EVALUATING AND REDUCING THE RISK AND COST OF MEDICATION ERRORS - PowerPoint PPT Presentation

EVALUATING AND REDUCING THE RISK AND COST OF MEDICATION ERRORS RELATED TO INCOMPLETE MEDICATION HISTORIES Haley Monolopolus, Pharm. D. PGY-1 Pharmacy Practice Resident Providence Alaska Medical Center, Anchorage, AK IRB status: approved 1

 Presenter: Haley Monolopolus  Conflict of interest: none  Sponsorship: no funding received to support research DISCLOSURE  The research presented is subject to different interpretation  This presentation is educational in nature and abides by non- commercial guidelines 2

1. Explain the goal of medication history and define undocumented intentional discrepancies and unintentional discrepancies LEARNING 2. Identify potential barriers to completing medication histories for patients admitted to the hospital OBJECTIVES 3. Give examples of medication error categories based on the National Coordinating Council for Medication Error Reporting and Prevention Index 3

 Largest hospital in the state  402 beds PROVIDENCE  62 emergency department beds ALASKA MEDICAL CENTER  Tertiary, non-profit, community medical center Anchorage, AK  Transition of care services  2.4 FTE medication history technicians:  Coverage: M-F 0900-1930 , Sa/Su: 1000-1830  Decentralized pharmacists, pharmacy residents, pharmacy students 4

1. Which of the following is an example of an undocumented intentional discrepancy? a) Hospitalist adds lisinopril 10 mg daily to the home medication list since the patient was taking it prior to admission. b) Hospitalist omitted ordering lisinopril 10 mg daily, by mistake. c) Hospitalist holds lisinopril 10 mg daily due to AKI, without documenting in the EHR. d) Hospitalist holds lisinopril 10 mg daily due to AKI and documents the change in the EHR. PRE-TEST 2. All of the following are potential barriers to completing medication histories for patients admitted to the hospital EXCEPT: ASSESSMENT a) Lack of appropriate documentation b) Standardized process required by Joint Commission c) Staffing capabilities d) Receiving documentation from outpatient pharmacies 3. What NCC MERP error category would the following scenario be classified as?: The physician unintentionally omits ordering allopurinol 100 mg daily from the home medication list and patient does not receive the medication a) A b) B c) C d) D 5

 The Joint Commission identified medication reconciliation as a National Safety Goal in 2005  Despite a formal process being mandated by accreditation organizations, a large percentage of patients have unintentional medication discrepancies on their home medication list BACKGROUND  Currently, there is no universal, standardized prioritization scheme for completing medication histories  At PAMC our goal is to complete medication histories within 24 hours of admission  If unable to complete within 48 hours, work is stopped unless continuation is requested by a physician and/or pharmacist 6

 Goals of medication reconciliation  Prevent ADRs at all interfaces of care (admission, transfer, discharge)  Confirm undocumented intentional discrepancies  Eliminate unintentional discrepancies  Undocumented intentional discrepancies  Prescriber intentionally adds /changes/discontinues a medication BACKGROUND without clearly documenting in the patient’s medical record  Unintentional discrepancies  Prescriber unintentionally adds/changes/omits a medication the patient was taking prior to admission  Potential barriers to completing medication history  Direct admissions, staffing capabilities, patient altered/unreliable, complex home medication lists, lack of documentation, receiving documents from pharmacies/other sources 7

 Primary Objective  Evaluate the number, type, severity, cost, and risk of errors occurring when medication histories are not completed within 48 hours of admission STUDY  Secondary Objectives OBJECTIVES  Evaluate current process of completing medication histories and identify prioritization scheme to capture higher risk patients  Evaluate number/types of changes made to previously completed medication histories for patients with “simple medication histories” 8

SIMPLE MEDICATION GROUP 48 HOUR HIGH RISK GROUP History completed after 48 History completed any time hours of admission which during admission which meets meets any of the following: any of the following:  >5 prescription medications  <5 prescription medications  Anticoagulants, anti-epileptics,  Only OTC medications METHODS insulin, transplant medications, and/or COPD medications • Data analyzed for patients having medication histories completed between June 1 st , 2019 and December 31 st , 2019 • Cost evaluated for medications incorrectly administered based on an inaccurate medication history • Medication errors and risk assessed using the NCC MERP Index 9

METHODS 10

SIMPLE GROUP Total patients = 345 RESULTS –  <3 Rx medications, including no medications = 238 patients ( 69 %)  < 3 Rx medications = 142 patients Patient Groups  No medications = 96 patients  3-4 Rx medications = 82 patients ( 24 %)  Only OTC medications = 25 patients ( 7 %) 11

HIGH RISK GROUP Total patients = 84 RESULTS –  > 5 Rx medications ONLY = 35 patients ( 42 %) Patient Groups  High risk medications ONLY = 2 patients ( 2 %)  > 5 Rx medications AND high risk medication = 47 patients ( 65 %) 12

SIMPLE GROUP HIGH RISK GROUP 345 84 Total Patients Patients with Error Present 194 (46%) 77 (92%) RESULTS – on List Errors Total Errors 425 463 • Wrong drug/dose/freq 134 errors (31.5%) 273 errors (59%) • Missing drug 291 errors (68.5%) 190 errors (41%) Errors per Patient ~2 ~6 13

SIMPLE GROUP  Wrong drug actually administered  6 medications ( 4.4 % )  30 total doses Medication Number PRN of Doses (Y/N) RESULTS – Aspirin 81 mg 2 N Budesonide-formoterol 160-4.5 mcg 6 N Wrong Drug Clonazepam 1 mg 10 Y Lisinopril 20 mg 1 N Metoprolol succinate 50 mg 6 N Omeprazole 40 mg 5 N  Total unnecessary Cost  Rx = $59.22  Patient = $1,143.50 14

SIMPLE GROUP  Missing drug actually omitted  81 medications ( 27.1 % )  510 total doses RESULTS – Missing Drug Prescription OTC/non-formulary Medications Medications Number of 34 (43%) 47 (57%) Medications Number of Doses 160 (31.6%) 347 (68.4%) 15

HIGH RISK GROUP  Wrong drug actually administered  76 medications ( 27.8 %)  556 total doses Medication: HIGHLIGHTS Number PRN of Doses (Y/N) RESULTS – Amitriptyline 100 mg 18 N Wrong Drug Pantoprazole 40 mg 20 N Carvedilol 3.125 mg 8 N Apixaban 5 mg 10 N SMX-TMP 800-160 mg 4 N  Total unnecessary Cost  Rx = $214.16  Patient = $16,584.17 16

HIGH RISK GROUP  Missing drug actually omitted  100 medications ( 52.6 % )  1172 total doses RESULTS – Missing Drug Prescription OTC/non-formulary Medications Medications Number of 72 (72%) 28 (28%) Medications Number of Doses 764 (65.2%) 408 (34.8%) 17

 All errors were categorized as A, B, or C based on NCC MERP RESULTS –  No medications incorrectly Safety administered or omitted caused known patient harm or additional intervention 18

SIMPLE GROUP HIGH RISK GROUP Time to Completion 0-24 hours: 310 patients ( 89.9 %) >24-48 hours: 21 patients ( 6.1 %) >48 hours: 14 patients ( 4 %) RESULTS – Reason for ICU 3 patients 3 patients Incomplete VA 1 patient 10 patients Time to at 48 hours Facility - 1 patients Completion Family - 2 patients Consult 2 patients 5 patients Unknown 8 patients 63 patients Average time to 11:16:00 83:39:00 Completion 83 patients completed at 00:00 19

 Potential limitations  Retrospective chart review  Undocumented intentional discrepancies  Lack of documentation  PTA medications may become inappropriate at admission  Discontinued medications may become appropriate at admission DISCUSSION  All medication histories included in the study were completed  Safety: NCC MERP error categories A, B, or C  Potential for D-I if continued throughout duration of hospitalization  High risk group: more disease states, more medications, more errors  Cost to the patient more than the cost to the pharmacy department 20

 High risk group had a higher percentage of medications administered incorrectly ( 27.8 % v 4.4 %) and a higher percentage of medications incorrectly omitted ( 52.6 % v 27.1 %), compared to the simple group  High risk group had a higher percentage of prescription medication doses omitted ( 65.2 % v 31.6 %), compared to the simple group  Most simple mediation histories are complete within 24 hours of CONCLUSION admission ( 89.9 %)  Stopping work on incomplete histories at 48 hours is failing to resolve medication discrepancies on home medication lists  More staff and changes to the medication history process at PAMC are necessary to prevent medication errors 21