Medication Safety in the Primary Care Physician’s Office

1. Medication Safety in the Primary Care Physician’s Office Kim Galt; Ann Rule; Bart Clark; JD Bramble; Wendy Taylor; and Kevin Moores Creighton University Health Services Research Program AcademyHealth Annual Research Meeting San Diego, CA June 2004 Support - Agency for Healthcare Research and Quality, Galt, K.A. 1-R18HS11808-01

2. AHRQ Study No. R18-HS11808-01 Impact of personal digital assistants (PDAs) on medication errors in primary care Potential Prescribing Errors Office technology assessment User technology assessment Drug Information assessment Year 1 Baseline Data RCT: 40,000 Rx’s/ Cht Reviews Error Measurement • Individual User Adaptation to PDA • Individual User Adoption of PDA • Barriers and solutions to • PDA adaptation/adoption Year 2 Intervention Data Direct observations Field journal notes Written surveys Direct observation Performance checklists Self-report surveys Field observations Potential Prescribing Errors Office technology assessment User technology assessment Drug Information assessment Year 3 Post-Intervention Data RCT: 40,000 Rx’s/ Cht Reviews Error Measurement Interviews Field observations 1. Galt, KA, et al. Impact of hand-held technologies on medication errors in primary care. Top Health Inform Manage, 2002, 23(2), 71-81. 2. Galt, KA. Medication errors in ambulatory care. Top Health Inform Mange, 2002, 23(2), 34-46. Direct observations Field journal notes Written surveys

3. The Electronic Medical Record?...

4. The data jack

5. Supposed to be a data jack...

6. Data jack strategically placed over examination table…

7. The Intervention… 2 3 1 4

8. Rationale • Medication safety is missing as a governing concept in primary care office-based practice.

9. Purpose • Assess medication safety in primary care practice through survey research and direct observation • Use evidence to identify areas of emphasis for medication safety best practices • Develop a medication safety best practices guide for office use

10. Domains for Medication Safety Domains Subdomains

11. Patient Renewal or Refill Physician’s Office • Prescribing • - Evaluate patient - Establish need for medication • Determine interactions and allergies - Consider financial situation • Consider formulary or insurance issues - Select correct medication New or Renewal • Counseling • - Counsel patient about medication1 - Answer medication related questions • Give written information - Give telephone number for medication information Documenting - Document in patient’s chart Pharmacy3 • Transmission • Transmit prescription to pharmacy • Write prescription & patient takes to pharmacy - Call pharmacy with prescription order - Fax prescription order to pharmacy Clinical Evaluation (Pharmacist) - Review prescription order - Review directions, reason for use, warnings, interactions and allergies - Contact prescriber about discrepancies if necessary Issuing Sample Medications (MD office) - Review prescription order - Counsel patient1 - Prepare sample medications - Distribute sample medications Dispensing - Prepare medication - Give medication to patient Administering (in-office use medication) - Evaluate patient - Review prescription order - Review warnings, interactions and allergies - Administer medication Counseling - Counsel patient about medication1 - Answer medication related questions - Give written information - Give telephone number for medication information Monitoring2 -Assess patient’s response to medication - Report results Monitoring2 -Assess patient’s response to medication - Report and document results Figure 1: Medication Use Process and Care Communications in the Outpatient Setting

12. Methods • Develop a 154 item medication safety assessment survey • Administer survey (interviewer-assisted) to 31 primary care office managers in Nebraska and Iowa in May, 2003 • Directly observe offices to assess environment, facilities, technology readiness, and office behaviors related to medication safety.

13. Results: Update Patient Record When Change Medication Care Plan • 71% of offices surveyed report that they do not update the chart when renewing medications by telephone. Med Profile Updated Med Profile Not Updated

14. Why do only 29% of offices update the chart after renewing a medication by phone?

15. Results: Prescriptions When telephone orders are given, only 36% report that the pharmacist always or almost always repeats the prescription back for verification. The Individual telephoning a prescription informs the pharmacist of the following: Only 32% of clinics report informing the pharmacist of the indication, a practice that has been shown to reduce errors.

16. Results: Sample Medications 56% - no established procedure for providing prescription medication samples to patients. Only 6% of clinics label samples for patients to use in the home to assure proper use.

17. Why do only 6% of offices label the sample for the patient before giving it to them to take home?

18. Early attempt at medication safety system

19. Efficient use of FTE’s… Pharmaceutical Representatives are part of the primary care workforce too!

20. Results Error Management • 33% - no outlined procedure to respond to a serious medication error • 88% - reporting mechanism in place Work Place Conditions • 24% - dismissed individuals from employment because of error • 65% - reference errors in personnel files • 71% - part of performance appraisal

21. Results – Areas for Improvement • Data gathering and chart documentation • basic patient health information and current medication history each change in care plan • Change what is included on a prescription • Indication • Date of birth, weight, allergies • High-risk co-morbid conditions

22. Results – Areas for Improvement • Incorporate safe sample management consistent with pharmacy practice standards • Use errors events to educate and improve process, not punish individuals • Educate routine staff about strategies designed to reduce errors • Incorporate no cost strategies to prevent/reduce errors

23. Medication Safety Best Practices Guideline Development • Survey items converted if met explicit criteria: • Direct relevance to medication safety • Increased risk if not attended to • Feasible to implement solution • Practices identified into 3 implementation categories: • Solution is individual behavior, no added resources • Solution is in policy/system, no added resources • Solution requires additional resources

24. Conclusion Medication safety practices in the primary care office are suboptimal to unacceptable Improving the medication use process in primary care offices is a critical step to improving medication safety for the public. Many solutions at no to low cost. A best practices guideline may assist office practices with these improvements.