Rats in the Swiss Cheese Model

1. Rats in the Swiss Cheese Model Challenges with Integrated Medication Management Rhonda McManus, Pharm D Director, Clinical Operations Cardinal Health

2. The Swiss Cheese Model of Systems Accidents

3. Objectives for Pharmacists • Know the prevalence of technologies used in medication management process • Describe synergies of integrated technologies • Explain challenges identified with integrated technologies • Understand work-arounds end users have established • Discuss opportunities for pharmacists created by integrated automated systems

4. Objectives for Pharmacy Technicians • List three technologies used in the medication management process • Describe techniques end users employ to bypass safeguards in the medication use process • Explain the role of the pharmacy technician in monitoring the medication distribution process

5. Newest Thing in Integrated Technologies http://producten.hema.nl/

6. No machine will ever take the place of good clinical judgment.

7. The Perfect Integrated Solution CPOE* PIS* ADM* BPOC* Billing * With step-specific and service specific embedded decision support and common formulary table

8. Supply Chain management Clinical Decision Support ADT Billing ADC CPOE PIS BPOC Lab, radiology, other ancillary departments Pharmacy storage and packaging Charting

9. 2 3 4 5 Medication Use Safety: Foundational Functionalities Provider Education and Baseline Assessment Order Management Point-of-Care Automation Bedside Verification CPOE 1 Patient Monitoring InformationIntegration Prescribing Transcribing Dispensing Administering Information Integration Information Integration Information IntegrationInformation Integration Drug Interaction Review EUM Replenishment ADE Review Patient Monitoring and Outcome Review

10. Phases of the medication management process where errors occur Process Physician Orders Order Management Pharmacy Control and Distribution Patient-Specific Medication Preparation and Dispensing Medication Administration at the Point of Care * Leape, L.L., D.W. Bates, D.J. Cullen, et al. for the ADE Prevention Study Group, 1995. “Systems Analysis of Adverse Drug Events.” Journal of the American Medication Association. 274: 35-43.

11. So How Many Health Systems have Implemented?

12. Adoption Rates: BCMA Schneider, Philip. “Opportunities for Pharmacists” American Journal of Health-system pharmacists, 64:s12-s16.

13. Adoption Rate: CPOE Schneider, Philip. “Opportunities for Pharmacists” American Journal of Health-system pharmacists, 64:s12-s16.

14. Decentralized Distribution Trends Schneider, Philip. “Opportunities for Pharmacists” American Journal of Health-system pharmacists, 64:s12-s16.

15. Benefits of CPOE • Reduced errors related to handwriting • Decreased order turn around time • Decreased look-alike, sound-alike errors • Integration with medical records and decision support systems • Decreased errors related to decimal point, trailing zeros and use of apothecary measures • Easily linked to drug-drug interaction programs

16. Benefits of CPOE • Link to ADE reporting systems • Links to lab for alerts • Standardization of therapy • Formulary control • Support for cost effective drug therapy choices • Decreased duplicate orders • Identification of prescriber • Access to data for analysis • Force inclusion of reason for therapy

17. Nine Unintended Consequences of Computerized Order Entry • More/new work for clinicians • Unfavorable work-flow issues • Endless demands by the system • Unwillingness to give up paper • Changes in communication patterns and practices • Negative feelings toward the system and those responsible for it • Introduction of new errors • Unexpected changes in the power structure such as the committee designing the computerized protocols making judgments about best practices • Over-reliance on the technology Source: “Types of Unintended Consequences Related to Computerized Provider Order Entry,” Journal of the American Medical Informatics Association, June 23, 2006.

18. More Unintended Consequences • Order sets created without nursing and pharmacy; broad orders with clinical decisions put nurses in jeopardy of practicing medicine • Order sets increase the number of orders pharmacists review and dispense • Weak interfaces between CPOE and PIS make pharmacy corrections necessary • Physicians use notes section to enter orders if they cannot find the medication listed, so pharmacists have to check the notes section

19. Examples of Errors Facilitated by CPOE • User errors • Wrong patient selection • Wrong medication selection • Unclear log-on and log-off • Failure to renew medication post surgery • Loss of data and time when CPOE system is down • Late day orders lost for 24 hours • Uncertainty regarding changing orders, discontinuing orders and resuming orders

20. Examples of Errors Facilitated by CPOE • Systems errors • Assumed dose information • Medication discontinuation failures • Procedure-linked medication discontinuation • Diluent options and errors • Allergy information delay • Conflicting or duplicate medications

21. CPOE Work-arounds • Increased verbal orders • Enter orders in physicians’ notes section • Override alerts and warnings • Over-use of order sets • Refuse to use CPOE and continue to use paper orders • Make less frequent adjustments to therapy

22. Benefits of ADM • Medication is available on nursing unit as soon as pharmacist verifies CPOE order • Decreased missing doses • Decreased chance for error due to “borrowing” medications • Warnings and alerts at medication preparation phase- not at patient bedside

23. ADM Challenges • Adequate equipment • Profile-enabled • Single drug access • Refill accuracy • Management of inventory levels • Integrating with BCMA • Perception of nursing of decentralized distribution model

24. ADM Work-arounds • Matrix drawers • Pocket and belt bag stock • “The Pumpkin” stock • Cancel transactions • Inventory feature • Return to pocket feature

25. ISMP ADM Focus Group • Met in March 2007 • Sponsored by Cardinal Health, McKesson and Omnicell • Meeting of pharmacists users, nurse users and vendors as well as ISMP • Purpose: to define best practice around the use of automated dispensing devices • Report of findings posted on ISMP Website and presented at ASHP in December 2007

26. ADC Core Processes • Provide ideal environmental conditions for the use of ADCs • Ensure ADC system security • Use pharmacy-profiled ADCs • Identify information that should appear on the ADC screen • Select and maintain proper ADC inventory • Select appropriate ADC configuration ISMP, 2008

27. ADC Core Processes • Define safe ADC restocking processes • Develop procedures to ensure the accurate withdrawal of medications from the ADC • Establish criteria for ADC system overrides • Standardize processes for transporting medications from the ADC to the patient’s bedside • Eliminate the process for returning medications directly to their original ADC location • Provide staff education and competency validation ISMP, 2008

28. BPOC Benefits • 5 Rights • Billing accuracy

29. BPOC Challenges • Bar codes • Purchase • Preparation • Unexpected changes in bar codes • Readable • Patient ID • Pharmacy Order Entry changes • Medication Management in BPOC world

31. BPOC Work-arounds • List of patients with bar codes • Patient “stickers” • List of medications with bar codes • Pick from patient list • Pick from medication list • Remove from ADM, no documentation of medication administration: Bad documentation or diversion?

32. Opportunities for Pharmacists • Take an active, leadership role in any and all technology implementations and upgrades • Clinical Decision support • Database management • Process redesign • Ongoing maintenance • Data to knowledge to action • Monitor process changes for new errors

33. Opportunities for Pharmacy Technicians • System maintenance • Data management • Process redesign • Increasing role in distribution responsibilities • Monitor for new errors, process work-arounds

34. Questions and Comments