Pharmacy Purchasing & Products: What are some of the most common errors reported to ISMP this year that have led to patient harm, and how should these errors be addressed?
Christina Michalek, BSc Pharm, RPh, FASHP: Each year, ISMP receives reports of errors involving high-alert medications, and this year was no exception. This is concerning, as high-alert medications carry a heightened risk of causing significant patient harm when they are used in error, and the harm caused can be devastating.
The ISMP 2018-2019 Targeted Medication Safety Best Practices for Hospitals were developed to identify, inspire, and mobilize widespread, national adoption of best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications.1 The intent of these best practices is to draw attention to proper management of these medications.
Three new recommendations were added in December 2017:
To read about one organization’s process to eliminate use of promethazine injection, see the presentation by Kelly Besco, PharmD, FISMP, CPPS, Medication Safety Officer, OhioHealth Pharmacy Services, at: www.eventscribe.com/uploads/eventScribe/PDFs/2018/2104/635197.pdf.
In early 2018, ISMP introduced a Self Assessment for High-Alert Medications,2 which is designed to:
Many organizations have already taken advantage of this assessment, and the tool is still available for interested organizations. ISMP is now in the process of releasing some of this preliminary comparative data.
PP&P: Which ISMP Best Practices suffer from low adoption rates?
Michalek: Due to low rates of compliance, ISMP is asking hospitals to focus on these existing best practices (see FIGURE 1):
PP&P: What patient education and follow-up should occur to help prevent patient harm?
Michalek: It is not uncommon for organizations to bypass patient education. This is unfortunate, as the proper education of patients is critical to preventing medication errors. During the discharge medication reconciliation process, each prescription should be discussed with the patient. Describe the purpose of each medication and how it should be taken. Compile a targeted list of high-risk patients (ie, those on high-risk or multiple medications), who should receive follow-up phone calls to verify medication compliance and address any questions they may have. Because patients may be distracted or not able to fully comprehend instructions at discharge, follow-up phone calls are critical to ensure medications are taken as instructed. The pharmacist can make these calls, or the technician or nurse can screen for the need and then alert the pharmacist that a call is required.
In reviewing the most common medication errors that occurred within the past year, ISMP noted that a lack of proper discharge medication reconciliation and follow-up were a common thread in medication noncompliance and errors. A simple conversation can prevent significant patient harm. For example, during discharge medication reconciliation, if the pharmacist or technician refers to the patient’s diabetes medication, and the patient responds that they do not have diabetes, that conversation has prevented a medication error.
PP&P: What are some considerations for avoiding vaccine errors?
Michalek: More than 500 vaccine error events have been reported to ISMP this year. Many of these errors occur due to confusion among age-dependent vaccine formulations. In addition, vaccine name and abbreviation misinterpretations, as well as misunderstanding of the various vaccine components, may result in errors. The most common contributing factors to vaccine errors are listed in TABLE 1.
Several approaches can help prevent vaccine errors. For example, vaccine storage locations should be clearly marked. In addition, bar code medication administration (BCMA) should be established prior to use; an EHR order must be present prior to scanning and administration. The EHR order should be linked to a specific patient, to alleviate age-related vaccine mistakes. Finally, vaccines with two components should be stored together or repackaged and stored together upon arrival into the facility. For example, a powder and a diluent should be stored together, as should two liquid components. A simple rubber band around the two components, or placing the components together in a plastic bag, is effective. It may be useful for manufacturers to consider packaging all vaccine components together in one package to help reduce confusion.
PP&P: How can pharmacy help prevent medication errors due to a patient’s drug allergies?
Michalek: An ISMP work group is currently collaborating with the ECRI Institute on an initiative to improve allergy documentation in order to accurately characterize and distinguish adverse drug reactions, toxicities, intolerance, idiosyncrasies, and allergies.3 At this time, no specific recommendations have been made; it is anticipated that recommendations will be available by the end of the year.
PP&P: How can pharmacists help prevent look-alike/sound-alike (LA/SA) drug errors?
Michalek: Use of Tall Man lettering is critical to illustrate differentiation among products. A format for capital and lowercase letters, and examples of Tall Man lettering, are available on the ISMP website (www.ismp.org/recommendations/tall-man-letters-list). Combatting LA/SA packaging is more challenging; some manufacturers are committed to making significant strides to provide differentiation among similar medication packages, including drug names and doses, while other manufacturers are less motivated. Moving forward, manufacturers should commit to a robust strategy of differentiation to prevent possible errors.
Upon receiving an error report related to a LA/SA product, ISMP may contact the manufacturer and advocate for a packaging change. For example, we received a report that one company’s packaging for adrenalin and adrenalin chloride was highly similar (see PHOTO 1). Thereafter, the company changed the packaging to better differentiate between the nasal solution and the injection solution. If a problem with lack of product differentiation persists, it may be prudent to order from a different manufacturer. However, in an age of drug shortages, this too can be a challenge. Moreover, there is no guarantee that a new item will be sufficiently differentiated. Communication among organizations, manufacturers, and ISMP should continue to improve packaging differentiation, which can help reduce the possibility of error.
PP&P: What staff training must occur to improve medication safety?
Michalek: Preventing medication errors must be a multidisciplinary effort and should include staff training and targeted education. All staff handling medications should receive basic safety training, while those involved in the medication management process and those who are responsible for analysis of near-miss events and errors should receive more targeted training. Medication safety competencies should be assessed on an annual basis. For those staff members imbued in medication safety work—for example, the medication safety officer, members of the medication safety committee or P&T committee, and quality and risk professionals—more robust, targeted medication safety training is required. These staff members should learn how to identify and analyze errors from a systems perspective, so changes can be implemented to prevent ongoing problems resulting from a poor process. Rather than blaming an individual who made an error, focus on fixing the system that allowed that error to occur.
PP&P: What can an organization do to foster a culture of safety?
Michalek: First of all, measure the current state of your organization’s culture. Thereafter, address any barriers that have been identified one by one, focusing on the most critical first. One of the most significant challenges is ensuring staff feels comfortable reporting and discussing errors as well as near-misses; if errors are not reported, they cannot be remedied. Some organizations increase reporting by offering a “good catch” or similar award to practitioners who identify a safety issue. Providing follow-up and feedback to those who report errors and/or safety issues is a positive step toward creating a culture of safety. Evaluate your hospital’s safety culture every 1-2 years, and then be sure to utilize the data you have gleaned.
An effective organization values safety over efficiency, while cultivating a balance between the two. In practice, this can be difficult to achieve, so a continuous effort is required. Dedicate a leader who will be responsible for heading up the safety effort. It is also important to understand that fostering a culture of safety will always be a work in progress—the job will never be complete.
Christina Michalek, BSc Pharm, RPh, FASHP, is a medication safety specialist at the Institute for Safe Medication Practices and oversees the operations of the Medication Safety Officers Society. She collaborates with health-system leaders and clinical staff participating in proactive risk assessments, targeted risk assessments, root cause analysis, and failure mode and effects analysis, in order to define and improve medication safety initiatives.
Opioid tolerance is defined by the following markers: Patients receiving, for 1 week or longer, at least: 60 mg oral morphine/day; 25 mcg transdermal fentaNYL/hour; 30 mg oral oxyCODONE/day; 8 mg oral HYDROmorphone/day; 25 mg oral oxyMORphone/day; 60 mg oral HYDROcodone/day; or an equianalgesic dose of another opioid, including heroin and/or non-prescribed opioids.1
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