Preventing Medication Errors (2007) / Chapter Skim
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5 Action Agenda for Health Care Organizations
5 Action Agenda for Health Care Organizations
Pages 221-265
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Recognizing that systemic change takes time, the committee proposes ways in which indi vidual physicians, pharmacists, and nurses can improve medication safety in the short term. In addition, health care providers must acknowledge that the work of making medication use safer is never finished.
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. Since 2003, JCAHO has set annual National Patient Safety Goals (JCAHO, 2005)
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(Out) · Ask regularly about side effects or adverse drug events (ADEs)
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(Amb and Hosp) · Request resources needed to promote accurate prescription dispensing (clinical decision support, bar code verification technology, time for counseling patients)
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BOX 5-4 National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations Relating to Medication Use Goal 1: Improve the accuracy of patient identification 1A. Use at least two patient identifiers (neither to be the patient's room num ber)
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Goal 13: Encourage the active involvement of patients and their families in the patient's care as a patient safety strategy Define and communicate the means for patients to report concerns about safety and encourage them to do so.
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12. Implement a computerized prescriber order entry system.
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Recommendation 3: All health care organizations should immedi ately make complete patient-information and decision-support tools available to clinicians and patients. Health care systems should capture information on medication safety and use this information to improve the safety of their care delivery systems.
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Much less is known about the information needs of providers other than physicians, but it is reasonable to assume that nurses, pharmacists, and others have frequent needs for clinical information. It should be noted that research indicates nurses prefer to gain knowledge from personal experience and interactions with coworkers and patients rather than from journal articles, textbooks, or research resources (Thompson et al., 2001; Estabrooks et al., 2005)
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. Even when clinicians have access to electronic databases, the process of seeking information from these sources is typically so time-consuming as to be impractical in many patient care settings (Alper et al., 2001)
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. The rapid growth of PDA computing capabilities has spurred major advances in health information programs (Galt et al., 2005)
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Linking of structured data in EHRs to clinical information repositories, together with continuous monitoring of decisions associated with selected activities, such as diagnosis, testing, and treatment, offers the best opportunity for rapidly improving the safety of care. Current working examples of this model are primarily in the pharmacotherapeutic arena, where monitoring of drugallergy, drugdrug, and drugdisease interactions is common with computerized physician order entry (CPOE)
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In addition, for these data to be maximally useful, they must be in a structured format including such components as the medication name, dose, route, frequency, duration, and start date. The messaging standard National Council for Prescription Drug Programs script (NCPDP, 2005)
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In most health care settings, the lack of an accurate list of medications, problems, and allergies places patients at risk for ADEs due to drugdrug interactions or allergies (Benson et al., 1988; Carpenter and Gorman, 2002; Weingart et al., 2004)
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Both paper and electronic formats can be used to improve patient care and patient safety (Tufo et al., 1977; Weed, 2004)
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In sum, the availability of interoperable data is a lynchpin of a safer health care system, as noted by the Institute of Medicine (IOM) in its report on patient safety (IOM, 2004)
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· Comparison of medication administration records with physician orders (Cunningham et al., 1996) · Voluntary reports of medication errors (Phillips, 2002)
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These include reporting, chart review, computerized detection of ADEs (Classen et al., 1991; Evans et al., 1991; Bates et al., 2003) , observation of medication administration (Barker et al., 2002)
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. Health care providers can take a number of actions to promote successful medication error reporting in their respective settings.
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For example, the Institute for Safe Medication Practices' (ISMP) Medication Safety Alert newsletter, United States Pharmacopeia (USP)
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Chart review is an effective way of finding medication errors and ADEs, but is costly to perform and requires special training for the chart reviewers. Recently, chart review has begun to make use of an ADE trigger tool designed by the Institute for Healthcare Improvement (Rozich et al., 2003)
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The IOM's Patient Safety report describes the functional requirements for electronic ADE detection systems, including rules for detecting possible ADEs using automated surveillance (Evans et al., 1991; Classen et al., 1991; Bates et al., 2001; IOM, 2004)
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Observation of Medication Administration Since 1960, studies have used nurses to observe medication administration in hospitals because the results provide an accurate measure of how often medication administration errors actually occur (Flynn et al., 2002)
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This process would be part of the hospitals routine quality monitoring program. Audits of Prescriptions Filled in Community Pharmacies Detection of medication errors and ADEs in ambulatory care settings is a fairly recent development.
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109-41) , protecting such data reported to patient safety organizations, community pharmacies should start sharing this information.
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More important, however, computerized prescribing enables a range of clinical decision support (Teich et al., 2005) , including checks for allergies, drugdrug interactions, overly high doses, clinical conditions, druglaboratory issues, and pregnancy-related issues, as well as suggestions about dose given the patient's level of renal function and age.
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, especially for drug drug interactions. To avoid this problem, it would be helpful if decision support rules were available in a publicly available location.
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To date, it has been impossible to deliver adequate clinical decision support on palm-top platforms, primarily because of the infeasibility of incorporating sufficient clinical information in these devices in a timely fashion, the shortage of space on palm-top screens, lack of interoperability, and issues related to transmission speed. The tablet PC provides more screen space than the palm-top device at the cost of some portability.
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· Adequate training of each team member in the specific functions each must perform. For example, the nurse or pharmacist managing the care of patients on warfarin must be trained in the use of protocols and computer programs for dosing and monitoring of the therapy, as well as in surveillance for important drug interactions.
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, although the impact on preventable ADEs is uncertain since a large randomized controlled trial has not been conducted. A key issue regarding CPOE is the depth and breadth of the decision support provided.
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. At the pharmacist order entry stage, Grisso
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At the medication administration stage, Oren and colleagues (2002) studied overrides of antimicrobial withdrawals from an automated dispensing machine and found that medication errors occurred in 21 percent of cases.
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Outpatient Setting In the outpatient setting, electronic prescribing will be important (Gandhi et al., 2003) , although evidence to date for its effectiveness in this setting is limited, and electronic prescribing without associated decision support is unlikely to yield the potential safety benefits (Gandhi et al., 2005)
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Another key lesson from the implementation of CPOE at Brigham and Women's Hospital is that hospitals should pay careful attention to workflow design to save nursing and physician time. At Brigham and Women's Hospital, the greatest efficiency was achieved through automation of the medication administration record.
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. The above practices apply for any clinical decision support system as well.
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Pro ceedings of the American Medical Informatics Association Symposium 26. AHRQ (Agency for Healthcare Research and Quality)
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1999. The impact of computerized physician order entry on medication error prevention.
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Journal of the American Medical Informatics Association 12(2)
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Proceedings of the Ameri can Medical Informatics Association Annual Symposium 235238. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL.
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Journal of the American Medical Informatics Association 1(5)
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2003. Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review.
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2005. Role of computerized physician order entry systems in facilitating medication errors.
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Proceedings of the American Medical Informatics Association Symposium 1085. Porter SC, Kohane IS, Goldmann DA.
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2005. Computerized physician order entry with clinical decision support in the long term care setting: Insights from the Baycrest Centre for Geriatric Care.
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Journal of the American Medical Informatics Association 12(4)
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