Preventing Medication Errors (2007) / Chapter Skim
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Appendix D Medication Errors: Prevention Strategies
Appendix D Medication Errors: Prevention Strategies
Pages 409-446
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D Medication Errors: Prevention Strategies Many organizations and researchers have recommended specific interventions for preventing medication errors (See Box D-1)
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410 APPENDIX D BOX D-1 Organizations with Published Prevention Strategies for Hospital Care · Agency for Healthcare Research and Quality (Shojania et al., 2001) · American Society of Health-System Pharmacists (American Society of Health-System Pharmacists, 1996)
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APPENDIX D 411 TABLE D-1 Recommendations for the Prevention of Medication Errors in Hospital Care Recommending Strength of Evidence Recommended Practice Body Supporting Efficacy Technological Interventions Implement computerized provider IOM, NCCMERP, Medium strength order entry (CPOE) MCPME, ASHP, IHI, NQF, PMS, AHRQ Implement bar coding technology at NCCMERP, Limited evidence the point of care MCPME, ASHP, PMS, AHRQ Ensure availability of pharmaceutical IOM, MCPME, Limited evidence decision support ASHP Use pharmaceutical software IOM, MCPME, Lower strength ASHP Use automated medication dispensing AHRQ Lower strength devices Ensure free-flow protection on all NCCMERP, JCAHO Limited evidence general-use and patient-controlled analgesia (PCA)
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412 APPENDIX D TABLE D-1 continued Recommending Strength of Evidence Recommended Practice Body Supporting Efficacy Limit and formally structure verbal NCCMERP, ASHP, Limited evidence communication of medication NQF, JCAHO prescriptions Implement unit dosing IOM, MCPME, Lower strength NQF, AHRQ Implement standard processes for IOM, IHI, ISMP, Limited evidence medication doses, dose timing, and USP dose scales in a given patient care unit Monitor for look-alike and sound-alike IHI, ISMP, JCAHO, Limited evidence medications USP Limit the number of different kinds of IOM Limited evidence common equipment Do not store concentrated solutions of IOM, MCPME, Limited evidence hazardous medications on patient care JCAHO, ISMP units, and limit the number of drug concentrations available in the organization Employ special procedures and written OM, MCPME, IHI, Medium strength protocols for the use of high-risk IV INQF, PMS, ISMP, and oral medications AHRQ, USP Institute policies and procedures NCCMERP, NQF, Limited evidence regarding labeling of all medications ISMP, JCAHO, USP Miscellaneous Nontechnological Interventions Adopt a systems-oriented approach to IOM, NCCMERP, Limited evidence medication error reduction MCPME, ASHP, IHI, PMS, ISMP, USP Use improved communication practices, NCCMERP, ASHP, Limited evidence such as always resolving medication IHI, JCAHO discrepancies prior to administration Take steps to reduce workplace fatigue, IHI, ISMP, USP Lower strength such as planned naps, careful scheduling, or light therapy Create a culture of safety NCCMERP, ASHP, Limited evidence IHI, NQF, PMS, ISMP, USP Collect a medication history, and ISMP, JCAHO, USP Limited evidence reconcile the list with the patient and other providers during care transitions
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APPENDIX D 413 TABLE D-1 continued Recommending Strength of Evidence Recommended Practice Body Supporting Efficacy Improve the work environment for IOM, ASHP, IHI, Limited evidence medication preparation, dispensing, NQF and administration Improve error detection and reporting, NCCMERP, Limited evidence and promote a nonpunitive atmosphere MCPME, ASHP, NQF, PMS Make relevant patient information IOM, MCPME, Indirectly supported available at the point of care IHI through evidence on CPOE, electronic medication adminis tration record (MAR) , and bar coding Use failure modes and effects analysis NCCMERP, PMS, Limited evidence or other strategies for risk management ISMP Improve patients' knowledge about IOM, MCPME, IHI, Limited evidence their treatment PMS NOTE: AHRQ = Agency for Healthcare Research and Quality; ASHP = American Society of Hospital Pharmacists; IHI = Institute for Healthcare Improvement; IOM = Institute of Medicine; ISMP = Institute for Safe Medication Practices; JCAHO = Joint Commission on Accreditation of Healthcare Organizations; MCPME = Massachusetts Coalition for the Prevention of Medical Errors; NCCMERP = National Coordinating Council for Medication Error Reporting and Prevention; NQF = National Quality Forum; PMS = Pathways for Medication Safety; USP = U.S.
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414 APPENDIX D were included: (1) randomized controlled trial; (2)
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APPENDIX D 415 Neither study was sufficiently powered to detect a difference in the preventable ADE rate. The remaining eight studies examined more focused aspects of the medication-use process.
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416 APPENDIX D that adjusted drug dose and frequency based on the patient's renal insufficiency. The proportion of prescriptions deemed appropriate by dose increased from 54 to 67 percent after the intervention (p <0.001)
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APPENDIX D 417 carried out. A number of subsequent studies have also found that CPOE can reduce medication error rates in the inpatient setting.
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418 APPENDIX D Automated Medication-Dispensing Systems Four studies evaluated automated medication-dispensing devices. In the only randomized trial, now more than 20 years old, a bedside automatic medication-dispensing machine was associated with a statistically significant reduction in medication error rate from 15.9 percent within the control group (a decentralized unit dose system)
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APPENDIX D 419 back benchmarked on national averages. Over a 2.5-year period, the use of beta-blockers increased by 7.3 percent in the intervention sites compared with 3.6 percent in the control sites (p = 0.04)
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420 APPENDIX D 87. Guidelines were implemented for antipsychotic drug use in October 1990 and for anti-anxiety drug use in April 1992.
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APPENDIX D 421 only, 33.3 percent with psychiatric diagnosis only, and 36 percent with both diagnoses (Semla et al., 1994)
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422 APPENDIX D residents in 16 nursing facilities in Wisconsin published before the implementation of the anti-anxiety guidelines (Svarstad and Mount, 2001a) and in a study of 372 nursing homes in Minnesota (Garrard et al., 1995)
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APPENDIX D 423 Compliance with Regulations Llorente and colleagues (1998) examined compliance with the OBRA regulations on psychotropic drugs.
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424 APPENDIX D Academic Detailing of Physicians In an important randomized controlled trial, 435 physicians (Avorn and Soumerai, 1983; Soumerai and Avorn, 1987) who were Medicaid prescribers (including 208 who practiced in nursing homes)
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APPENDIX D 425 Residents in experimental homes showed less deterioration in cognitive functioning. Jones and colleagues (Jones et al., 2004, 2005; Hutt et al., 2006)
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426 APPENDIX D In addition, it is unclear how the relative use of the different classes of medications was quantified. Another study using the Systematic Assessment of Geriatric drug use via Epidemiology (SAGE)
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APPENDIX D 427 Use of Technology Four studies describe or evaluate technology interventions in the nursing home setting. Although some are represented as research, the articles are largely experiential and anecdotal.
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428 APPENDIX D Medication Reconciliation The Institute for Safe Medication Practices suggests the following steps for implementing medication reconciliation, a 2006 JCAHO national patient safety goal (ISMP, 2005a; JCAHO, 2005c) , at the interface between care settings: obtain the most accurate list of medications possible, plus information such as the dose, frequency, indication, and time of last dose for each medication; prescribe needed medications, taking into consideration the patient's current medications; reconcile medications and resolve discrepancies; reconcile medications again upon each transfer and at discharge; fully resolve any medication discrepancy; share the list with all health care providers; give the list to patients; and encourage patients to share the list with their providers and pharmacists.
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APPENDIX D 429 clinically important prescribing problems (p = 0.007) and decreased omission errors (p = 0.01)
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430 APPENDIX D tients. During this period, the rate of therapeutic goals achieved increased from 74 percent at the time of patients' initial pharmaceutical care encounters to 89 percent at patients' latest encounters (Isetts et al., 2003)
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APPENDIX D 431 The Community Pharmacy Setting Strategies that have been proposed for reducing dispensing errors in the community pharmacy setting include the following: · A quality working environment (Buchanan et al., 1991; Flynn et al., 1996, 1999) · Checking of work by another person (Davis, 1990)
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432 APPENDIX D sets during which one or more distractions occurred was 6.55 percent (Flynn et al., 1999)
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APPENDIX D 433 improvements in clinical indicators and higher rates of self-management. Mean total health costs (including the medication therapy costs)
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434 APPENDIX D cational programs)
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APPENDIX D 435 committee is not aware of any study evaluating the procedures included in these documents. PREVENTION STRATEGIES FOR PEDIATRIC CARE The committee reviewed published error reduction strategies of 10 organizations: the Pediatric Pharmacy Advocacy Group (Levine, 2001)
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436 APPENDIX D TABLE D-2 Recommendations for the Prevention of Medication Errors in Pediatric Care Evidence Source of Specific to Supporting Recommended Practice Recommending Body Children Evidence Computerized provider PPAG, ISMP, AHA, None Adult data/ order entry AHRQ, IOM, NQF, expert opinion MHA, NCCMERP, AAP/NICHQ Automated medication- PPAG, ISMP, AHA, None Adult data/ dispensing devices AHRQ expert opinion Pediatric presence with PPAG, ISMP, AHA, None Expert opinion formulary management AAP/NICHQ Appropriate and competent PPAG, ISMP, AHA, None Expert opinion pharmacy personnel and NQF, NCCMERP, environment AAP/NICHQ Pharmacist available on call PPAG, ISMP, AHA, None Expert opinion when pharmacy is closed MHA Policies on verbal orders PPAG, ISMP, AHA, None Expert opinion NQF, NCCMERP, AAP/NICHQ, JCAHO Clear and accurate labeling PPAG, ISMP, AHA, None Expert opinion of medications NQF, NCCMERP Quality improvement efforts PPAG, ISMP, AHA, None Expert opinion with drug-use evaluation and MHA, NCCMERP, medication error reporting AAP/NICHQ and review Access of health care PPAG, ISMP, AHA, None Expert opinion workers to current clinical IOM, MHA, information and references NCCMERP, AAP/NICHQ Emergency medication PPAG, ISMP None Expert opinion dosage calculation tools Accurate documentation PPAG, ISMP, MHA, None Expert opinion of medication administration NCCMERP Medication standardization ISMP, AHA, IOM, None Expert opinion and appropriate storage NCCMERP, JCAHO Training of all health care PPAG, ISMP, IOM, None Expert opinion providers in appropriate NQF, MHA, medication prescribing, NCCMERP, labeling, dispensing, moni- AAP/NICHQ, toring, and administration JCAHO Patient education on ISMP, AHA, IOM, None Expert opinion medications MHA, NCCMERP, AAP/NICHQ
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APPENDIX D 437 TABLE D-2 continued Evidence Source of Specific to Supporting Recommended Practice Recommending Body Children Evidence Direct participation of AHRQ, IOM, NQF None Expert opinion pharmacists in clinical care Computer detection/alert AHRQ None Adult studies systems for adverse drug events (ADEs) Reduction of ADEs related AHRQ None Adult studies to anticoagulants Unit-dose drug distribution AHA, AHRQ, NQF, None Adult studies/ systems MHA expert opinion Special procedures and AHA, IOM, NQF, None Expert opinion written protocols for high- MHA, JCAHO alert medications Use of pharmaceutical AHA, IOM None Expert opinion software Pharmacy-based intravenous MHA None Expert opinion (IV)
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438 APPENDIX D medications are taken on the advice of physicians. It is up to consumers to diagnose their problem properly, select the best medical product if it is necessary, read and understand the instructions for its use, take it properly, and know when it is time to terminate the treatment.
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APPENDIX D 439 Anglim AM, Klym B, Byers KE, Scheld WM, Farr BM.
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440 APPENDIX D Brock KA, Doucette WR.
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APPENDIX D 441 Friedman RH, Kazis LE, Jette A, Smith MB, Stollerman J, Torgerson J, Carey K
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442 APPENDIX D ISMP (Institute for Safe Medication Practices)
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APPENDIX D 443 Landrigan CP, Rothschild JM, Cronin JW, Kaushal R
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444 APPENDIX D Meyer TA.
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APPENDIX D 445 Peterson JF, Kuperman GJ, Shek C, Patel M, Avorn J, Bates DW.
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446 APPENDIX D Soumerai S, Avorn J
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