ABATING THE RISK OF ADE’s THROUGH AUTOMATED MEDICATON CYCLE MANAGEMENT Colleen Burch, RN P. Bruce Campbell, MD Francine Miranda, RN, BSN, FASHRM, HRM Tom Smith, R.Ph., MS Jim Webb, Panel Moderator
INTRODUCTION INTRODUCTION 100,000 • A word about timing 80,000 • Enormous public 60,000 scrutiny 40,000 • Pending legislation 20,000 • Adverse drug events are 0 Annual Deaths costly Auto Accidents – human terms Adverse Medical Events AIDS – economic terms Breast Cancer ADE's • ADEs are largely preventable
THE RISK MANAGER’S THE RISK MANAGER’S PERSPECTIVE PERSPECTIVE The Organization’s Imperatives Francine Miranda, RN,FRM
Lehigh Valley Hospital and Health Network Background • Non-profit based in Allentown, PA – Lehigh Valley Hospital – Muhlenberg Hospital – Lehigh Valley Health Services • Advanced regional resources include Level 1 trauma center, burn, kidney transport, perinatal/neonatal, cardiac and cancer center
Lehigh Valley Hospital Risk Management: What Is It? A systematic approach to the prevention of loss to protect and maintain the financial assets of the institution by preventing liability situations from occurring through proactive interventions.
Lehigh Valley Hospital Liability Exposures - Where do ADE’s fall? • Medication errors • Falls with fractures • Misdiagnosis
Lehigh Valley Hospital Medication Management Process • What is your medication management process? • Know the strengths and weaknesses of your process • Know where to look for process issues and be able to identify errors
Lehigh Valley Hospital Medication Management Process (continued) • Have a well defined system for process improvement • Once you have the process …. then look for the causes of breakdown
Lehigh Valley Hospital Medication Management Areas of Concern • Physician Ordering • Transcription • Dispensing • Administration
Lehigh Valley Hospital Physician Ordering Risks • Order incomplete • Inappropriate/ unacceptable • Order illegible abbreviations • Order written on • Route selection the wrong chart • Patient drug allergies • Inappropriate drug not identified selection • Decimal misplaced
Lehigh Valley Hospital Transcription Risks • Order not transcribed • Allergies not transcribed • Order not completely signed off • Incomplete order not clarified • Incorrect transcription onto • Transcription MAR illegible
Lehigh Valley Hospital Administration Risks • Incorrect IV setting • Wrong time • Omitted/over- • Wrong drug looked • Wrong route • Extra/duplicated • Wrong dosage • Given without an order
Lehigh Valley Hospital Dispensing Risks • Incorrect product • Delay in delivery not obtained and • Product incorrectly delivered prepared in • Incorrectly labeled pharmacy • Product not • Miscalculation delivered to the nursing unit
Lehigh Valley Hospital Important Points to Remember • Do not make the process punitive • Cost of automation is a major concern/obstacle • Know your administration’s view/ support on medication errors • Have a core multi-disciplinary team work towards reduction of errors
THE PHYSICIAN’S THE PHYSICIAN’S PERSPECTIVE PERSPECTIVE Medication Orders: Why Physicians Will Buy In P. Bruce Campbell, MD
Physicians and Medication Errors • How to reconcile “primum non nocere” and >7,000 annual medication-related deaths? – Unaware of frequency of medication errors – Unaware of costs of medication errors – Fatalistic attitude re. Medication errors – Competing demands for time and attention
Physicians, Medication Errors, and Computers • Compelling demonstrations of decreased medication errors and adverse drug events with computerized order entry • Physician usage crucial to realizing system benefits • Physician reluctance to utilize computerized order entry no longer tenable
Clinical Systems Implementation at an Urban Medical Center • May, 1990: “big bang” implementation of RN documentation, results retrieval, order entry after two years of planning • May, 1990: clinical information system implodes • May, 1992: system universally reviled
Clinical Systems Implementation at an Urban Medical Center Errors in implementation process • Administrative failure – Articulation of commitment – Coherent expression of benefits and expectations – Adjudication of interdepartmental disputes
Clinical Systems Implementation at an Urban Medical Center Errors in implementation process • Errors of design: operationalization • Slavish dedication to deadlines • Involvement of physicians in design and implementation – Education, training, and participation insufficient
Physician Order Entry at an Urban Medical Center POE as Per Cent of Non-verbal Orders 90 80 70 60 50 40 30 20 10 0 7/93 7/97 7/94 7/95 7/96 7/98
Successful Re-implementation of Physician Order Entry • Secured senior hospital and clinical commitment to the project
Successful Re-implementation of Physician Order Entry • “Super-users” adopt Explorers the innovation unreservedly Early Adopters • Some will never adopt Early the innovation unless Majority forced Late Majority • Majority need a prod to adopt an innovation Laggards 0 10 20 30 40
Characteristics Critical to Adoption of an Innovation • Compatibility with values, experiences, and needs of potential adopters • Relative advantage over the status quo • Observability • Feasibility • Complexity
Physician Attitudes to Computers • No innate resistance to computer usage • No innate fears of a cultural revolution • Concerned solely with requirements for additional time for order entry • Would invest additional 15-45 min. per day to achieve an increase in quality or 10% reduction in costs
Successful Re-implementation of Physician Order Entry • Needs assessment to identify top MD priorities for system development –7/10: more data –1/10: easier access –1/10: simplicity –1/10: pie-in-sky technology (VR)
Successful Re-implementation of Physician Order Entry • Demonstrated system benefits for physicians (compatibility, observability) – Pharmacy order execution: seconds vs. 90 minutes – Online heparin dosing: • Calculated dosing based on height, weight, and coagulation status
Online Heparin Dosing and Quality of Care • Conventional Dosing Effect on Therapeutic Levels of Heparin Conventional Dosing vs. Protocol Dosing – At 6 Hours: 20% Underdosed and 60% Overdosed – At 24 Hours: 50% Underdosed and 10% Overdosed 100% (10% Therapeutic) 80% 10% Overdosed 60% • Protocol Dosing: 75% 90% Therapeutic 40% Underdosed – At 6 Hours: 20% Underdosed, 5% Overdosed (75% 0% 20% Therapeutic) 0% s s s s r r r r – At 24 Hours: 5% Underdosed, 5% Overdosed (90% u u u u o o o o H H H H 4 4 6 6 Therapeutic) 2 2 Conventional Protocol
Successful Re-implementation of Physician Order Entry • Identify and utilize system champions – Opinion leaders most effective as majority mimics the behavior of role models – Therefore, tailor the tools to their needs (at least initially) • Cannot overeducate – Repeated demonstrations of system capabilities and benefits – Train, train, train
Clinical Systems Implementation • Physicians (must,will) adopt order entry • Physician utilization can either be mandated or marketed • Physician involvement in system design and implementation is crucial to success – Ensures compatibility with values and needs – Ensures end users realize meaningful benefits
THE PHARMACIST’S THE PHARMACIST’S PERSPECTIVE PERSPECTIVE Filling, Dispensing, and Redeployment of Pharmacists Tom Smith, MS, R.Ph.
Moore Regional Hospital Background • 3 hospital system • 35 clinics • Primary facility – 400 bed community hospital – Census remains high at 80% – Pre-automation pharmacy staff of 42
Moore Regional History of Medication Administration Systems 60’s • Decentralized medications • Centralized pharmacists • Errors > 20%
Moore Regional History of Medication Administration Systems 70’s • Unit dose systems developed • Centralized medications • Centralized pharmacists • Errors reduced
Moore Regional History of Medication Administration Systems 80’s • Satellite pharmacies • Decentralized medications • Decentralized pharmacists • Unit-based cabinets • Faster turn-around times for medications
Moore Regional History of Medication Administration Systems 90’s • Managed care • Reduced staffing • Closed satellites • Re-centralized medications • Emergence of automation –Bar codes and bedside scans
Moore Regional Steps to Automation • Adhere to ASHP’s standards • Eliminate/control medication errors – Implement proven bar-code technology – Implement justifiable automation • Robotics • Unit-based cabinet technology • Closed-loop systems
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