Managing High-Alert Medications

1 Managing HighManaging high -- alert alert Medications Medications Brought to you by the Brought to you by the Washington Patient Safety CoalitionWashington Patient Safety CoalitionJune 10, 2009 June 10, 2009 Goals of high alert medication Goals of high alert medication Policies and ProcessesPolicies and Processes To eliminate harm to the patient from the use of high alert Medications To develop standardized medication handling processes for high alert Medications To monitor and continually improve the standardized delivery process for high alert medicationsHigh alert MedicationsHigh alert MedicationsBased on 3,184 reports submitted to the US Pharmacopeia MedMarxdatabase involving parenteral routes during 2000 2004. Narcotics/opioids, insulin and heparin combined for of the errors in this review. Between 3-5% of these errors actually caused harm to the / PresentersTopics / Presenters InsulinInsulin Carol Lyn Carol Lyn VanevenhovenVanevenhoven, , PharmDPharmD, Pharmacy Clinical , Pharmacy Clinical Operations Assistant Manager/ medication Safety Operations Assistant Manager/ medication Safety Officer, Yakima Valley Memorial HospitalOfficer, Yakima Valley Memorial Hospital Narcotics/Narcotics/OpioidsOpioids Tim LynchTim Lynch, , PharmDPharmD, MS, FABC, Pharmaceutical , MS, FABC, Pharmaceutical Services Manager, St.

2 Joseph Medical CenterServices Manager, St. Joseph Medical Center HeparinHeparin Jackie Jackie BieryBiery, , PharmDPharmD, medication Safety Pharmacist, , medication Safety Pharmacist, University of Washington Medical Center University of Washington Medical Center Yakima Valley Memorial Yakima Valley Memorial HospitalHospitalMedication Safety ProgramsMedication Safety Programs6 Yakima, WA225 bed acute care community hospitalAdmission and Discharge rate: 50-80/dayYakima Valley Memorial HospitalYakima Valley Memorial HospitalAnesthesiaAnesthesia--based Interventions for based Interventions for Error Reduction Error Reduction medication Safety ProgramsMedication Safety Programs medication Safety OfficerMedication Safety Officer QuantrosQuantros: Online error reporting: Online error reporting MERT: medication Error Review TeamMERT: medication Error Review Team 2 Pharmacy Representatives2 Pharmacy Representatives Safety and OperationsSafety and Operations 3 Nursing Representatives3 Nursing Representatives Med/Med/OncOnc, ICU/Tele, Surgery, ICU/Tele, SurgeryHigh alert MedicationsHigh alert Medications Insulin, narcotics, sedatives, Insulin, narcotics, sedatives, anticoagulants, potassium, chemoanticoagulants, potassium, chemo Tracked quarterly for trendsTracked quarterly for trends Proactive focus on actionable itemsProactive focus on actionable itemsInsulinInsulin Where we startedWhere we started Initiation of BedInitiation of Bed--Side Side BarcodingBarcoding Switching to pensSwitching to pens New problemsNew problems New ProcessNew ProcessNew ProcessNew ProcessLong Acting InsulinsLong Acting Acting InsulinsShort Acting InsulinsContinuing EducationContinuing EducationInsulin Fast Facts Insulin Fast Facts Rapid acting insulin (Rapid acting insulin (aspartaspart) and short acting insulin )

3 And short acting insulin (regular) are kept in the (regular) are kept in the AccudoseAccudosecabinets on most cabinets on most floors. They require a nursing double check documented floors. They require a nursing double check documented in MAK. Intermediate acting insulin (NPH) and long acting insulin Intermediate acting insulin (NPH) and long acting insulin ((GlargineGlargine) are sent from the pharmacy in pre) are sent from the pharmacy in pre--drawn up drawn up syringes. They do not require a nursing double check in syringes. They do not require a nursing double check in MAK because pharmacy is the double because pharmacy is the double check. IF a Patient is ever put on BOTH IF a Patient is ever put on BOTH aspartaspartand regular and regular insulin please call pharmacy to clarify the please call pharmacy to clarify the order. You are part of every safe patient day!You are part of every safe patient day!University of Washington Medical University of Washington Medical CenterCenter Seattle, WASeattle, WA 400 bed academic 400 bed academic medical centermedical center Regional referral Regional referral center center medication Safety StructureMedication Safety Structure medication Safety OfficerMedication Safety Officer Safe medication Practices CommitteeSafe medication Practices Committee Patient Safety CommitteePatient Safety Committee Pharmacy & Therapeutics CommitteePharmacy & Therapeutics Committee Patient Safety Net (PSN): Online incident Patient Safety Net (PSN): Online incident reporting system through UHCreporting system through UHC : Husky Event Analysis.

4 Husky Event Analysis Team Center for Clinical Excellence, Patient Safety Officer, Center for Clinical Excellence, Patient Safety Officer, medication Safety Officer, Risk Management, Nursing, medication Safety Officer, Risk Management, Nursing, Transfusion, RadiologyTransfusion, RadiologyUWMC high alert MedicationsUWMC high alert Medications HeparinHeparin InsulinInsulin Concentrated ElectrolytesConcentrated Electrolytes ChemotherapyChemotherapy OpioidsOpioidsMedication Errors with Harm at UWMC medication Errors with Harm at UWMC FY2008FY2008024681012 Number of EventsInsulinHydromorphoneHeparinIV fluid/TPND obutamineLevofloxacinMorphinePain CocktailAntiinflammatoryChemotherapyDrug NameyRISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORDCONFIDENTIAL PURSUANT TO RCW AND Drip Errors at UWMC Heparin Drip Errors at UWMC FY2008FY20080123456789dose omissionwrong dosemonitoring errorwrong drugwrong rateother med errorextra dosewrong routewrong timeunauthorizedRISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORDCONFIDENTIAL PURSUANT TO RCW AND Infusion ProtocolXProtocol ErrorsMonitoring ErrorsUsing the UWMC Heparin ProtocolUsing the UWMC Heparin ProtocolNursing EducationNursing Education

5 Mandatory Nursing EducationMandatory Nursing Education CaseCase--basedbased SelfSelf--study or Nursing Ed Days study or Nursing Ed Days PresentationPresentation Online competency examOnline competency examCASE 2 CASE 2JA is a 65 year old male with a history of atrialfibrillation who was admitted to the hospital for an acute exacerbation of heart failure. He is receiving heparin by IV infusion as a substitute for his usual outpatient warfarin therapy, which is used for stroke prevention, and to prevent left ventricular thrombus formation. He has been on heparin for several days at a stable rate, with aPTTs all between 60 and 100. 1. Drip running at 1800 units/hr01002. qam aPTT blood draw due07003. aPTT results available0900(aPTT = 200)5. Turn off heparin infusion09004. HOLD HEPARIN INFUSION until aPTT<2005. Redraw aPTTimmediately = 09006. aPTT results available1000(aPTT = 96)7. Resume drip at 1800 units/hr1000 medication Errors with Harm at UWMC medication Errors with Harm at UWMC FY2009FY2009012345678910 Number of EventsDr u g Nam eRISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORDCONFIDENTIAL PURSUANT TO RCW AND Drips Errors at UWMCH eparin Drips Errors at UWMCFY2008 vs.

6 FY2009FY2008 vs. FY20090123456789 Number of EventsError CategoryFY2008FY2009 RISK MANAGEMENT/QUALITY IMPROVEMENT WORK PRODUCTDO NOT PLACE IN MEDICAL RECORDCONFIDENTIAL PURSUANT TO RCW AND Anticoagulation Services UWMC Anticoagulation Services WebsiteWebsite http:// Heparin Safety InitiativesAdditional Heparin Safety Initiatives Limiting Heparin ConcentrationsLimiting Heparin Concentrations Limiting the use of Heparin FlushesLimiting the use of Heparin Flushes NeuraxialNeuraxialGuidelines and Order Entry AlertGuidelines and Order Entry alert Heparin Induced Thrombocytopenia AlertHeparin Induced Thrombocytopenia alert Smart Pump Infusion TechnologySmart Pump Infusion TechnologyFranciscan Health System (FHS)Franciscan Health System (FHS) 5 Hospitals located in Pierce and King County5 Hospitals located in Pierce and King County St. Joseph Medical Center 320 Beds, Level II TraumaSt. Joseph Medical Center 320 Beds, Level II Trauma St. Francis Hospital 130 Beds, Level IV TraumaSt.

7 Francis Hospital 130 Beds, Level IV Trauma St. Clare Hospital 110 BedsSt. Clare Hospital 110 Beds St. Anthony Hospital 65 BedsSt. Anthony Hospital 65 Beds Enumclaw Regional Hospital 23 Beds, Critical AccessEnumclaw Regional Hospital 23 Beds, Critical Access Inpatient Hospice FacilityInpatient Hospice FacilityMedication Safety Leadership Team medication Safety Leadership Team (MSLT)(MSLT) Regional committee charged with improving Regional committee charged with improving medication safety throughout FHSmedication safety throughout FHS Meets monthly to review quality information Meets monthly to review quality information related to medication to medication safety. Composed of VP of Quality, Safety Officer, Composed of VP of Quality, Safety Officer, Directors of nursing from all hospitals, the chairs Directors of nursing from all hospitals, the chairs of the nursingof the nursing--pharmacy committees from all pharmacy committees from all hospitals and and educators. Chaired by a pharmacy manager and nursing Chaired by a pharmacy manager and nursing Safety Process for NarcoticsMed Safety Process for Narcotics IRISIRIS--Incident Reporting Information SystemIncident Reporting Information System Electronic system where errors are reported via the FHS Electronic system where errors are reported via the FHS intranet for review by department managers and risk intranet for review by department managers and risk Data from events collected and reviewed for tending and Data from events collected and reviewed for tending and problem identification.

8 Events classified by standard error reporting nomogram Events classified by standard error reporting nomogram as category D and above reviewed by nursingas category D and above reviewed by nursing--pharmacy pharmacy committee to identify system issues. committee to identify system issues. System problems and solutions are brought to MSLT for System problems and solutions are brought to MSLT for discussion and possible implementation systemdiscussion and possible implementation In early 2007 anecdotal reports were In early 2007 anecdotal reports were presented to MSLT of increased over presented to MSLT of increased over sedation events associated with events associated with narcotics. A proposed cause for this was the movement A proposed cause for this was the movement from meperidine to hydromorphone. from meperidine to hydromorphone. Lack of familiarity with dosing of Lack of familiarity with dosing of hydromorphone by all providers was thought hydromorphone by all providers was thought to be the reason for increased be the reason for increased events.

9 Increased focus on pain related issues and Increased focus on pain related issues and aggressive Narcotics --HFMEAHFMEA MSLT determined that an HFMEA process MSLT determined that an HFMEA process would be used to identify issues and would be used to identify issues and provide recommendations for preventing provide recommendations for preventing over sedation sedation events. An HFMEA team, chaired by pharmacy and An HFMEA team, chaired by pharmacy and nursing was formed in October was formed in October 2007. Included physician, pharmacy and nursing Included physician, pharmacy and nursing Narcotics --HFMEAHFMEA Review of incident reports and analysis of events Review of incident reports and analysis of events to determine scope of determine scope of problem. Review of literature as well as other hospitals to Review of literature as well as other hospitals to determine benchmark benchmark rate. Literature referenced over sedation rate between Literature referenced over sedation rate between and 1 %and 1 % Literature supported our observation of increased Literature supported our observation of increased over sedation events associated with sedation events associated with narcotics.

10 Links drawn towards new standard of care with pain Links drawn towards new standard of care with pain as the fifth vital sign and aggressive management of as the fifth vital sign and aggressive management of pain Narcotics --HFMEAHFMEA FHS Baseline rate determined through analysis of Code FHS Baseline rate determined through analysis of Code Green events (rapid response team) and IRIS events (rapid response team) and IRIS reports. HFMEA performed on PCA administration process from HFMEA performed on PCA administration process from prepre--op screening to postop screening to post--op care, including PCA without op care, including PCA without Focus on items with hazard score >16 (Severity and probability)Focus on items with hazard score >16 (Severity and probability) Areas for improvement identified:Areas for improvement identified: H & P, high risk screeningH & P, high risk screening OR hand off to PACUOR hand off to PACU PCA set up and admin PACUPCA set up and admin PACU PACU hand off to floorPACU hand off to floor RN knowledge and skillRN knowledge and skill Protocols and proceduresProtocols and proceduresNarcotics Narcotics --HFMEAHFMEA FY07 rate of established (Rate (%) = OSD (patients FY07 rate of established (Rate (%) = OSD (patients with over sedation by PCA) per PDC (adults/peds with over sedation by PCA) per PDC (adults/peds discharges) / 1000discharges) / 1000 Goal of HFMEA reduce rate of over sedation events by Goal of HFMEA reduce rate of over sedation events by 50% for FY0850% for FY08 HFMEA Goals:HFMEA Goals.))