Medication Safety Pharmacist Jackie Biery, Pharm.D. University of - PowerPoint PPT Presentation

Medication Safety Pharmacist Jackie Biery, Pharm.D. University of Washington February 21, 2006

Medication Errors in the United States � Medical errors are the eighth leading cause of death in the United States � Medication errors account for at least 7,000 deaths in the United States each year � Annual cost of medication errors is approximately $2.8 million for a 700-bed teaching hospital.

Unlabeled Containers Lead to Patient’s Death – November 2004 � A 69y/o Seattle female died during a cerebral angiography � Accidentally injected with chlorhexidine (an antiseptic skin prep solution) instead of contrast media � JCAHO adopts new labeling standards

Three Neonates Die from Heparin Overdoses - September 2006 � 1mL vials of heparin 10,000units/mL were placed in an ADC instead of 1mL vials of heparin 10units/mL � Total of 6 babies affected � Similar overdose of heparin in 2001 � Limit concentrations of heparin stocked in the hospital and pharmacy

Role of the Medication Safety Pharmacist � Manage Medication Error Reporting � Review reports submitted through the online reporting system � Determine root cause of error

Harm Score

Role of the Medication Safety Pharmacist � Identify best practices for medication safety � Analyze current practices that contribute to medication errors � Take proactive steps for prevention � Facilitate process and system changes to reduce the likelihood of occurrence/recurrence of error � Educate pharmacy staff and other clinicians to promote safe medication practices � Develop educational programs to improve medication safety and regulatory compliance

Role of the Medication Safety Pharmacist � Participate in committees related to medication safety � Safe Medication Practices Committee � Patient Safety Committee � H.E.A.T. Meetings � Medication Reconciliation Committee � Use of Two Patient Identifiers Committee

Role of the Medication Safety Pharmacist � Assist in development and review of medication-use policies � Monitor compliance with standards set forth by JCAHO � National Patient Safety Goals

Patient Safety Initiatives � Sound-alike/ Look-alike medications � Dangerous abbreviations � Medication Reconciliation � Medication Labeling � Patient Identification � Standardize and limit the number of drug concentrations

Patient Safety Organizations � The Institute of Safe Medication Practices � http://www.ismp.org � JCAHO � http://www.jointcommission.org � Institute of Medicine � http://www.iom.edu � Institute for Healthcare Improvement � http://www.ihi.org/ihi � Agency for Healthcare Research and Quality � http://www.ahrq.gov

Safe Medication Management Fellowship � Offered by ISMP � 12 month program � Huntingdon Valley, PA � Qualifications � Healthcare professional � ≥ 1 year postgraduate clinical experience

Education � Pre-pharmacy at the University of Illinois � Pharmacy school at the University of Illinois � General Practice Residency at the University of Washington

Work History � Pharmacy technician at Walgreens and Evanston Northwestern Hospital � General pharmacy practice resident at UWMC � General Surgery Clinical Pharmacist at UWMC � Medication Safety Pharmacist

Questions