Patient Safety in an imperfect world

Cheryl McCullagh

Director Clinical IntegrationMarch 2016

Safety First

Lifetime Care

E ref

Registered with pt portal

My team

Triage/Pre assessment

Education commences

referrer informed of

plan and dates

SMS reminders

Allied/nursing check in

E-clinic with GP

Self check in kiosk

Specialty clinic face to face

billing

Specialty care

Team update

eRFA Pre planning

education

billing

admit

Self check inPt portal

update for DC

IP notes

IP education

DC communication

Follow up

The MEMORY strategy describes the plan for implementation of a fully integrated

health record across SCHN; it involves more than 30 projects. Aims include:

safer care

better access, for multiple users

current complete records

reduced risk around missing or incomplete information

reduced errors

accessible to all from anywhere

improved reporting

In supporting these strategic aims, there are implications for the way we do business. The overarching guiding principles and business implications need

to be dealt with as much as possible before implementation

Westmead

Randwick

2013 2014 2015 2016 2017

EMM

Clin-docs EMR2

SurgiNet

PathNetc/compass

Move off iPMto SCHN stack

Voice Recin ED

eRFA

PAS feedTo CHW

EMM

FirstNet

SCHN Roadmap

7

EIR SCH scanning

HealthenetNEHR

Voice Rec. Doc

EMR SCHN

BackscanningLanier

Endoscopy

Endoscopy

VR Lanier

VR Lanier

Reports Lync MRD Scanning Coding Email tap-on log-on WIFI IT support BYOD

NAP forms

CCIS

CCIS

NAP forms

EMR SCHN

Mental Health doc.

Mental Health Doc.

Rehab

Referrals

EMR2

FirstNet

Oncology

Billing App.

HealthenetNEHR

EMM Progress so far…..

8

• Project formally commenced in March 2014

• Completed IT2

• Technical go-live in 4 weeks

• Design reviews

• Pharmacy processes: 48 representatives from eHealth, SESI and Pharmacy

• Oncology processes: Almost 70 staff from Oncology (CHW and SCH)

• Medication Processes: 250 staff from Medical, Nursing, Pharmacy, Allied Health, Blood Bank, Nuclear Medicine, Radiology, eHealth and members from other EMM pilot sites

• Focus groups formed for specific issues

• Future state workflows in partnership with NSW

• Training has commenced

• Research plan underway with support of Macquarie University and NHMRC partnership grant

SCHN

Board

Exec

ISEC

SCHN

HCRC

AlliedMedicalNursing

State EMR2

TechnicalAdmin

Forms POW

Governance

SCHN

HCQC

State EMM

MEMORY

SCH

(forms)

EMM/EMRPCHW

(forms)

EFG

ICT SES

EMR SES

POW EMMDoc.

Imaging

Principles for safe EMM

Don’t make things worse

Decisions are clinically lead

New risks have to balance current state

Safety nets for risks

Mandatory training JIT

E-process becomes the standard

Research and evaluation

Consider the question safe vs Safer?

Current drivers

Networked patients

Shared care

Patient Safety

SCHN reported in 2015

1523 Medication/IV Fluid Events were reported

931 (61%) related to administration

404 (27%) related to prescribing

56 (4%) related to dispensing

Top 10 Medications Implicated in Medication/IV Fluid Incidents CHW SCH Grand Total

IV Fluids 86 49 135

Morphine 39 30 69

Paracetamol 27 34 61

Parenteral nutrition 34 9 43

Vancomycin 26 16 42

Piperacillin + tazobactam 17 19 36

Oxycodone 19 10 29

Flucloxacillin 19 10 29

Fentanyl 14 14 28

Gentamicin 14 10 24

Over 200 different medicines were reported during 2015.

Cerner eMM

MedChart eMM

ICCIS

HPPL

HNE LHD

MDC

12

SCHN, SESI,

SWS

St Vincents

NSW Health

(metavision)

NSW Health

(iPharmacy)

JHH and others

Working with ehealth and

other sites

To standardise content and

encourage intra-operability

between systems.

Improved Patient Safety

Benefits of eMM translated into research

DecisionSupport

and Alerts

AllergyChecking

Automated Rules

ImprovedLegibility of

Prescriptions

Dosage Calculation Support

Improved communicatio

n between HCP and care

settingsImproved worflow

Reduction in serious

errors

Increased staff and patient /carer

satisfaction

Standard-isation

Supporting safer medication workflows, working with the software

Drug-Drug interactions

Dose capping

Reference text links

Height, Weight, Allergy rule

Phone order process

Banner bar weight

Order sentence filtering

Referenced order sentences

Paracetamol alert

Minimal interval checking

Powerplans

IV fluid m-page

Hot Keys

• This is standard Cerner functionality.

• We have aligned with the other lead sites and set the

sensitivity to Major-Contraindicated for prescribers and Major

+ Major Contraindicated for pharmacists

Drug-Drug Interactions

• SCHN is a testing partner for new functionality

• Targeted to high risk drugs and utilising the “normalised” or

mg/kg weight-based calculations to ensure that maximum

doses are not exceeded for overweight patients

Dose Capping

• Hyperlinks to specific drug related policies on the SCHN

intranet

• Reference text can be set to pop-up or open after clicking an

icon

• E.g. direct link per drug to the AMS approval form for restricted

antimicrobials

Reference text links

• Alerts prescriber if patient parameters are missing

• Once the medication order is selected, alert is fired when

patient parameters have not been recorded.

Height, Weight & Allergy Rule

Proposed phone order process –

Nurse 1 takes

phone order and

searches for drug

and order sentence

Selects name of

prescriber from list

and chooses

‘phone order’

communication type

Completes order

details, change

frequency to ONCE

Nurse 2 reads back

order details to

prescriber

Nurse 2 enters

name in order

comments as

“Phone Order”

Nurse 1 administers

medication

Nurse 2 witnesses

and password entry

for dose

administration

Prescriber gets

message to

approve order in

message centre

Proposed Banner Bar weight

20

Current

Proposed

• To minimise the risk of inappropriate selection from long lists

• Paediatric lists are long due to various age and weight options

Order Sentence Filtering

Filtering by age and weight

22

• SCHN is a test partner for this new functionality.

• Improves the prescriber’s experience by displaying relevant orders

• Improves patient safety by minimising risk of inappropriate doses being

selected (e.g. neonatal doses won’t display for adolescents and vice versa)

• All order sentences have been referenced where possible via

the Drug Dosage Guidelines field to indicate source of

information (e.g. CHW or AMH references)

Referenced Order Sentences

• Warns nurses if the patient is about to receive more than the

maximum recommended daily dose.

• The rule is being configured to check for doses that would

exceed 60mg/kg/day and 4000mg/day, whichever is the lower

value.

• Common overdosing error, and can be fatal in paediatrics

Paracetamol Alert

• Warns nurses if they are attempting to give a dose too soon

after a previous dose. Particularly useful for PRN orders.

• E.g. Oxycodone ordered as a PRN medication

• Alert is fired when attempting to administer the medication

before the scheduled time.

Minimum Interval Checking

• PowerPlans are lists of commonly prescribed medications and

order sentences, grouped together to facilitate best practice

prescribing

• E.g. The IV fluids plan has been developed to match the new

Paediatric IV fluids standards, including rate calculation rules.

PowerPlans

IV fluids m-page app.

What if the software doesn’t do what you need?

Hotkeys –unintentional errorY = 1st January

R = 31st December

M = 1st day of the current month

H = last day of the current month

W = 1st day of the current week (last Monday)

K = last day of the current week (next Sunday)

T = today

If the medication has a mandatory witness field, and you don’t move the cursor

into the field before typing, and the witness has a surname beginning with one of

the letters listed above, they may inadvertently adjust the time the medication is

documented to one of the above dates.

Default settings -No restriction on backdating, 60 minute restriction for forward

dating.

Delay issue 1. Additional doses

Issue: 1072 Status

Inappropriate additional dose

administration tasks generated on

MAR by system due to various end-

user activities.

These include nurse documenting an

administration task prior to the

scheduled time and a modify action

occurring between the early

administration time and the scheduled

administration time:• Clinician or Pharmacy modify on Core

attributes to the order• Modify on user defined fields

Modify on order comments

Mitigation strategies have been

proposed for Australian paediatric

setting.

Fix requires code (no release date and

code upgrade required)

Overall, this defect in the Millennium code results in non-physician prescribing

– the system is generating additional dose administration.

Modifications Leading to Additional Task

Pharmacist ‘verify’ or ‘modify’ an order in PharmNet, including adding a

comment (annotation), specifying a dose form (product assignment required for

dispensing).

Prescriber modifying an order, including adding an Antimicrobial Approval

Number.

2. MO changes

dose of

morphine or

Pharmacist

verifies order

and adds order

comment.

3. Patient returns to room after dressing

change – shift change, new nurse

reviews chart and sees outstanding task,

task is now overdue and shows up red

1. Nurse gives dose

of morphine one

hour early as

dressing change

rescheduled.

4. Patient is on

multiple

medications so

MAR is visually

complex. The last

morphine dose is

not shown on the

screen5. The minimum

interval checking

doesn’t fire, the

extra dose is given

and the patient

develops respiratory

depression.

Possible Mitigation Strategies (1 of 2)

Mitigation Factor Work Effort Next Step

Minimise core modifications by

seeking to increase Auto Product

Assignment.

Revisit APA and evaluate

whether risk of inappropriate

APA is outweighed by task

generation

Build review

(order

catalogue,

order

sentences)

Review all order sentences and

include dose form where possible

Will require more dose form

specific order sentences

Build review

Rule to advise Prescribers and

Pharmacists that they may be

creating an additional task and to

review and act on it.

Not possible functionally for

prescribers but is for

pharmacists in PharmNet on

verification.

Workflow

changes

Rule to warn nursing staff of

duplicate task on opening chart.

Possible functionally. Will

require acceptance by

nursing.

Workflow

changes

Rule when fired can also produce

following actions: page, message

centre, task list, email.

Under investigation (including

who would receive and act on

the information)

Cerner

Investigating

Possible Mitigation Strategies (2 of 2)

Mitigation Factor Work Effort Next Step

Minimal interval alert Will require education/training

for exceptions.

Update training

point

Last dose administered tile along all

orders

Will require

education/training.

Update training

point

Single chart open at any one time Alert fires on chart opening if

additional task present.

Requires

configuration

Close chart after each medication

administration session

Education/Training point Update training

point

Audit report at each Go Live (of

alert)

Which medications and

actions created the task

Create report

No order modification by

Prescribers (Oncology excepted)

Oncology prescribers Workflow

changes and

Training

24/7 pharmacist support From Go Live onwards for

prompt verification of all

orders

Executive

Decision

Impact in Tertiary Paediatrics vs Other Sites

Task Other sites Risk at CHW

Pharmacy

verification

Workflow differs to American workflow, where 24/7

Pharmacy services and unit dose dispensing allow

for verification prior to all doses being

administered.

Many more doses given

before verification.

Autoverification Some adult sites in Australia utilise autoverification

– CHW has this preference turned off as few

orders would qualify due to the high usage of

weight based dosing and other paediatric

complexities.

As above – more orders

affected by the defect.

Auto product

Assign

Utilised by adult sites in Australia but turned off for

CHW as dose form assigned often inappropriate

(50% cases for dispensed products)

Dose form could be included

by adding many more order

sentences – could introduce

menu selection error risk.

Dose form in order

sentence

Utilised in other sites to maximise APA and AV See above

Administration prior

to scheduled time

Schedule built according to NIMC and to minimise

menu selection error with all potential schedules

included.

Each ward at CHW has a different variance on

administration times due to medications

prescribed, meals and snacks, sleep patterns,

gate leave, shift patterns, patient acuity,

procedures and interventions. Challenge to

standardise administration times.

Rescheduling of doses

common. Dose are more

likely to be administered

before the scheduled time.

Adverse Events Reported At Other Sites in Australia

Site Adverse Events

A Incident has occurred but was picked up

B 2 incidents occurred.

C Investigating – an issue early on, less of a problem now

Alternative workflows/mitigations not accepted

• Ops job created to run continuously to remove additional tasks so

it is not visible to the administrator

• Reports created to check additional dose events

Consequence, 4 +4 week delay $500K

Issue 2 Between the flags

• Issues with the current build were identified

36

Issues CHW CERS Committee comments Status/Cerner’s comments

Alterations to calling Criteria (ACC) 48hrs is

the maximum time an ACC should be

prescribed for (as per State policy), however

the current build allows clinicians to enter an

indefinite review date/time (for example; the

next review may be set for 24 months’ time).

Once an ACC is prescribed it disables the

pop-up alert that notifies clinicians that the

patient is in the yellow or red zone. This is

a significant patient safety issue as staff

may not realise a patient is in the red

zone and/or deteriorating, and requires a

mandatory Rapid Response.

This item is not currently included

within the enhancements project.

Issues CHW CERS Committee comments Status/Cerner’s comments

Alterations to calling Criteria (ACC) 48hrs is

the maximum time an ACC should be

prescribed for (as per State policy), however

the current build allows clinicians to enter an

indefinite review date/time (for example; the

next review may be set for 24 months’ time).

Once an ACC is prescribed it disables the

pop-up alert that notifies clinicians that the

patient is in the yellow or red zone. This is

a significant patient safety issue as staff

may not realise a patient is in the red

zone and/or deteriorating, and requires a

mandatory Rapid Response.

This item is not currently included

within the enhancements project.

CHW CERS Committee comments Status/Cerner’s comments

2. Prescribing an Alteration to Calling Criteria (ACC)

does not require the user to sign off/enter their

password. There is box labelled ‘sign’ that must be

selected to complete the transaction but selecting it

just results in the user activating the prescription

and exiting the screen.

This prescription can currently be completed

by any clinician with access to it. State policy

identifies that only a Medical Officer has the

authority to do this.

Logged as an enhancement (ref 7.5

Acc Form Design CR 1-8777290216 -

7.5.2 Requirements #13) and

available for install to all domains by

this time next year.

Issues CHW CERS Committee comments Status/Cerner’s comments

3. Observations that are charted outside the

range of the chart are not able to be viewed.

Single observations and trending of

observations will be impacted. This is a

particular concern for those patients (such

as febrile/neutropenic oncology patients)

that can sit outside the graph for extended

periods of time.

Logged as an enhancement (ref

7.3 Extreme Values Displayed CR

1-8777290173 - 7.3.2

Requirements #6 & #10) and

available for install to all domains

by this time next year.

Issues CHW CERS Committee comments Status/Cerner’s comments

The most recently entered heart rate measure

is cut off affecting the readability of the

observation.

This issue is also transferred to the

printed version of the chart (in the

instance the patient is transferred to

another facility or is the subject of a case

review and the chart needs to be printed).

This will be addressed in the

enhancements under 10.7 Time

Modification and available for

install to all domains by this time

next year.

An additional 15 minutes of blank

graph space beyond the current

time will be visible to the right of

the graph so that observations are

displayed clearly.

Issue examples: Cannot see the trend where measurements are off the chart

41

Issue examples: alerts have to be suspended before review

42

Implications of BTF

• eHealth/Cerner have agreed to changes/corrections for delivery in 2016

• CHW CERS Committee recommended that the issues be addressed prior to implementing within SCHN

• SCHN decision to delay introduction of electronic charts

• Interruption of emm/emr workflow

• Delay device integration with vitals monitors

• Paper charts to continue to be used

• Delay to importing observations from fixed and mobile monitors

• BTF will go live after the EMM/EMR rollout, split workflow with aspects of meds, iview, carecompass, and devices

43

Delay Issue 3 Prescription outputOption Risk / Challenges

Implement ‘V1 - white’ prescription for go-live.

• Computer generated prescriptions for hospital

dispensing

• Schedule 2, 3 and 4 meds

• Schedule 8 meds

• May need to exclude S4B and Clause 37

meds

• Handwritten prescriptions for S100 HSD meds

(current state)

• Handwritten prescriptions from outpatient clinics

(current state)

• Require legislative exemptions (eHealth to

facilitate)

• Split workflow for different medication types and

prescription types

• Credibility / adoption

• Risk of error

• V1-white requires further testing and potentially

defect resolution

Do not go-live with prescription output in April and

continue with handwritten prescriptions.

Implement ‘V2 – white, blue and green’ when

available

Split electronic/paper transcribing workflow

• Credibility / adoption

• Risk of error

Lack of resources to test and implement final V2

code when available

V2 White, Blue and Green would be developed by

another site. CHW lose control of development.

Concern that estimate to complete V2 White, Blue,

Green is too low. This is being validated.

Implications

• 2 month delay to project

• Cost of $500K

• Modified workflow for some medications for an

indeterminate period

• Future implications of aiming for a paper workflow

within and electronic workflow

Doing it safer

• Be aware not all solutions suitable to US sites work in Australia

• Involve the state or authority where it is important

• Have the support of your executive to keep safety as the first principle

• All risks need to be accepted by clinical leadership

• All risks have to be weighed against current state risks

• Work closely with vendors to resolve issues

• Don’t wait for perfect, but manage risk with strong mitigations

• Training is important but cant solve variance

• Beware the emotional whistle blower

Please

share

error data!