N101Y Health Information Technology Module . Medication Safety Patient Safety Error Prevention. Patient Safety . What is a culture of safety?. A Culture of Safety . Medication Errors Adverse Drug Events Adverse Drug Reactions. IOM: To Err is Human: Building a Safer Health System (19919)
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N101Y Health Information Technology Module Medication Safety Patient Safety Error Prevention
Patient Safety What is a culture of safety?
A Culture of Safety • Medication Errors • Adverse Drug Events • Adverse Drug Reactions • IOM: • To Err is Human: Building a Safer Health System (19919) • Crossing the Quality Chasm – A New Health System for the 21st Century (2001) • Assessing the Culture • Teamwork • Patient Involvement • Systems • Openness/Transparency • Accountability
Medication Errors Types and when they occur
Types of Med Errors • Wrong drug-preparation error • Wrong administration-technique error • Deteriorated drug error • Monitoring error • Compliance error • Other medication error • Prescribing error • Omission error • Wrong time error • Unauthorized drug error • Improper dose error • Wrong dosage-form error American Society of Hospital Pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993; 50:305–14.
When Med Errors Occur • Ordering: wrong dose, wrong choice of drug, • Transcribing: wrong frequency of drug administration, missed dose because medication is not transcribed, • Dispensing: drug not sent in time to be administered at the time ordered, wrong drug, wrong dose, • Administering: wrong dose of drug administered, wrong technique used to administer the drug, and • Monitoring: not noting the effects of the given medication
Med Error Discussion Think about medication administration As a student have you experienced • A near miss? • A medication error • Witnessing a near miss • Witness a medication error From http://www.psqh.com/sepoct05/barcodingrfid1.html
Beyond the 5 Rights. Preventing Medication Errors:Technology and Equipment
Medication Administration Technology ORDERING/TRANSCRIBING: • eMARs • ePrescriptions • CPOE (Computerized Provider Order Entry) • CDSS (Clinical Decision Support Systems)
Medication Administration Technology MONITORING: • Smart Rooms • EMR DISPENSING: • Automated medication dispensing devices (“Pyxis®”) ADMINISTERING: • BCMA (Bar Code Medication Administration) • RFID • Smart Pumps
EMR and Human Error Elements in the EMR that reduce human error: • CPOE • Bar Code systems • CDSS • High Alert Medication Documentation • Point of Care Documentation • Mandatory Fields • Communication Tool • Med. Recon.
Potential for errors with technology Errors with BMCA: • Medication does not come packaged as bar-coded unit-dose product • Pharmacy does not scan products arriving in pharmacy for readability • Pharmacy applies correct label with bar code to wrong product • Drugs not available in ready-to-use unit-doses for nurse (e.g., tablets not broken in half) • Nurse fails to scan patient • Nurse fails to scan medication • Bar code on patient and/or medication is unreadable • Patient wristbands are not on patients but other locations (e.g., clipboards, med rooms) • Nurse overlooks alert displayed on computer screen • Nurse overrides alert without investigating its cause
Potential for errors with technology ERRORS WITH CPOE/EMR/eMAR/ePrescribing: • Mostly user interface issues: • Wrong patient chosen • Drop down menu issues (too many choices!) • Software issues In 2010 computers at a major Midwest hospital chain : • EMR would switch to another patient record without the user directing it to do so • electronic pharmacy orders weren't being delivered to nurses for dispensing to patients http://www.huffingtonpost.com/2010/08/04/fda-obama-digital-medical_n_670036.html
Emerging Patient Safety Technologies The present and the future
Other patient safety technologies What is patient safety technology? 1. Used in direct hands-on care of the patient 2. Documentation tools 3. Meeting the needs of patients and families 4. Supporting the staff caring for the patient and the family SOME EXAMPLES: • Bedside monitoring • CDSS • Communication Tools • Educational • Smart rooms
Smart Rooms • http://youtu.be/09PSFU7loV0
Potential for errors OTHER TECHNOLOGIES: DISCUSS What are some other areas that might have potential for error • CDSS • Automated medication dispensing devices • Smart Pumps • Smart Rooms • Others?
The Nurse’s Role • Participate or organize equipment fairs to evaluate technology and equipment before it is purchased at your facility • Practice and learn to use new technology on challenging scenarios in a simulated setting • Mentor and oversee temporary (agency) nurses and other personnel as they use your facility’s technology • Become critical users of technology by identifying problems early and communicating them to vendors and in-house biomedical engineering staff • Ensure that adverse events associated with medical devices are reported to the Food and Drug Administration MAUDE reporting system and/or ECRI’s Problem Reporting System • Serve as a resource person on your unit for new technologies by being a SuperUser! From: http://www.ncbi.nlm.nih.gov/books/NBK2686/ Culture of safety Technology The future