Creating a Culture of Safety to Reduce Medication Harm

1. Creating a Culture of Safety to Reduce Medication Harm Megan Winegardner, Pharm.D. Medication Safety Coordinator Henry Ford Hospital, Detroit MI International Safety Symposium November 10th, 2011

2. Objectives • Describe the incidence and severity of adverse drug events in the United States • Explain the differences between a Punitive Culture, a Blame-Free Culture, and a Just Culture • List steps that can be taken to establish a culture of safety to reduce medication harm

3. Causes of Death in the US Number of deaths per year Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.

4. Adverse Events in Hospitalized Patients • Bleeding • Delirium • Hypoglycemia • Acute renal failure • Hypotension • Respiratory complications • Allergic reaction • 13.5% of Medicare patients experience a serious adverse event during hospitalization (134,000 pts/month) • Most common causes: • Medications (31%) • Ongoing patient care (28%) • Surgery (26%) • Infection (15%) Office of Inspector General. Adverse events in hospitals: National incidence among Medicare beneficiaries. November 2010.

5. Adverse Events in Hospitalized Patients • Delirium • Hypoglycemia • Opportunistic infection • Allergic reaction • Others • An additional 13.5% of Medicare patients experience temporary harm during hospitalization • Most common causes: • Medications (42%) • Ongoing patient care (36%) • Surgery (18%) • Infection (4%) • 50% of medication-related events considered preventable Office of Inspector General. Adverse events in hospitals: National incidence among Medicare beneficiaries. November 2010.

6. Recommendations Enhance patient safety leadership and knowledge Use error reporting systems to learn from errors Set performance standards Create safety systems Institute of Medicine. To Err is Human: Building a Safer Health System. 2000.

7. Culture of Safety Timeline Punitive Culture Blame-Free Culture Just Culture • Fear of retribution • Decreased reporting • Work-arounds • Lack of accountability Institute for Safe Medication Practices. Medication Safety Alert. Sept 7, 2006.

8. Just Culture Institute for Safe Medication Practices. Medication Safety Alert. September 21, 2006.

9. Just Culture During a busy shift, a pharmacist fails to check a patient’s renal function when entering an order for an antibiotic. The patient is not harmed.

10. Just Culture A pharmacist inadvertently hits the zero key an extra time and enters an order for 100 mg instead of 10 mg. The patient receives an overdose and must be transferred to the ICU. Response is dictated by type of behavior, not outcome of patient.

11. Creating a Culture of Safety Critically evaluate your reporting system Increase medication safety incident reporting Develop a system for follow-up of reports Analyze incident report data Provide feedback to staff members

12. 1. Evaluating a Reporting System • Standard fields: • Patient • Date/time/location • Description of event • Outcome • Additional fields to consider for medication-related events • See NCC MERP Taxonomy of Medication Errors • Provides standard language and structure

13. NCC MERP Taxonomy for Medication Errors * Not an all-inclusive list National Coordinating Council for Medication Error Reporting and Prevention, 1998.

14. Maximizing Output • Minimize free-text fields • Lose ability to “pull” data • May be necessary for description of event • Sortable/retrievable lists: • Drug name (generic or brand) • Drug class • Type of error • Process node (prescribing, dispensing, administration) • Causes / contributing factors

15. 2. Increasing Incident Reporting Classen DC et al. Health Affairs 2011;30:581-589.

16. Ideas to Increase Reporting Pharmacy Department Incident Reporting Provide education Set targets Provide incentives

17. 3. Incident Report Follow-up • Required follow-up • Does a pharmacist review ALL medication incidents? • Division of responsibility • Large group: smaller workload, hard to spot trends • Small group: larger workload, easier to spot trends • Ensuring accuracy of information in report • Example: severity level often too “high” • Garbage in = garbage out

18. 4. Analyzing Your Data Create a medication safety dashboard

19. Analyzing Your Data • Create dashboard cross-tabs to answer questions • Medication class most commonly reported to cause patient harm? • Medication class x “High severity” incidents • Wrong patient errors occurring during medication prescribing? • “Wrong patient” error type x “Prescribing” process node • Compare yourself to national data • USP MEDMARX database • IHI 5 million lives campaign • Others

20. 5. Providing Feedback to Staff • Share examples of system-based changes • New manufacturer for look-alike vials • Change to instruction field of MAR • Create a medication safety annual report • Summarize dashboard data • Point out high risk medications, processes • Identify areas for future quality improvement activities • Establishes a non-punitive culture of openness, transparency

21. Creating a Culture of Safety Critically evaluate your reporting system Increase medication safety incident reporting Develop a system for follow-up of reports Analyze incident report data Provide feedback to staff members

22. Challenges • Criminal penalties for medication errors • 2006: • Wisconsin nurse charged with criminal neglect for an epidural error that resulted in the death of a pregnant patient • 2009: • Ohio pharmacist sentenced to prison for a chemotherapy error that resulted in the death of a child www.ismp.org

23. Creating a Culture of Safety to Reduce Medication Harm Megan Winegardner, Pharm.D. Medication Safety Coordinator Henry Ford Hospital, Detroit MI International Safety Symposium November 10th, 2011