improve safety and reduce errors

A Pharmacist in the ED: Improve Safety and Reduce Errors

Joe Spillane, Pharm.D., DABATAnd

Sue Dill Calloway RN MSN JDCPHRM, CCMSCP

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Wednesday, June 4th, 2014

Speaker

Joe Spillane, Pharm.D., DABAT

Pharmacy Practitioner, Emergency MedicineUF Health Jacksonville

655 W 8th St., Jacksonville, Fl [email protected]

(904) 244-5207

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Speaker• Sue Dill Calloway RN, Esq. • CPHRM, CCMSCP• AD, BA, BSN, MSN, JD• President• Patient Safety and Education• 5447 Fawnbrook Lane• Dublin, Ohio 43017• 614 791-1468• [email protected]

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1. Define the role of the ED pharmacist.

2. Explain how the ED pharmacist can help reduce the occurrence of medication errors.

3. Explain new and revised standards, regulations, and laws put forth by CMS, TJC and the federal government.

4. Evaluate compliance requirements and penalties.

Learning Objectives

ED Pharmacist & Med Errors Objectives

• Why the emergency department (ED) is prone to med errors.

• Types/examples of medication errors in the ED.

• Role of the ED pharmacist & how they can help reduce medication errors.

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www.EmergencyPharmacist.org 7

ED Pharmacist & Med ErrorsED Environment

• ED patients: numerous and unfamiliar• Chaotic environment-

– interruptions/transitions/distractions

• Time pressures• High alert medications

Ann Pharmacother 2009;43:1755-64.Crit Care Nurs Clin N Am 2005;17:65-9.Emer Med Clin N Am 2004;22:845-63.

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ED Pharmacist &Med ErrorsED Environment

• Tight coupling– -immediate medication access

• High workload• Verbal orders• Limited pharmacy involvement

Emer Med Clin N Am 2003;21:141-58.Acad Emer Med 2004;11(3):289-99.

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Med Distribution Systems:Hospital Floor & Emer Dept

• Hospital Floor• Written/CPOE orders• Limited RN load• Medication Rm• Controlled envir.• Limited med access

• Emergency Dept.• Verbal Orders• NOT• NOT• Chaos• Immed med access

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• Hospital Floor• Allergy awareness• Patient Identifiers• Max # patients• Familiar meds

• Emergency Dept.• ?Allergy awareness• “Bed 7”• NO MAX• Variable & high alert

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• Hospital Floor:• Profile• Minimal overrides• Specialized pt type• Minimal pt turnover• Pt easily located

• Emergency Dept.• Non-Profile & Profile• Common overrides• Various pt type/acuity• Constant pt turnover• Pt location=mystery

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• Hospital Floor• Emergencies minimal

• One med procedure

• PHARM INVOLVED

• Emergency Dept.• Constant emergencies

• Several med procedures

• LIMITED PHARM

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Medication Errors in ED

• All stages of drug ordering & delivery• Prescribing• Transcribing• Dispensing• Administration• Monitoring

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These contain 0.3 mg of 1:1,000 epinephrine to be delivered IM and are clearly labeled “Use only for

anaphylaxis,”

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Meds Involved in ED Med Errors

• Heparin 6.3%• Insulin 3%• Ceftriaxone 2.9%• Morphine 2.6%• Acetaminophen 2.1%• Meperidine 2.1%• Levofloxacin 2.1%• Promethazine 1.9%• Ketorolac 1.9%• Nitroglycerin 1.9%

Santell, JP, Hicks RW, Cousins DD. Medication Error in Emergency Department Settings-Poster ASHP Summer Meeting Las Vegas June , 2004. 20

Opioid Prescribing & the ED

• Pressure to prescribe– Pain as the “5th vital sign”– Up to 58% ED pxs present w/ painful conditions– ED opioid prescribing increased 49% 2001->2010

• ED as diversion source– ED docs prescribe 10% of opioids for 20-39yr olds– 21% of HS non med opioid users obtain from ED– 88% of ED docs report “doctor shopping” weekly

Acad Emer Med 2014;21:236-243.Med Care 2013;51:646-653. 21

Washington State ED Prescribing Guidelines

• Formed interagency group– State gov, ED docs, pain docs, addiction experts ,etc.

• Dealing w/ frequent flyers• EDIE• Draft guidelines for opioid prescribing• Surveyed ED practitioners about guidelines

– “Oxy-free ED”• Washington ACEP as sponsor

J Med Tox 2012;8:353-59.22


• One provider for all opioids w/ chronic pain

• No iv/im opioids in ED for acute exacerbations

• No replacement Rx’s or methadone

• No sustained release prescribing

J Med Tox 2012;8:353-59.23


• Rx’s say picture ID required to fill

• ED care coordination and EDIE

• Screen and intervene w/ suspected Rx abuse

• No meperidine & maximum 30 pills

• ED required to evaluate not to medicate

J Med Tox 2012;8:353-59. 24

New York City ED Prescribing Guidelines

• 9 major points—Jan 2013

• Screen for opioid misuse/addiction– One question

• No replacement Rx’s or methadone

• No sustained release /methadone prescribing

JAMA 2013;309(9):879-80.25

New York City ED Prescribing Guidelines

• Chronic pain exacerbations: non-opioids, refer

• 3 day course, avoid opioids if on benzos

• Counsel about opioid risks, safe storage, disposal

• ED required to evaluate but not to medicate

JAMA 2013;309(9):879-80.26

*Why We Did A Program In Ohio• Unintentional death rate in Ohio increased more than

300% largely driven from prescription drug overdoses• More people die in Ohio from drug overdoses than from

vehicle crashes or suicides and it is the leading cause of death

• More than 3 patients die every day in Ohio due to drug poisoning such as overdoses

• Opioids involved in 37% of all drug-related poisonings in Ohio

• From 1999• 26.5% of all high school students report using a drug

without a prescription 27

*EMTALA CMS Region 4 and 5• Every hospital that accepts Medicare or Medicaid

patients must follow the federal EMTALA law• EMTALA stands for the Emergency Medical Treatment

and Labor Act• Washington, Ohio, Oregon, and Colorado have

developed and displayed posted on opioid administration in the ED

• Posting signs regarding guidelines regarding narcotic policy might be considered to be coercive or intimidating to patients who present to the ED with painful medical conditions

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*CMS Letter

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Do Not Post Policy in Lobby on Narcotic P&P

• Therefore violating both the language and intent of the EMTALA statute and regulation

• Some patients with legitimate need for pain control might be unduly coerced to leave the ED before receiving an appropriate medical screening exam

• Consider removing the ED guidelines that may be posted in your ED although no prohibition against following SOC

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Posters Regarding Prescribing Pain Medication

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www.acepnow.com/article/ed-waiting-room-posters-prescribing-pain-medications-may-violate-emtala/www.acepnow.com/article/ed-waiting-room-posters-prescribing-pain-medications-may-violate-emtala/

*Opioid Prescribing Toolkit

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www.med.ohio.gov/webhost/OOAT_Screen_Tools.html

CMS Medication and Safe Opioid Use• CMS issues 32 page memo March 14, 2014 on

medication administration and safe opioid use• Advance copy so will publish effective date• Any hospital that accepts Medicare or Medicaid

patients must follow and must follow for all ED patients

• Has a section on educations recommended for all nurses

• Includes a section on IV and blood transfusions requirements and safe opioid use

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*Medication and Safe Opioid Use

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www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage

Location of All CMS Manuals

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New website at www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf

CMS Medication Errors

• Medication errors are the most common medical errors in the ED today

• CMS and IOM said medication errors harm at least 1.5 million patients every year

• Drug related adverse outcomes impact 1.9 million inpatients and 838,000 ED patients

• The HHS national action plan for adverse drug event prevent found that adverse drug events affect one-third of all hospital admissions and prolong length of stay 1.7 to 4.6 days

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CMS Education Recommendations• CMS recommend training in orientation and as

part of continuing education• Training may include the following;

– Safe handling and preparation of authorized medications

– Knowledge of the indications, side effects, drug interactions, compatibility, and dose limits of administered medications

– Equipment, devices, special procedures, and/or techniques required for medication administration (IV pumps, PCA, tubing, etc.)

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Basic Safe Practices for Administration of Meds

• Hospital P&P must reflect standards of practice• Discusses the five rights of medication

administration• This includes:

– Right patient– Right medication– Right dose– Right route and right time

• Also have blue boxes which are advisory and one mentions nine rights of medication administration40

Nine Rights of Medication Administration

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Blue Box Advisory Pharmacist to Prepare IV

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P&P Requirements• What must be included in the training during

orientation or CNE to demonstrate competence• Training content and documentation of competence• It is important to note that CMS has another section in

nursing that talks about the responsibility of the hospital to ensure competencies in nursing

• There is a list that requires competency related to any nurse who gives IV medication or administers any blood or blood product

• It is contained in tag 409 which was amended in 2014

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Blood Transfusions and IVs 409 2013 & 2014•Standard: Blood transfusions and IV medications must be administered with state law and MS bylaws–CMS previously issued a memo on May 13, 2011 but amended June 7, 2013 and in March 14, 2014 memo

•Use to require special training for this and there was a long list of things that nurses had to be trained on

• CMS eliminated the regulations mandating training for non-physicians who administer IV medication and blood and blood products– CMS says because this training is already standard practice

– Must follow your P&P and state scope of practice

Blood and IV Medication Training• Must still follow state law requirements

– In some states an LPN can not hang blood– Or the LPN can not push certain IV medications

in some states– Must show they are competent

• Must still have approved Medical Staff Policies and Procedures in place

• Staff must follow these which have most of the things that were previously required

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Staff Must be Competent 409• However, there must be evidence that staff is

competent in:• Maintaining fluid and electrolyte balance• Venipuncture technique• Blood transfusions: blood components, process to

verify right blood for the right patient, transfusion reactions and how to report transfusion reactions, how to monitor the patient with blood including frequency, and hospital P&P and nationally recognized standards of practice46

Blood Transfusions and IVs 409 2014• Discusses peripheral lines, PICC lines, arterial

lines, central lines, and arterial lines• Hospital P&P must discuss what medications can

given in each type of access• Trace lines and tubes prior to administration• Verify proper programming of infusion devices

such as flow rate, concentration, and dose rate• Must have P&P to address appropriate IV

medication monitoring requirements– Must include frequency of monitoring and risk factors

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Blood Transfusions and IVs 409 2014• Hospital P&P is expected to address:

– Monitoring for fluid and electrolyte balance– Monitoring patients for high alert medications

including opioids– Expected to address monitoring for over-sedation and

respiratory depression for safe opioid use• Can erroneous assume patient is asleep when they are having

progressive symptoms of respiratory compromise• Factors that put patients at high risk include snoring, history

of sleep apnea, first time use of IV opioids, increased opioid dose, longer length of time receiving general anesthesia, pulmonary or cardiac disease or thoracic or surgical incisions

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Assess and Monitor Patients 2014• Need to assess and monitor the effects of the

medications• To allow for early identification of adverse effects• Some may need to use clinical and lab data to

evaluate efficacy of medication therapy• For opioids may need to monitor respiratory

status, BP, O2 sat, and carbon dioxide levels• Evaluate symptoms such as confusion, agitation,

unsteady gait, pruritus, somnolence etc.• Be aware of high alert medications

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Safe Opioid Use & Safe Medication Use• Patients at great risk for adverse events include

age, liver or kidney failure, history of sleep apnea, history of smoking, drug-drug interaction, first time medication use and weight– Obesity could increase apnea and smaller patients

could more sensitive to dose levels of medications• Risk factors need to be considered in determining

how often to monitor and what type of monitoring• Must communicate important information in hand-

offs such as change of shift51

Safe Opioid Use & Safe Medication Use• ADR, such as opioid-induced respiratory depression

require timely intervention as per established hospital protocols

• Must also report to physician or LIP immediately• High alert medications would want to check VS, O2

sat, (ETCO2), and sedation levels to prevent respiratory depression and arrest

• Staff are expected to include patient’s reports of his experience of the medication’s effects

• Educate the patient and family about notifying staff if difficulty breathing

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Safe Opioid Use & Safe Medication Use

• Hospital policy is expected to address the manner and frequency of monitoring

• Hospital P&P is expected to include information to be communicated at shift change

• It is important to document order, medication record, lab reports, vital signs etc.

• Document after actual administration of medication and no documentation in advance

• Surveyor will make sure staff is knowledgeable about intervention protocol if ADE occurs53

*Discharge Instructions• Make sure patient gets a user friendly list of

medications to take when leaving the ED• Make sure there is education on any new

medication• Use teach back to ensure the patient understands

their medication instructions• Remember to use an interpreter if patient has

limited English proficiency• Remember the issue of low health literacy so

make sure the instructions are understandable54

*Medication List

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Discharge Instructions • One study found 78% of ED patients did not

understand one area of their discharge instructions

• Another study showed that patients are 30% less likely to be admitted or return to the ED if they understand their discharge instructions

• Source: Discharge Instructions: A Commitment to Patient Safety and Risk Reduction, Dr. Dan Sullivan at www.thesullivangroup.com/pdf/news/TSG_DischargeInstructionAnalysis.pdf

Promethazine Misadventures in ED

• Promethazine (Phenergan)-injection with low pH (4-5.5)-caustic-complications w/ IV route -burning, pain, thrombosis, tissue necrosis, gangrene

• NO hand or wrist veins• Dilute in 10-20ml NS• Slow administration, ask about pain & STOP!!• ALTERNATIVES: ondansetron(Zofran) preferredJ Emer Nursing-Feb2007 33:1:53-56

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J Emer Nurs 2007;33:1:53-56. 58

Ondansetron Shortage

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ED Meds on Shortage• Phenytoin/Fosphenytoin• Norepinephrine/Dopamine/Phenylephrine• Amikacin, Gentamicin• Nitroglycerin/Diltiazem/Droperidol• Cotrimoxazole IV• Fentanyl*/ Morphine*/Hydromorphone*• Promethazine, Ondansetron• Succinylcholine, Vecuronium, IV FLUIDS!!!!!

* Only certain dosage forms 60

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Medications Shortages• FDA has a website on current shortages and can

sign up to get this information sent via email• FDA drug shortage program designated by

Center for Drug Evaluation and Research (CDER) Center Director

• FDA also has list of drugs to be discontinued• Sign up to get email notification at

www.fda.gov/cder/drug/shortages/default.htm• ED should have a plan to address this critical

issue and Congress passed a federal law to help

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www.fda.gov/cder/drug/shortages/default.htm

Sign Up To Get Drug Shortage Information

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https://public.govdelivery.com/accounts/USFDA/subscriber/new?pop=t&topic_id=USFDA_22

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ASHSP Drug Shortage Website• American Society of Health System Pharmacist

also has website on current shortages and drugs no longer available

• Has other resources such as articles and news on drug shortages

• Has two articles on understanding and managing drug product shortages which you can use to help draft this required P&P

• http://www.ashp.org/shortages

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www.ashp.org/shortages

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ASHP Managing Drug Shortages

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www.ashp.org/s_ashp/docs/files/BP07/Procure_Gdl_Shortages.pdf

GAO Drug Shortage Better but Still Continue

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www.gao.gov/assets/670/660785.pdf

ED Medication Errors

• Prospective, observational• 178 med errors in 923 med orders (19.3%)• 178 med errors in 192 pxs (59.4%)• Prescribing 54%, Admin-35%, Trans-11%• Boarded pxs as a risk factor

Ann Emer Med 2010;55:522-6.70

ED Boarders & ED Culture

• ED “Boarders”• Problems with MAR’s• Lack of RN reminders• True vs perceived emergencies• Emergency medicine culture

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ED Medication Errors & Crowding

• Prospective, observational• Increased errors w/ increased crowding• As ED volume incr. more abx delay• Least busy—31% delayed or no abx• Most busy—72% delayed or no abx

Am J Emer Med 2010;28:304-309.Ann Emer Med 2007;50:501-509.Ann Emer Med 2007;50;510-516.

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“Numerous mistakes have been reported when practitionersconverted weights from one measurement to another or accidentally weighed a patient in pounds but entered kilogram amounts in the medical record. One pound equals 2.2 kilograms, which can cause a greater than twofold dosing error”

ISMP Med Safety Alert Dec 2011;16(24):3.

Medication Calculation Errors

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Types of Medication Errors in ED

• ALLERGIES!!!!!!!!!!!

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Medication History Errors in ED

• Comparison: triage med hx-Tx area med hx• Avg # meds-2.6, 31% on no meds at all• 9.8% discontinued meds,28% omitted meds• Increased privacy, decreased time pressures• Cut and paste mistakes

Acad Emer Med 2011;18:102-104.

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Pharmacists in the ED

• Began in 1970’s

• Initial activities: – distributive– inventory– cost containment

• Developed in parallel w/ICU pharmacy

Am J Hosp Pharm 1977;34:843-6.

www.EmergencyPharmacist.org

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Pharmacists in the ED

• Current Services:– E D pharmacy “services” in 3-14% of ED’s– More common in teaching hospitals– More common with ED residencies

• ED Pharmacy Hours: – Variable 8hrs/day24/7– Peak hours usually– Rare satellite pharmacies

Am J Hlth Sys Pharm 2009;66:1353-61.Am J Hlth Sys Pharm 2003;60:1561-4. 77

Pharmacy Activities in the ED

• ED rounding• Alerts & resuscitation participation• Prospective order review• Participation high risk situations• Patient counseling• Medication monitoring

Am J Hlth Sys Pharm 2009;66:1353-61.Am J Hlth Sys Pharm 2008;65:2380-3.

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• Procure/prepare medication• DocumentADR’s, med errors, resus’s • Conduct pharmacy “infusion rounds” • Suggest alternative meds, doses, routes, regimens• Identify medications• Provide drug compatibility information

Am J Hlth Sys Pharm 2009;66:1353-61.Am J Hlth Sys Pharm 2010;67:375-9.

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• Medication information• Toxicology consultation• Medication histories/home med reconciliation• Med utilization evaluation• Emergency preparedness• CARE OF BOARDED PATIENTS

Am J Hlth Sys Pharm 2004;61:934-7.Am J Hlth Sys Pharm 2009;66:1353-61.Am J Hlth Sys Pharm 2008;65:2325-6.

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• Liason pharmacy & emergency department• Education:

– pharm students, pharm residents, nursing, ED residents/physicians etc.

• Quality Assurance• Medication safety/compliance• Committee work• Research/publication

Am J Hlth Sys Pharm 2009;66:1353-61.Am J Hlth Sys Pharm 2003;60:1561-4. 81

The Value of an ED PharmacistDecreasing ED medication errors

• Observational in 4 academic ED’s• ED pharm. “recovered” med errors

– 7.8 errors/100pxs, 2.9 errors/100meds• Retrospective chart review• Error rate decrease by 66% w/ ED pharm

Am J Hlth Sys Pharm 2008;65(4):330-3.Ann Emer Med 2010;55(6):513-21.

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The Value of an ED Pharmacist

• ED staff survey or ED pharm value– 99%improved quality of care– 93% consulted ED pharm in last 5 shifts

• Increased med error reporting– Improved medication utilization

Am J Hlth Sys Pharm 2010;67:1851-5.Emer Med J 2007;24:716-8.

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* ED Pharmacist Resources• As discussed, American Society of Health

System Pharmacist (ASHP) started the Emergency Department Pharmacy Mentorship Program in 2007– Which was supported by a grant by AHRQ

• AHRQ has a number of good resources to help hospitals

• Created “The Emergency Pharmacist Research Center”

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ED Pharmacist Research Center AHRQ

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www.innovations.ahrq.gov/content.aspx?id=1916

*Emergency Pharmacist Research Center•Resources include additional information on the role of the EPh such as a job description•Includes information on qualification•Includes information on a conference on a presentation on “The Optimized Emergency Pharmacist Role”•Includes ASHP position on use of pharmacists in the ED along with other great resources

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ED Pharmacist Job Description

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http://www.emergencypharmacist.org/toolkit.html

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ED Medication Error Reporting

• Reporting & Pharmacy involvement in ED– 6mos prior to pharm-31 med errors reported– 6mos after pharm-371 med errors reported

• Prescribing>prep>transcript>admin• Reporting: Pharm:96%,Nursing-4%

Am J Hltth Sys Pharm 2010;67:1851-5.91

Increased Reporting->Improvements

• New med storage for boarders• Infusion guides for RN badges• Order set enhancements• Omnicell revisions• Improved labelling for drips• Increased education

Am J Hltth Sys Pharm 2010;67:1851-5.92

Med Error Reporting

Rates of Reporting throughout Hospital--as low as 0.07%

Barriers to Reporting:--Fear of punitive measures--Fear of loss of credibility--ED culture--Time

J Emer Nursing 2003;29:1:12-16.93

Most Common Type of Med Error in ED

Unreported Ones!!!

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*Dilaudid (HYDROmorphine)

• Even though this drug is used frequently, it is one of the top 10 medications to harm patients

• Always include both names and use tall man lettering

• Staff get it confused with Morphine• It is a 7:1 to help people remember and use

laminated dosing charts• Make sure include information on this in

orientation for new staff and periodically• Do not stock in 4 mg vials only 2 mg 95

*ISMP Remembering the Correct Dose

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*Dilaudid (HYDROmorphine)• Limit the starting doses of HYDROmorphone to 0.5 mg

– Especially for opioid naïve patients and those with other risk factors such as obesity, asthma, obstructive sleep apnea or those receiving other medications that can potentiate the effects

• Employ technology to alert practitioners– Barcode medication verification, hard stops in smart infusion

pump libraries for catastrophic doses

• Perform independent double checks when HYDROmorphone is removed from stock– Especially if a pharmacist has not reviewed the order prior

to drug administration97

*EMPSF Patient Safety Brief

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www.empsf.org

Free Toolkit at Pa Patient Safety Authority

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http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/Pages/home.aspx

Safe Injection Practices • Have a safe injection practices policy• Train all staff in orientation and periodically• Make sure it is consistent with the 10 CDC

requirements• One needle and one syringe every time• If they make it in a single dose vial you need to

buy it in a single dose vial• If not make sure meticulous about cleaning off

lid and scrub for 15 seconds with alcohol and wait until it dries 100

Not All Vials Are Created Equal

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*Safe Injection Practices • ED doctor must wear a mask when doing an LP• Make any multidose vial that it expires in 28 days

unless sooner by manufacturer• Do not take multidose vials into patient rooms• One IV bag for every patient• Make sure sharps container do not go past the fill

line• CMS has a section on safe injection practices in

the infection control worksheet• EMPSF has free patient safety brief

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*Safe Injection Practices Memo

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Section on Safe Injection Practices & Sharps

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• ED staff should know about the Beers list– Update in 2012

• It is a list of medications that should not be used in older adults who are 65 or older

• Medication toxic effects and drug related problems have profound effects on elderly

• Studies that show 4 or more or 8 or more drugs increase risk for falls

• Post the list on the medication bulletin board and provide a copy to all the physicians– Next time it is updated we need to get an emergency medicine

physician on the committee

*Beers List of Inappropriate Medications

10 Medications Older Adults Should Avoid

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*Beers List Do Not Use in Elderly • Can also cause depression, constipation, confusion

and hip fractures• 48 individual medications or classes to avoid• Also list of medications to avoid in 20 specific

diseases and conditions• ED staff should monitor any of these drugs

ordered very closely for ED patients who are over 65

• Will increase their risk for falls so use in fall assessment especially patients who will stay in the ED because of over crowding

Choosing Wisely

• Be familiar with the website Choosing Wisely• Helps patients choose by selecting care that is

evidenced based• Has a list of things that providers and patients

should question• Many prestigious organizations are partners• Have a list of things that should be questioned

and helps educate patients on making wise decisions

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Choosing Wisely• List first published in Archives of Internal Medicine• ACEP has a list of tests and procedures that are not

effective• Two are related to medications• Avoid antibiotics and wound cultures in patients with

uncomplicated skin abscesses after successful I&D with adequate follow up– Abscesses become walled off and form pus under the

skin and antibiotics offer no benefit after I&D done• Avoid IV fluids before doing a trial of oral rehydration

in cases of mild to moderate dehydration in children111

ED Pharmacist & Med Errors Summary

• ED is prone to med errors:– Tight coupling, distractions, unfamiliar,

boarders– Less safeguards, different med. distrib. sys.

• Types of medication errors in the ED:– Unreported, prescribing, admin, high alert meds– Calculations, shortages, opioid prescribing

• Role of the ED pharmacist:– Safe, effective med use, educate, improve qual.114

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• CPOE for all medications prescribed in the ED• Perform medication reconciliation in all ED patients by

listing all drugs, doses, and consult if medication given• Document allergies and contraindications• Have P&P and do education on safe opioid use and

include in orientation and periodically– Make sure it includes what CMS requires in the

hospital CoPs• Be careful in giving medications to patients who are being

boarded because a bed is not available– If nurse is not familiar with the drug should look it up

and check with pharmacist– ED overcrowding is associated with an increased frequency of medication errors. Kulstad EB,

Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.

*Recommendations to Reduce Errors

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*Recommendations• Implement automated dispensing unit in ED with

pharmacy review• Educate ED staff on safe medication

administration techniques• Monitor ED staff to ensure compliance with

medications P&Ps• Special warnings on neuromuscular blockers or

stored in a separate place• Have a ED medication champion to provide

quarterly updates

New Labeling of Injectable

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• Educate ED staff and implement double checks on high-alert medications such as Heparin, Opioids, neuromuscular blockers and insulin

• Make sure staff trained on all new equipment such as IV pumps or PCA pumps

• Monitor ED staff to ensure compliance with all medication-related policies and procedures

Check for look-alike/sound-alike (LASA) drugsstored in the ED and make certain they areseparated to prevent confusion and possibleerror

Recommendations

*Recommendations• Place a chart at triage on confused drug names

so staff can make sure to write down correct medication patient is taking

• Place of a list of do not crush medications in the medication room and train all staff– Make sure 2014 list and copy at

www.ISMP.org– Crushing some medications and putting them

down a tube can increase absorption and cause an overdose

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List of Do Not Crush Medications ISMP

http://ismp.org/

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ISMP List of Confused Drug Names

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USP Confused Name List

www.usp.org/pdf/EN/patientSafety/qr792004-04-01.pdf

*Recommendations• Make sure all staff are aware of the high risk

medication policy– CMS and TJC require a policy on high alert

medications– Make sure staff know what they are suppose to do

such as two nurses check or bar coding etc.• Train staff in the hospital’s list of do not use

abbreviations and post a list– TJC has 9 required do not use abbreviations– ISMP has a list that everyone should be familiar

with123

ISMP List of High Alert Drugshttp://ismp.org/

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So What’s In Your Policy?

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High Alert How to Guide IHI

www.ihi.org/NR/rdonlyres/8B2475CD-56C7-4D9B-B359-801F3CC3A8D5/0/HighAlertMedicationsHowToGuide.doc

*TJC List of Abbreviations IM.02.02.02• U, u so write out units

- IU so write out international units- Q.D., QD, q.d., qd- Q.O.D., QOD, q.o.d, qod- Trailing zero (X.0 mg) so write as Valium 2 mg and not Valium 2.0 mg because if decimal point is not seen can get too much - Lack of leading zero (.X mg) so write as Lanoxin 0.125 mg PO so 0 before the dose- MS, MSO4, MgSO4 so write out Morphine Sulfate or Mag Sulfate

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ISMP List of Do Not Use Abbreviation

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*Recommendations• Make sure all medications errors, near misses and

ADEs are reported into the PI process– A CMS and TJC requirement– CMS issues recent memo that says this is not done

86% of the time• Must monitor for medications errors or ADE

– CMS says cannot just rely on incident reports but must actively monitor under tag 508

– One study found that 3.6% of patients in the ED received an inappropriate medication while in the ED and 5.6% when discharged

• Chin MH, Wang LC, Jin L, et al. Appropriateness of medication selection for older persons in an urban academic emergency department. Acad Emerg Med. 1999; 6:1232-42. 129

*Recommendations• Have a medication board where new published

articles can be posted and include in education• Be familiar with the most common medication

errors in the ED• Many staff are surprised to find it out it is often

medications that are given often where the errors are occurring

• Be careful in giving Insulin as studies show a high number of errors

• Weigh children only in Kg 130

Medications Involved in ED Med Errors• Heparin 6.3%• Insulin 3%• Ceftriaxone 2.9%• Morphine 2.6%• Acetaminophen 2.1%• Meperidine 2.1%• Levofloxacin 2.1%• Promethazine 1.9%• Ketorolac 1.9%• Nitroglycerin 1.9%

Santell, JP, Hicks RW, Cousins DD. Medication Error in Emergency Department Settings-Poster ASHP Summer Meeting Las Vegas June , 2004. and also MEDMaRX 2008 report 131

Use Kg and Not Pounds for Children

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This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials

does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal

counsel familiar with your particular circumstances.

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Questions?

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Thank you for attending!!

Speaker

Joe Spillane, Pharm.D., DABAT

Pharmacy Practitioner, Emergency MedicineUF Health Jacksonville

655 W 8th St., Jacksonville, Fl [email protected]

(904) 244-5207

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Speaker• Sue Dill Calloway RN, Esq. • CPHRM, CCMSCP• AD, BA, BSN, MSN, JD• President• Patient Safety and Education• 5447 Fawnbrook Lane• Dublin, Ohio 43017• 614 791-1468• [email protected]

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improve safety and reduce errors

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