MEDICATION SAFETY

1. MEDICATION SAFETY Rola Hammoud.MD Medical Quality Director

2. COUNT ONLY ONCEHow many “f’s”

3. COUNT ONLY ONCEHow many “f’s” • Finished files are the result of years of scientific study combined with the experience of years.

4. COUNT ONLY ONCEHow many “f’s” • Finished files are the result of years of scientific study combined with the experience of years

5. COUNT ONLY ONCEHow many “f’s” • Finished files are the result of years of scientific study combined with the experience of years.

6. TO ERR IS HUMANPlutarch c 100 AD ERRORS Intended action, not performed SLIPS Action based errors MISTAKES Errors in planning actions SKILL-BASED ERRORS Errors in correctly executing planned actions Knowledge –based errors LAPSES Memory based errors Rule Based errors Non appliance of good rules Appliance of bad rules Technical errors

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8. Medication Safety Encompasses errors which are not side-effects of the intended drug, These are the result of the wrong drug being administered in error or the right drug being given in the wrong dose or via the wrong route. Adverse drug events

9. Medication Error Two forms: • An adverse event if a patient is harmed; • A near miss if a patient is nearly harmed; • Neither harm nor potential for harm.

10. Global Increase of Medication Use • Multi-medication use and drug interactions • Errors in administration • Adverse events.

11. Prevalence • Harm from adverse drug events account for a quarter of all medical errors. • USA, Australia and France : ADEs occur in 4% of hospital admissions and death results from these errors 5-10% of the time. • NPSA: almost one in ten inpatients experience medication-related harm • In the United Kingdom : Over 1000 people died ADEs in 2001 alone. • 75% of these errors are preventable.

12. Prevalence The IOM : • 1 medication error per hospitalized patient per day in the United States • 1.5 million preventable adverse drug events per year in the United States • 7000 deaths per year from medication error in US hospitals.

13. The National Coordinating Council for Medication Error Reporting and Prevention

14. MEDICATION CYCLE

15. ERRORS in MEDICATION CYCLE

16. Medication Management Process

17. Monitoring • Observing the patient • Determine if the medication is working, • Determine if it is used correctly • Observe for any harm to the patient • Documentation.

18. Patient Education • Name, purpose and action of the medication • Dose, route and administration schedule • Special instructions, directions and precautions • Common side-effects • Drug- drug interactions • Drug- food interactions • How the medication will be monitored • Encourage patients to keep a written record of their medications and allergies • Encourage patients to present this information whenever they consult a doctor

19. Potential Errors in Each Step

20. Potential errors in each step

21. Contributory factors to medication errors

22. Contributory factors to medication errors

23. Recommendations to Decrease ADEs LOOK ALIKE SOUND ALIKE CLEAR LABELS CHECKING ENGAGE PATIENTS

25. STAKEHOLDERS

26. PHYSICIAN : MEDICAL ORDER

27. PHYSICIAN : MEDICAL ORDER

28. CLINICAL PHARMACIST 1. Involved in multidisciplinary rounds 2. Review of medical orders 3. Provide drug information to all healthcare providers 4. Fill, label and dispense all drugs to in-patients in unit dosage form 5. Control of all narcotic & controlled substances 6. Collect and report adverse drug reactions (ADRs) 7. Maintain an up-to-date medication database 8. Prepare, under aseptic techniques, parenteral fluids (TPN, cytotoxics) 9. Provide patient counseling services when required/ Reconciliation

29. Multidisciplinary rounds • Doctor • Pharmacist • Nurse • Dietician

30. REVIEW OF MEDICATION ORDERS

31. REVIEW OF LAB RESULTS

32. DISPENSING • Dispensing • Filling • Labelling • Unit dose form

33. MONITORING • Collecting and reporting of adverse drug reactions:

34. PREPARATION • Preparing, under aseptic conditions, parenteral fluids (TPN, cytotoxics)

35. PREPARATION • Total Parenteral Nutrition Chemotherapy

36. Storage of medications • All Medications available in the pharmacy and floor stocks are stored under monitored conditions • Temperature is directly controlled by the Building Management System (BMS) • Receiving: rotates stock in the storage areas • Protect from light

37. Storage of medications • Look alike - Separate - Extra Labels • Sound alike - Tallman lettering

38. Storage of medications • A pharmacist shall store all controlled substances in the main pharmacy narcotics safe

39. Medication distribution • Medications are filled in closed carriages

40. NURSE: Medication Administration 7 RIGHTS • Right Patient • Right Medication • Right Dose • Right Route • Right Frequency • Right Documentation • Right Indication

41. High Risk Medications • Narrow therapeutic window • Multiple interactions with other medications • Potent medications • Complex dosage and monitoring schedules • Examples: • Oral anticoagulants • Insulin • Chemotherapeutic agents • Neuromuscular blocking agents • Aminoglycoside antibiotics • Intravenous potassium • Emergency medications

42. Develop Checking Habits • Upon prescription • Upon administration • Check for allergies • Check the 7 Rs • Computerized systems still require checking • Always check and it will become a habit! • Unlabelled medications belong in the bin • Never administer a medication unless you are 100% sure you know what it is

43. Medication Reconciliation • Establish what medications a patient should be receiving in a formal record to prevent communication breakdowns. • WHO recommends that a complete list of medications is kept for each patient, which: is provided at every care transfer; • includes hospital and over the counter medications; • specifies the timing, dose and route; and • matches the patient’s actual habits. • Visible Medication administration records • MAR checked & updated regularly • Clear communication at transitions of levels of care • Use of standardized forms if possible

44. Medication Reconciliation : Pharmacist’s role

45. Medication Reconciliation : Pharmacist’s role Type Date

46. FOCUS-PDCA Incidents reporting Leadership rounds Unit Clinical Pharmacist Focus Groups Conscious sedation use Surveys on Safety Culture TRIGGER TOOLS Environmental rounds Patient Tracers Report and learn from medication errors

47. INCIDENTS REPORTING • Electronic Anonymous

48. INCIDENT REPORTING

49. TRIGGER TOOLS Purpose: Establish an effective and dynamic way to identify medication errors that do cause harm to patients, in the objective of immediate action Triggers: clues, such as certain drugs or lab test and results, used to identify adverse drug events. Selection criteria: Length of stay at least 24hours Patient age 18years or older 5 units: ICU-CCU-5th-6th-7th Excluding triggers found in ER records

50. TRIGGER TOOLS List of Triggers • T1: Claritine Reaction to medication with known allergy • T2: Konakion Over anticoagulation • T3: platelet <50 000 Thrombocytopenia related to drug • T4: Kayexelate Hyperkalemia related to renal impairment or drug effect • T5:Rising serum creatinine Renal insufficiency related to drug use • T6: Anexate : Over sedation with benzodiazepine