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Potential impact of efforts to improve patient safety and reduce medication errors
1. What are the quality issues in
PATIENT SAFETY and the potential
impact of an effort to improve?
Medication errors
2. Medical error: a preventable adverse event
or near miss due to the failure of a planned
action to be completed as intended or use of a
wrong plan to achieve an aim
Adverse event: unintended patient harm
caused by medical management rather than
by a disease process, which results in a
prolonged hospital stay, morbidity, or mortality
Near miss: an error or mishap that had the
potential to cause patient harm, but did
not, either by chance or thanks to timely
intervention
(Cuong
Pham,J., Aswani,M.S., Rosen,M., Lee,H.W., H
3. Systems issues that contribute to
medication errors:
Lack of adequate staffing
Patient acuity levels
Inadequate access to policy and medication
information
Physical environment – ie lighting, bedside
Organisational culture
Organisation communication channels
Organisational routines
Pharmaceutical related issues
Incident reporting culture
4. Personnel issues:
Understanding of how errors occur
Failure to adhere to policy and procedure
documents
Number of hours on shift
Distractions
Lack of knowledge about medications
Dosage calculation
Workload
Care delivery method
5. The nurses’ role in preventing
medication errors
In administering any medication, nurses and
midwives are required to:
Know the relevant legislation relating to
medication administration
Have adequate knowledge of the medication, its
therapeutic purpose, usual dose, frequency and
route of administration, specific precautions,
contra-indications, side effects and adverse
reactions. Nurses and midwives should also be
aware of the correct storage requirements for
medications.
Adhere to required checking policies and
procedures developed by agencies.
http://www.nursing.health.wa.gov.au/docs/nmo/NMBWA_M
edication_Management_Guidelines.pdf
6.
7. Systems implemented to prevent
medication errors :
Computerized physician order entry
(CPOE) systems and clinical decision
support systems (CDSS)
Bar-coding systems
Medication Reconciliation
Standardised ordering and
administration
Training, education, and organisational
interventions
8. Trigger Tool for Measuring Adverse
Drug Events – Institute for
Healthcare
The World Health Organization (WHO)
Collaborating Centres for International Drug
Monitoring defines an adverse drug event (ADE)
as:
“Noxious and unintended and occurs at doses
used in man for
prophylaxis, diagnosis, therapy, or modification of
physiologic functions.” — WHO Publication
DEM/NC/84.153(E), June 1984.
9. Trigger Tool for Measuring Adverse
Drug Events – Institute for
Healthcare
The Trigger Tool for Measuring Adverse Drug
Events provides instructions for conducting a
retrospective review of patient records using
triggers to identify possible ADEs. This tool
includes a list of known ADE triggers and
instructions for collecting the data you need to
measure the number of ADEs per 1,000 doses
and the percentage of admissions with an ADE.
The tool provides a process for accurately
identifying ADEs and measuring the rate of ADEs
over time.
10. Previous study on use of
Computerised Provider Order Entry
(CPOE) system
The study reviewed electronic health records for all
the inpatients coming to 5 community hospitals for a 6
months duration (July 2010 – December 2010).
Responses to 9 alerts/CDSS tools were studied, and
these were displayed and prompted on computer
screens when providers were putting in medication
orders
The study found that the CDSS system changed the
physician behaviour & patient therapy 42% of the time
when medication orders were placed. These alerts
substantially decreased the medication error
rate/adverse drug events (ADE’s) in the patients
receiving care at these 5 hospitals.
Cuong Pham, J., Aswani, M.S., Rosen, M., Lee, H.W., Huddle, M., Weeks, K., & Pronovost, P.J. (2011). Reducing medical errors and adverse events. The Annual Review of Medicine, 63 (27.1-27.17).
McBride-Henry, K., & Foureur, M. (2006). Medication administration errors: Understanding the issues. Australian Journal of Advanced Nursing, 23(3).
McBride-Henry, K., & Foureur, M. (2006). Medication administration errors: Understanding the issues. Australian Journal of Advanced Nursing, 23(3).
Nurses and Midwives Board of Western Australia. (2010). Medication Management Guidelines for Nurses and Midwives. Retrieved from:http://www.nursing.health.wa.gov.au/docs/nmo/NMBWA_Medication_Management_Guidelines.pdfAccording to the Nurses Board of Western Australia, in administering any medication, nurses and midwives are required to:Know the relevant legislation relating to medication administration,Have adequate knowledge of the medication, its therapeutic purpose, usual dose, frequency and route of administration, specific precautions, contra-indications, side effects and adverse reactions (essentially the 6 rights of medication administration: right drug, right dose, right time, right patient, right route, and right documentation). Nurses and midwives should also be aware of the correct storage requirements for medications, and be able to adhere to required checking policies and procedures developed by agencies.
Cuong Pham, J., Aswani, M.S., Rosen, M., Lee, H.W., Huddle, M., Weeks, K., & Pronovost, P.J. (2011). Reducing medical errors and adverse events. The Annual Review of Medicine, 63 (27.1-27.17). Institute of Medicine recommended prescriber actions for medication safety> includes various guidelines that should be followed and carried through.
The computerized physician order entry (CPOE) systems ensure messy physicians’ handwriting is eliminated, with direct medication orders entered directly into the computer. Studies have also found that by pairing the Computerised Physician Order Entry with automated clinical decision support systems (CDSS) this can also further eliminate medication errors by helping to improve drug choice, and with electronic health records to help complete the patient’s medication list and history. CDSS can help to identify drug allergy checking, basic dosing guidance, formulary decision support, and checks for duplicate therapies and drug to drug interactions. The use of bar-coding systems ensure that patient, medication, and employee identification codes are scanned to automatically check for the right patient, drug, dose, route, and time before administering the drug.The Institute for Healthcare Improvement (http://www.ihi.org) proposesthree generic steps in order to complete a medication reconciliation process: (a) verification, where a medication history or list is collected; (b) clarification, where medications and dosages are checked for appropriateness; and (c) reconciliation, where any changes are documented. This check list is to be completed prior to medication administration. Standardised ordering and administration includes, pre-packaging medications in the correct dosages, as well as standardising abbreviations, labelling and equipment, conventions such as limited and formally structured verbal order processes, and limited access to high-alert medications.Training, education and organisation interventions are also thought to influence the attitudes of the staff and staff development, and ensure that correct medication administration is completed and incorrect incidences are reduced.
The institute of healthcare proposed the use of a trigger tool in order to measure the incidence of adverse drug events. According to the World Health Organisation Collaborating Centres for International Drug Monitoring defines an adverse drug event (ADE) as:“Noxious and unintended and occurs at doses used in man for prophylaxis, diagnosis, therapy, or modification of physiologic functions.”
http://www.ihi.org/knowledge/Pages/Tools/TriggerToolforMeasuringAdverseDrugEvents.aspxTraditional methods used to measure adverse drug events predominantly focused on the voluntary reporting and tracking of errors. However, researchin the public health sector (in the USA) have found that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent caused no harm to patients. Hospitals needed a more effective way to identify events that do cause harm to patients, in order to select and test changes to reduce harm, and so the institute for healthcare proposed a trigger tool be implemented. The Trigger Tool for Measuring Adverse Drug Events provides instructions for conducting a retrospective review of patient records using triggers to identify possible ADEs. This tool includes a list of known ADE triggers and instructions for collecting the data you need to measure the number of ADEs per 1,000 doses and the percentage of admissions with an ADE.
Saxena, K., Lung, B.R., & Becker, J.R.(2011). Improving Patient Safety by Modifying Provider Ordering Behaviour Using Alerts(CDSS) in CPOE system. AMIA Annual Symposium Proceedings. The study was conducted using a prospective time series analysis, evaluating the use of Clinical Decision Support System (CDSS)/alerts in helping providers not to make errors, when putting in orders in a CPOE system. The study reviewed electronic health records for all the inpatients coming to 5 community hospitals for a 6 months duration (July 2010 – December 2010). Responses to 9 alerts/CDSS tools were studied, and these were displayed andprompted on computer screens when providers were putting in medication orders. These alerts guided the providers regarding any drug duplications, interactions, contraindications of the prescribed medicine with patient’s clinical condition etc. The study found that the CDSS system changed the physician behaviour & patient therapy 42% of the time when medication orders were placed. These alerts substantially decreased the medication error rate/adverse drug events (ADE’s) in the patients receiving care at these 5 hospitals.
Saxena, K., Lung, B.R., & Becker, J.R.(2011). Improving Patient Safety by Modifying Provider Ordering Behaviour Using Alerts(CDSS) in CPOE system. AMIA Annual Symposium Proceedings. This example taken from the study highlights the learning process carried out when an alert system on computerised equipment is in place. It shows that learning and changing behaviour occurs in most cases provided that action is taken, with the alert system working to remind providers of care necessary.
