Reducing Medication Errors PHAR 841 – PHAR MACY PR AC T ICE MAN AGEMEN T WEEK 12 HOUR 2 R I CHAR D D’ASSALENAUX, PHAR MD 1 Objectives Describe the law that requires pharmacies to have a quality assurance program Define the steps to investigate errors Classify the requirements of a quality assurance program Explain how to report errors to ISMP Differentiate MERP elements in a hospital versus community setting Interpret system errors that may occur 2 AR What is the Role of the Community Pharmacist? Business and Professions Code 4125: Pharmacy Quality Assurance Program Required; Records Considered Peer Review Documents* (a) Every pharmacy shall establish a quality assurance program that shall, at a minimum, document medication errors attributable, in whole or in part, to the pharmacy or its personnel. The purpose of the quality assurance program shall be to assess errors that occur in the pharmacy in dispensing or furnishing prescription medications so that the pharmacy may take appropriate action to prevent a recurrence. * Peer Review Documents are not discoverable in a court of law 3 1711. Quality Assurance Programs (c) (1) Each quality assurance program shall be managed in accordance with written policies and procedures maintained in the pharmacy in an immediately retrievable form (2) When a pharmacist determines that a medication error has occurred, a pharmacist shall as soon as possible: (A) Communicate to the patient or the patient’s agent the fact that a medication error has occurred and the steps required to avoid injury or mitigate the error. (B) Communicate to the prescriber the fact that a medication error has occurred. 4 How Do You Address This? Keep accurate records: ◦ ◦ ◦ ◦ Date, location, and participants in the quality assurance review; Pertinent data and other information related to the medication error(s) reviewed; Findings and determinations; and Recommended changes to pharmacy policy, procedure, systems or processes, if any. Have Policies and Procedures regarding the Quality Assurance process 5 Investigate Errors Once a medication error has been discovered, the pharmacy has two business days to investigate the error (suggest doing a root cause analysis). All medication errors will be compiled and reviewed in a Quality Assurance Review ◦ Policy should address how often the review occurs and by whom ◦ Policy should allow for emergency review in case of a major error (e.g. life-threatening) 6 How to Decrease Medication Errors from Dr. Gunther Develop a “plan” to substantially reduce medication-related errors ◦ Policies and Procedures ◦ Medication Error Reporting System Conduct an annual review to assess effectiveness of plan Identify weakness or deficiencies that could contribute to errors Include a multidisciplinary process (RPh, RN, MD and Administration) to regularly analyze errors Dr. Gunther’s PHAR 741 Presentation “Introduction to Medication Errors and Adverse Drug Events” 7 Roles of a Pharmacist from Dr. Gunther Assessment: ◦ Examine/evaluate causes ◦ Analyze data to determine trends, significance and frequency Prevention strategies: ◦ Develop interventions towards med error reduction ◦ Establish goals and measurable standards ◦ Monitor interventions and make changes Reporting ◦ Communicate results to all health care providers, patients and caregivers ◦ Promote reporting of med errors to national system for review and analysis Dr. Gunther’s PHAR 741 Presentation “Introduction to Medication Errors and Adverse Drug Events” 8 May Use ISMP https://www.ismp.org/errorReporting/Default.aspx 055 While ISMP widely disseminates case studies of events and what has been learned about the causes and prevention of medication and vaccine errors, identifiable details regarding individual events, where they occurred, and the identity of patients, involved staff, and reporters remains strictly confidential. Your identity, affiliation, and location will NOT be revealed in any ISMP publications. tape Institute for Safe Medication Practices (ISMP) 9 Simple ISMP Error Reporting Form 10 What to Report to ISMP ISMP encourages healthcare practitioners and consumers to report medication errors, vaccine errors, preventable adverse drug reactions, close calls, and hazards to ISMP. Examples include, but are not limited to: ◦ ◦ ◦ ◦ Errors when prescribing, transcribing, dispensing, and administering medications/vaccines Errors related to patient monitoring of the effects of medications and vaccines Errors with medications or vaccines that are captured before they reach the patient Potential or actual confusion regarding look- and sound-alike drug or vaccine names, packaging similarities, or label ambiguity ◦ Misuse, nonuse, or malfunction of medication-related tools (e.g., syringes, needles), equipment (e.g., tubing, infusion pumps), and technology (e.g., computerized order entry systems, barcode scanning) Please do NOT submit any provider- or patient-identifiable information. 11 Which of the 11 MERP Elements are Involved in Community Pharmacy? 1. Prescribing 6. Dispensing 2. Prescription order communication 7. Distribution 3. Product labeling 9. Education 4. Packaging and nomenclature 10. Monitoring 5. Compounding 8. Administration 11. Use 12 System Based Med Errors ISMP has identified 10 key elements that have the greatest influence on medication use system. System based causes of medication errors can be directly traced to weaknesses or failures in these key elements: 6. Drug storage, stock, and 1. Patient information distribution 2. 3. 4. 5. Drug information Communication of drug information Drug packaging, labeling, and nomenclature Drug device acquisition and use 7. Environmental factors 8. Staff competency and education 9. Patient education 10. Quality processes; and risk management 13 Summary Implement a Quality Assurance Program Write Policies and Procedures describing your QA Program Investigate Medication-Related Errors Develop an Action Plan to try to prevent the error from happening again Maintain records of Medication Error Reviews Utilize the resources of ISMP 14 Don’t Let This Happen to You! Top: Eric Cropp, Ohio Pharmacist Right: RaDonda Vaught, Tennessee Nurse 15

Reducing Medication Errors

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