGH RISK GROUP  Missing drug actually omitted

 100 medications (52.6%)  1172 total doses Prescription Medications OTC/non-formulary Medications Number of Medications 72 (72%) 28 (28%) Number of Doses 764 (65.2%) 408 (34.8%)

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RESULTS – Safety

 All errors were categorized as A, B, or C based on NCC MERP  No medications incorrectly administered or omitted caused known patient harm or additional intervention

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RESULTS – Time to Completion

SIMPLE GROUP HIGH RISK GROUP Time to Completion 0-24 hours: 310 patients (89.9%) >24-48 hours: 21 patients (6.1%) >48 hours: 14 patients (4%) Reason for Incomplete at 48 hours ICU 3 patients 3 patients VA 1 patient 10 patients Facility

• 1 patients

Family

• 2 patients

Consult 2 patients 5 patients Unknown 8 patients 63 patients Average time to Completion 11:16:00 83 patients completed at 00:00 83:39:00

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DISCUSSION

 Potential limitations

 Retrospective chart review  Undocumented intentional discrepancies  Lack of documentation  PTA medications may become inappropriate at admission  Discontinued medications may become appropriate at admission

 All medication histories included in the study were completed

 Safety: NCC MERP error categories A, B, or C  Potential for D-I if continued throughout duration of hospitalization

 High risk group: more disease states, more medications, more errors  Cost to the patient more than the cost to the pharmacy department

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CONCLUSION

 High risk group had a higher percentage of medications administered incorrectly (27.8% v 4.4%) and a higher percentage of medications incorrectly omitted (52.6% v 27.1%), compared to the simple group

 High risk group had a higher percentage of prescription medication doses omitted (65.2% v 31.6%), compared to the simple group

 Most simple mediation histories are complete within 24 hours of admission (89.9%)  Stopping work on incomplete histories at 48 hours is failing to resolve medication discrepancies on home medication lists  More staff and changes to the medication history process at PAMC are necessary to prevent medication errors

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POST-TEST ASSESSMENT

1. Which of the following is an example of an undocumented intentional discrepancy?

a) Hospitalist adds lisinopril 10 mg daily to the home medication list since the patient was taking it prior to admission. b) Hospitalist omitted ordering lisinopril 10 mg daily, by mistake. c) Hospitalist holds lisinopril 10 mg daily due to AKI, without documenting in the EHR. d) Hospitalist holds lisinopril 10 mg daily due to AKI and documents the change in the EHR.

2. All of the following are potential barriers to completing medication histories for patients admitted to the hospital EXCEPT:

a) Lack of appropriate documentation b) Standardized process required by Joint Commission c) Staffing capabilities d) Receiving documentation from outpatient pharmacies

3. What NCC MERP error category would the following scenario be classified as?: The physician unintentionally omits ordering allopurinol 100 mg daily from the home medication list and patient does not receive the medication

a) A b) B c) C d) D

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