December, 2009 sc,alt

1. Medication Errors WorkshopPresented by: APS HealthcareSouthwestern PA Health Care Quality Unit(HCQU) December, 2009 sc,alt

2. Disclaimer Information or education provided by the HCQU is not intended to replace medical advice from the consumer’s personal care physician, existing facility policy or federal, state and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented. Certificates for training hours will only be awarded to those who attend a training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.

3. Note of Clarification While mental retardation (MR) is still recognized as a clinical diagnosis, in an effort to support the work of self-advocates, the APS SW PA HCQU will be using the terms intellectual and/or developmental disability (I/DD) to replace mental retardation (MR) when feasible.

4. Objectives Upon completion of the session the participant will: • 1. Describe how a systems approach can help to prevent/reduce medication errors • 2. Utilize key system elements to identify contributing factors to medication errors • 3. Analyze a medication error using the root cause analysis method

5. Workshop Plan • Brief review of medication errors • Group activities • Identification of medication errors • Typing of medication errors • Categorizing of medication errors • Performance of root cause analysis

6. Medication Error Defined • Preventable event • May cause/lead to inappropriate medication use or individual harm • Medication in control of healthcare professional or consumer National Coordinating Council for Medication Error Reporting and Prevention • Violation of one of five rights • Incorrect medication procedure Office of Developmental Programs

7. Where Errors Occur

8. Types of Medication Errors • Omission • Commission

9. Wrong dose Wrong time Wrong person Wrong medication Discontinued medication Extra dose Wrong medication Wrong route Wrong position Wrong technique or method Wrong form Errors of Commission

10. Principles of Medication Error Reduction & Prevention • Goal of every organization • Use of systems approach • Assess risk • Failure mode and effects analysis (FMEA) • Assess errors and near misses • Root cause analysis (RCA)

11. Key System Elements • Policies & procedures • Individual information • Medication information • Communication • Medication names • Labeling & packaging • Standardization, storage, & distribution

12. Key System Elements • Delivery systems • Environment & staffing • Competency & education • Individual education • Monitoring • Documentation • Quality improvement & risk management

13. Policies & Procedures • Basis for medication use system • Govern sub-processes

14. Individual Information • Vital to physician, pharmacist, and staff

15. Medication Information • Current • Readily available • Identification of High Alert Medications

16. Verbal B/W team members Method used Written Prescriptions Use of abbreviations, symbols, dose expressions Communication

17. Medication Names • Sound alike • Look alike

18. Labeling & Packaging • Similarities • Confusing • Mislabeling

19. Medication Standardization, Storage, & Distribution • Standards in place • Safe storage • Timely ordering and delivery

20. Medication Delivery Systems • Syringes: Oral vs. Parenteral • Glucose monitors

21. Environment • Lighting • Noise • Temperature • Distractions • Interruptions • Unit organization

22. Staffing • Physical health • Emotional health • Work schedule • Fatigue • Medications • Interpersonal relationships • Confirmation bias

23. Competency & Education • Orientation • Certifications • Annual competencies • Skills labs • In-services

24. Program Participant Education • Knowledge of medications • Encouraged to ask questions

25. Monitoring • Adverse side effects/toxicity • Medication interactions • Diagnostic studies • Allergies

26. Documentation • Standardized • Individual

27. Quality Improvement & Risk Management • Leadership • Non-punitive systems based approach • Error reporting

28. Benefits of Systems Based Approach • Reduction of medication errors and near misses • Safer medication use system • Empowers staff • Morale improves

29. Group Activities • Identification of medication errors • Typing of medication errors • Categorizing of medication errors • Performance of root cause analysis

30. References Institute for Safe Medication Practices (2009). FAQ. Retrieved August 24, 2009 from , Web site: http://www.ismp.org/faq.asp Cardinal Health (2009). Statistics. Retrieved August 24, 2009 from , Web site:http://www.legacycarefusion.com/clinicalcenter/education/statistics

31. References Morrow, J., & Breen, B. (2004). PA DPW OMR: Training how to administer medications the right way. National Coordinating Council for Medication Error Reporting and Prevention ( 2009). What is a medication error?. Retrieved August 24, 2009 from , Web site:http://www.nccmerp.org/aboutMedErrors.html

32. References Folino, E. (2004). Medication errors: Preventing the preventable ppt. National Coordinating Council for Medication Error Reporting and Prevention ( 2009). Council recommendations. RetrievedAugust 24, 2009 from , Web site:http://www.nccmerp.org/councilRecs.html

33. Suggested Supplemental Training • Medication Administration • Preventing & Reducing Medication Errors • Aging: Medication Management • Medication Side Effects

34. To register for future trainings,orfor more information on this or any other physical or behavioral health topic, please visit our website at www.hcqu.apshealthcare.com

36. EvaluationPlease take a few moments to complete the evaluation form found in the back of your packets.Thank You!

37. Test ReviewThere will be a test review after all tests have beencompleted and turned in to the Instructor.