MEDICATION SAFETY
Meeting HFAP Accreditation
Standards for Pharmacy Services
and Medication Use
Part One
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HFAP Chapter 25 keeps you in
compliance with the Medicare
Conditions of Participation
Medication Safety Series
1.
2.
3.
4.
5.
Prescribing challenges
Procurement in an era of drug shortages –
keeping it safe
Preparation and dispensing – includes
sterile preparation
Administration of medications – timing, unit
dose, bedside medication verification
Monitoring of therapy, Medication Use
Evaluations
Prescribing Challenges Objectives
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Describe the optimal environment for
safe prescribing
List the necessary tools for enhancing
the knowledge of medications
Discuss the advantages and
disadvantages of computerized
physician order entry (CPOE)
The Problem
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The Institute of Medicine Report revealed that
errors in medical care are responsible for
many deaths
Many health care providers are not aware of
their responsibilities
Medication errors responsible for numerous
adverse outcomes, including death
This results in high cost (emotional and
financial)
Who are the participants?
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Physicians
Nurses
Pharmacists
Respiratory Therapists
Patients
The casual observers who can alert the
care providers about opportunities for
errors
RESPONSIBILITIES
Physicians Nurses
Pharmacists Respiratory
Therapists
X
Prescribing
X
Preparation
X
X
X
X
Dispensing
X
X
X
X
Administration
X
X
X
X
Monitoring
X
X
X
X
Regulatory Standards
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HFAP – Chapter 25
CMS Conditions of Participation 482.25
The Medication Use Process
Components
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Prescribing
Procurement
Preparation
Dispensing
Administration
Monitoring
Where Do Errors Occur?
Prescribing
Transcribing
Dispensing
Administering
39%
11%
12%
38%
PRESCRIBING
25.01.12, 25.01.13
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Is a collaborative effort
There is an increasing body of
knowledge
– New therapeutic entities
– Drug interactions
– Allergies database
– Food-drug interactions
– Post-marketing data
PRESCRIBING
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Physician (and other prescribers)
responsibilities:
– Diagnosis
– Drug and dosing choices
– Medication reconciliation
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Pharmacist responsibilities (25.01.15, 25.01.16)
– Drug information
– Protocol-based management of patient
medications
– Review of physician orders
Training, Memory and Best Efforts
As Safety System Tools
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1980: medical school graduates needed
to really know 60 drugs well
2000: this number was estimated at 600
drugs
2012: add another 100-200 drugs
Drug-drug interactions increase
exponentially with these numbers
Training, Memory and Best Efforts
As Safety System Tools
Medications
Potential DDIs
2
1
4
6
8
28
16
120
DDI = drug-drug interaction
Karas S. Ann Emerg Med 1981; 10:627-630
HIGH ALERT MEDICATIONS
25.01.01, 25.01.20
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Adrenergic agonists
Intravenous adrenergic antagonists
Amiodarone/Amrinone
Benzodiazepines (especially
midazolam)
Intravenous calcium
Chemotherapeutic agents
THE ABBREVIATION
PROBLEM
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U
ug
q.d.
qod
SC
TIW
Medication Prescribing Process
Components: Communication
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Written Prescription Orders
Medication Ordering Systems
Electronic Order Transmission
Dosage Calculations
Verbal Orders
Medication reconciliation
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Written Medication Orders:
Illegible Handwriting
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16% of physicians have illegible handwriting.1
Common cause of prescribing errors.2, 3, 4
Delays medication administration.5
Interrupts workflow. 5
Prevalent and expensive claim in malpractice
cases.3
1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8; 3. Cabral
JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm 1993; 50: 305-14; 5. Cohen MR.
Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Illegible Handwriting:
Error Prevention
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Prescribers’ Obligation
Write/Print More Carefully
Computers
Verbal Communications
Written Medication Orders:
Complete Information
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Patient’s Name
Patient-Specific Data
Generic and Brand Name
Drug Strength
Dosage Form
Amount
Directions for Use
Purpose
Refills
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Written Medication Orders:
Patient-Specific Information
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Age
Weight
Renal and Hepatic Function
Concurrent Disease States
Laboratory Test Results
Concurrent Medications
Allergies
Medical/Surgical/Family History
Pregnancy/Lactation Status
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Written Medication Orders:
Do Not Use Abbreviations
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Drug names
“QD” or “OD” for the word daily
Letter “U” for unit
“µg” for microgram (use mcg)
“QOD” for every other day
“sc” or “sq” for subcutaneous
“a/” or “&” for and
“cc” for cubic centimeter
“D/C” for discontinue or discharge
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Jones EH. Clev Clin J Med 1997; 64: 355-9.
Written Medication Orders: Decimals
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Avoid whenever possible1
– Use 500 mg for 0.5 g
– Use 125 mcg for 0.125 mg
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Never leave a decimal point “naked” 1, 2, 3
– Haldol .5 mg  Haldol 0.5 mg
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Never use a terminal zero
– -Colchicine 1 mg not 1.0 mg
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Space between name and dose1,3
– Inderal40 mg  Inderal 40 mg
1.
2.
3.
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.18.23.
Jones EH. Clev Clin J Med 1997; 64: 355-9.
Cohen MR. Am Pharm 1992; NS32; 32-3.
Written Medication Orders:
Drug Names
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“Look-Alike” or “Sound-Alike” Drug
Names
“Confirmation Bias”
Addition of Suffixes
– Example Adalat CC 30 mg vs. Adalat 30 mg
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Cohen MR. Am Pharm 1992; NS32: 21-2.
Look-alike And Sound-alike
Drug Names
Accupril®
Accutane®
Alprazolam
Lorazepam
Cardene®
Cardura®
Flomax®
Fosamax®
Lamisil®
Lomotil®
Nizoral®
Neoral®
Plendil®
Prilosec®
Zantac®
Zyrtec®
USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.
Medication Prescribing Process:
Computerized Prescriber Order Entry
(CPOE)
– Computer with 3 Interacting Databases
• Drug History
• Drug Information/Guidelines Database
• Patient-Specific Information
– Avoids
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Illegible Prescriptions or orders
Improper Terminology
Ambiguous Orders
Incomplete Information
Schiff GD. JAMA 1998; 279: 1024-9.
Computerized Physician Order
Entry (CPOE)
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Provides Decision Support
Warns of Drug Interactions
– Drug-Drug
– Drug-Allergy
– Drug-Food
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Checks Dosing
Reduces Transcription Error
Reduces number of lost orders
Reduces duplicative diagnostic testing
Recommends cost effective, therapeutic
alternatives
CPOE Advantages
Automate ordering process
 Reduces Order Errors
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– Standardized, legible complete orders
– Alerts
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Data collected on variances in practice
Improved Quality
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CPOE allows for physician reminders of
best practice or evidence-based
guidelines
Indiana University study
– Pneumococcal vaccine in eligible patients
0.8%
36.0%
– Heparin prophylaxis
18.9%
32%
CPOE Disadvantages
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Errors still possible
Alerts
Multiple steps
Access
Dosage Calculations
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Recognized cause of medication errors
Use patient-specific information
– height
– weight
– age
– body system function
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Dosage Calculations:
Error Prevention
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Avoid calculations
Cross-checking
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
ISMP Medication Safety Alert 1996; 1 (15).
Verbal Orders:
Error Prevention
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Avoid when possible
Enunciate slowly and distinctly
State numbers like pilots
(i.e., “one-five mg” for 15 mg)
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Spell out difficult drug names
Specify concentrations
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Conflict Resolution
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Communication is essential
No one is right all the time
Take the time to listen
Beware of instilling an atmosphere of
fear
Interdisciplinary collaboration
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Patient Education
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Educate patients about their medications
Purpose of each medication
Name of drug, dose, how to take, etc.
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Provide patients with understandable written
instructions
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Lack of involving patients in check systems
Inform patients about potential for error with
drugs known to be problematic
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PRESCRIBING REVIEW
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Right indication
Right drug choice
Correct dosage
Absence of contraindications
– Allergies
– Drug interactions (food, other drugs)
– Pregnancy and lactation
HIGH ALERT MEDICATIONS
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Insulin
Lidocaine
Intravenous magnesium sulfate
Opiate narcotics
Neuromuscular blocking agents
Intravenous potassium
Intravenous sodium chloride (high
concentration)
PROBLEMS
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Lack of knowledge of proper dose
Outdated information
Illegible handwriting
Incomplete orders
Use of the apothecary system
Order on the wrong chart
Nameless prescription
PROBLEMS
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Ordering a total course of therapy
instead of daily doses
Lack of knowledge about proper routes
of administration
Ability to bypass controls in automated
systems
Verbal orders poorly communicated
SOLUTIONS
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Clear handwriting (Print)
Avoid abbreviations when errors could
occur
Prescriber order entry
Avoid verbal orders
Double check doses
Review cases of polypharmacy
SUMMARY
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Prescribing inappropriately can result in
serious medication errors.
Major advances have been made in
improving prescribing safety
Technology is our friend
Interdisciplinary interactions go a long
way toward preventing errors
NEXT SESSION
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Medication procurement in an era of
medication shortages
Compounding pharmacies – friend or
foe?