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Patient Safety CME Curriculum

Patient Safety: The Other Side of theQuality Equation

Under a Grant fromUnder a Grant from

The Agency for Healthcare ResearchThe Agency for Healthcare Research

and Qualityand Quality

Principal InvestigatorPrincipal InvestigatorChristel MotturChristel Mottur--Pilson, PhDPilson, PhD

Director, Scientific PolicyDirector, Scientific Policy

ACPACP--ASIMASIM

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Patient Safety:

The Other Side of the Quality EquationSeven Modules in Ambulatory Care

SystemsSystems The influence of systems on the practice of medicine.The influence of systems on the practice of medicine.

Cognitive CapacityCognitive Capacity Coping mechanisms under information overload and timeCoping mechanisms under information overload and time

pressurespressures

CommunicationCommunication Communication barriers, lack, and unclearCommunication barriers, lack, and unclear

communicationcommunication

Medication ErrorsMedication Errors Uniform dosing, lookUniform dosing, look-- and soundand sound--alikes, forcing functionsalikes, forcing functions

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Patient Safety:

The Other Side of the Quality Equation

Seven Modules in Ambulatory Care

The Role of PatientsThe Role of Patients

Patients as allies in patient safetyPatients as allies in patient safety

The Role of ElectronicsThe Role of Electronics

Supportive products and processesSupportive products and processes

Idealized Office DesignIdealized Office DesignMedical practice design to supportMedical practice design to support

patient safetypatient safety

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Logistics

CME:CME: To receive your CME, please fill out the usualTo receive your CME, please fill out the usualformsforms

Evaluation formEvaluation formCME formCME form

Research Grant SurveysResearch Grant Surveys

PrePre--CME assessment of knowledge levelCME assessment of knowledge level

PostPost--CME assessment of knowledge levelCME assessment of knowledge level

SixSix--month follow up to CMEmonth follow up to CME

Virtual Patient Safety Electronic CommunityVirtual Patient Safety Electronic Community

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Preventing Medication

Errors Related ToPrescribing

Under a Grant fromUnder a Grant from

The Agency for Healthcare Research and QualityThe Agency for Healthcare Research and Quality

Developed by Michael R. Cohen, RPh, DScDeveloped by Michael R. Cohen, RPh, DSc

Institute for Safe Medication PracticesInstitute for Safe Medication Practices

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Medication Errors

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Medication Errors Reporting

Program

Operated by the

United States Pharmacopeia in cooperation

with the

Institute for Safe Medication Practices

Report medication errors in confidence:1 800 23 ERROR

www.ismp.org/www.usp.org

(USP and ISMP are FDA MEDWATCH partners)

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Where Do Errors Occur?

Prescribing 39%Transcribing 11%

Dispensing 12%

Administering 38%

Where Do Errors Occur?

Prescribing 39%Transcribing 11%

Dispensing 12%

Administering 38%

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Medication Prescribing Process

Components: Communication

Written Prescription OrdersWritten Prescription Orders

Medication Ordering SystemsMedication Ordering Systems

Electronic Order TransmissionElectronic Order Transmission

Dosage CalculationsDosage Calculations

Verbal OrdersVerbal Orders

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Written Medication Orders:

Illegible Handwriting 16% of physicians have illegible handwriting.16% of physicians have illegible handwriting.11

Common cause of prescribing errors.Common cause of prescribing errors.2, 3, 42, 3, 4

Delays medication administration.Delays medication administration.55

Interrupts workflow.Interrupts workflow. 55

Prevalent and expensive claim in malpracticePrevalent and expensive claim in malpractice

cases.cases.33

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Illegible Handwriting:

Error Prevention Prescribers ObligationPrescribers Obligation

Write/Print More CarefullyWrite/Print More Carefully

ComputersComputers

Verbal CommunicationsVerbal Communications

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Complete Information Patients NamePatients Name

PatientPatient--Specific DataSpecific Data

Generic and Brand NameGeneric and Brand Name Drug StrengthDrug Strength

Dosage FormDosage Form

AmountAmount

Directions for UseDirections for Use

PurposePurpose

RefillsRefills


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Patient-Specific Information AgeAge

WeightWeight

Renal and Hepatic FunctionRenal and Hepatic Function Concurrent Disease StatesConcurrent Disease States

Laboratory Test ResultsLaboratory Test Results

Concurrent MedicationsConcurrent Medications

AllergiesAllergies

Medical/Surgical/Family HistoryMedical/Surgical/Family History

Pregnancy/Lactation StatusPregnancy/Lactation Status


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Do Not Use Abbreviations Drug namesDrug names

QD or OD for the wordQD or OD for the word dailydaily

Letter U forLetter U forunitunit g forg formicrogrammicrogram (use mcg)(use mcg)

QOD forQOD forevery other dayevery other day

sc or sq forsc or sq forsubcutaneoussubcutaneous

a/ or & fora/ or & forandand

cc forcc forcubic centimetercubic centimeter

D/C forD/C fordiscontinuediscontinue orordischargedischarge

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Weights, Volumes, Units

Use metric systemUse metric system

Avoid apothecary systemAvoid apothecary system


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Case 3: Weights, Volumes,

Units

Confusion With Apothecary SystemConfusion With Apothecary System1/200 grain (0.3 mg)1/200 grain (0.3 mg) {{ 1/100 grain1/100 grain

(0.6 mg) + 1/100 grain (0.6 mg)(0.6 mg) + 1/100 grain (0.6 mg)


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Written Medication Orders: Decimals

Avoid whenever possibleAvoid whenever possible11

Use 500 mg for 0.5 gUse 500 mg for 0.5 g

Use 125 mcg for 0.125 mgUse 125 mcg for 0.125 mg

Never leave a decimal point nakedNever leave a decimal point naked 1, 2, 31, 2, 3

Haldol .5 mgHaldol .5 mg pp HaldolHaldol 0.5 mg0.5 mg

Never use a terminal zeroNever use a terminal zero

--Colchicine 1 mg not 1.0 mgColchicine 1 mg not 1.0 mg

Space between name and doseSpace between name and dose1,31,3

Inderal40 mgInderal40 mg pp Inderal 40 mgInderal 40 mg


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Drug Names

LookLook--Alike or SoundAlike or Sound--Alike DrugAlike DrugNamesNames

Confirmation BiasConfirmation Bias

Addition of SuffixesAddition of Suffixes

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Look-alike And Sound-alike

Drug Names

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Insert Figure 3Insert Figure 3


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Medication Prescribing Process:

Electronic PrescribingComputer with 3 Interacting DatabasesComputer with 3 Interacting Databases

Drug HistoryDrug History

Drug Information/Guidelines DatabaseDrug Information/Guidelines Database

PatientPatient--Specific InformationSpecific InformationAvoidsAvoids

Illegible PrescriptionsIllegible Prescriptions

Improper TerminologyImproper Terminology

Ambiguous OrdersAmbiguous Orders

Incomplete InformationIncomplete Information

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Computerized prescribing

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Dosage Calculations Recognized cause of medication errorsRecognized cause of medication errors

Use patientUse patient--specific informationspecific information

heightheight

weightweight

ageage

body system functionbody system function


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Dosage Calculations:

Error Prevention

Avoid calculationsAvoid calculations

CrossCross--checkingchecking

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Verbal Orders:

Error PreventionAvoid when possibleAvoid when possible

Enunciate slowly and distinctlyEnunciate slowly and distinctly

State numbers like pilotsState numbers like pilots

(i.e., one(i.e., one--five mg for 15 mg)five mg for 15 mg)

Spell out difficult drug namesSpell out difficult drug names

Specify concentrationsSpecify concentrations


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Conflict Resolution


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Patient Education

Educate patients about their medicationsEducate patients about their medications

Purpose of each medicationPurpose of each medication

Name of drug, dose, how to take, etc.Name of drug, dose, how to take, etc. Provide patients with understandable writtenProvide patients with understandable written

instructionsinstructions

Lack of involving patients in check systemsLack of involving patients in check systems

Inform patients about potential for error withInform patients about potential for error withdrugs known to be problematicdrugs known to be problematic

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Patient Education

Proper use of medication deliveryProper use of medication delivery

devicesdevices

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Preventing Medication

Prescribing Errors

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References

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Patient Safety Interactive

Learning Community (PSI

LC)

http://www.acponline.org/ptsafetyhttp://www.acponline.org/ptsafety

Program InformationProgram Information

& Updates& Updates

All Seven ModulesAll Seven Modules

Refresher ExercisesRefresher Exercises

Email DiscussionEmail Discussion

GroupsGroups

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Refresher Exercises

http://www acponline org/ptsafetyhttp://www acponline org/ptsafety

Med Errors

Documents

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