Annual Topic of Current InterestAnnual Topic of Current Interest

Medication IncidentsMedication Incidents

2001/2002 Annual Report: 2001/2002 Annual Report: Hospital Pharmacy in Canada Hospital Pharmacy in Canada

SurveySurvey

Medication Incident Reporting Medication Incident Reporting System and ReviewSystem and Review

Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

Medication Safety PlanMedication Safety Plan

Establish a Establish a multidisciplinary multidisciplinary medication safety medication safety committeecommittee

Adopt a safety Adopt a safety culture: culture: Encourage Encourage reporting and reporting and disclosure of disclosure of medication medication incidentsincidents

Implement “ Best Implement “ Best Practices” and Practices” and measure outcomes: measure outcomes: medication incident medication incident reduction strategiesreduction strategies

Inform health care Inform health care professionals and professionals and patients of the patients of the outcomes of your outcomes of your medication safety medication safety initiativesinitiatives

Caldwell et al. Medication Safety and Cost RecoveryCaldwell et al. Medication Safety and Cost RecoveryA four-Step Approach for ExecutivesA four-Step Approach for Executives

Medication Incident Reporting Medication Incident Reporting SystemsSystems

Medication incident reporting system is in Medication incident reporting system is in use: 92%use: 92% Written hospital policy: 88 %Written hospital policy: 88 % Clear definition of an error: 76% ( Qc: 50%)Clear definition of an error: 76% ( Qc: 50%)

Reporting of “near-misses” :Reporting of “near-misses” : Prescribing errors detected in Rx: 21%Prescribing errors detected in Rx: 21% In pharmacy detected in Rx: 27%In pharmacy detected in Rx: 27% Before medication is administered: 96%Before medication is administered: 96%

Hospital reporting data to:Hospital reporting data to: Provincial group: 8 % (Atlantic region)Provincial group: 8 % (Atlantic region) Other organizations (i.e: ISMP): Other organizations (i.e: ISMP): 6 %6 %

Medication Incident Reporting Medication Incident Reporting SystemsSystems

Medication incident report is part of the Medication incident report is part of the permanent patient / health record: 29%permanent patient / health record: 29%

Individual medication incident report can be Individual medication incident report can be

subpoenaed for legal proceedings: subpoenaed for legal proceedings: 44%?44%?

Review undertaken by the committee could Review undertaken by the committee could be subpoenaed for legal proceedings: be subpoenaed for legal proceedings:

71% ?71% ?

Adopt a Safety Culture:Adopt a Safety Culture:Encourage ReportingEncourage Reporting

Non punitive medication incident reportingNon punitive medication incident reporting Name of the person reporting the incident is on Name of the person reporting the incident is on

the form:the form: 94%94% Name of the person involved in the incident is Name of the person involved in the incident is

on the form 40%on the form 40%

Medication incidents are reported and Medication incidents are reported and openly discussed by staff without fear of openly discussed by staff without fear of reprisal : 72% ( 61% / 11%)reprisal : 72% ( 61% / 11%)

Medication incident reports can be used Medication incident reports can be used during performance appraisals: during performance appraisals: 33 %33 %

Strategies to Strategies to increase medication incident increase medication incident reporting: 68%reporting: 68%

Adopt a Safety Culture:Adopt a Safety Culture:Encourage DisclosureEncourage Disclosure

Medication incidents are disclosed to Medication incidents are disclosed to patients and/or familiespatients and/or families

Most of the time (Most of the time (90%..): 90%..): 18%18%

Some of the time (Some of the time (90%): 67%90%): 67%

Mutidisciplinary Safety Committee:Mutidisciplinary Safety Committee:

Medication Incident ReviewMedication Incident Review Designated committee responsible for Designated committee responsible for

medication incident review: 69%medication incident review: 69%

Membership of the committee: Membership of the committee: Patient representativePatient representative Information servicesInformation services

Mandate of the committeeMandate of the committee Promote a culture of safety (1)Promote a culture of safety (1)

Position dedicated to safety initiatives: 21%Position dedicated to safety initiatives: 21% Pharmacist FTEs: Pharmacist FTEs: 0.05-0.100.05-0.10

Communicate information : Communicate information : Outcomes of Safety InitiativesOutcomes of Safety Initiatives

Routinely provide to staff information Routinely provide to staff information regarding:regarding:

Internal medication incidents: 54%Internal medication incidents: 54%

Published medication incidents: 46%Published medication incidents: 46%

Subscribe to ISMP newsletter: 63%Subscribe to ISMP newsletter: 63%

Implement « Best Practices »:Implement « Best Practices »:Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

Concentrated potassium chloride: Concentrated potassium chloride: Availability on nursing unitsAvailability on nursing units

8% (10/123) : not available8% (10/123) : not available 31% (38/123) : less than 10% 31% (38/123) : less than 10% 54% (67/123) : greater than 10% 54% (67/123) : greater than 10%

Implement « Best Practices »:Implement « Best Practices »:Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

There is a designated list of There is a designated list of dangerous abbreviations that dangerous abbreviations that are not acceptedare not accepted

23% (28/123)23% (28/123)

Implement « Best Practices »:Implement « Best Practices »:Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

AdultsAdults

76% (71/93) 76% (71/93)

PediatricsPediatrics

79% (41/52)79% (41/52)

Orders for chemotherapy include the Orders for chemotherapy include the total doses as well as mg/kg or total doses as well as mg/kg or mg/m2mg/m2

    

Hospitals (n=)

   

All(123)

Bed Size Teaching Status

100-200(29)

201-500(66)

>500 (28)

Yes (52)

No (71)

Computerized physician order entry (CPOE)

Approved plan to implement

Operational

           

 17

 1

 8

 8

 8

 9

 9

 3

 3

 3

 9

 0

Implement « Best Practices »:Implement « Best Practices »:Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

Patient allergy status is known Patient allergy status is known prior to dispensing a prior to dispensing a medicationmedication

Most of the timeMost of the time

59%59%

Some of the timeSome of the time

34%34%

Implement « Best Practices »:Implement « Best Practices »:Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

Single standard infusion Single standard infusion concentrations are used in at concentrations are used in at least 90% cases for insulinleast 90% cases for insulin

46% (56/123)46% (56/123)

Implement « Best Practices »:Implement « Best Practices »:Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

Vincristine is prepared and Vincristine is prepared and dispensed in an intravenous dispensed in an intravenous minibag or infusion bag (NOT minibag or infusion bag (NOT a syringe)a syringe)

31% (28/89)31% (28/89)

Implement « Best Practices »:Implement « Best Practices »:Medication Incident Reduction Medication Incident Reduction StrategiesStrategies

Bar coding is used in the Bar coding is used in the medication use systemmedication use system

11% (13/123)11% (13/123)

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Pharmacy Computer System is Used to Check

Why this special interest Why this special interest topic?topic?

•Provoke further review of medication use systems in Canadian hospitals

•Decrease the probability that a patient or health care worker will be harmed by a medication incident