improved quality of medication management helps to …€¦ · avoid reliance on memory 2. simplify...
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IMPROVED QUALITY OF MEDICATIONMANAGEMENT HELPS TO REDUCEMEDICATION ERRORS
Pr Pascal BONNABRYHead of pharmacy
CarefusionSingapore March 3, 2016
SafetyAmong the 3 main sources of avoidable adverse events
EfficiencyDifficult to perform highly without appropriate toolsfor stock management
EconomicsValue of decentralized stocks
TraceabilityIncreasing requirements by authorities
Medication: challenges
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Centralpharmacy stock
Industrystock
Wardstock
Prescription
Administration
An obsolete organisation ?
Bates DW, JAMA 1995;274:29
Avoidable
adverse drug events:
6.5% of admissions
39%
11%38%
Interception 48%
Interception 33% Interception
2%
The addition of 2 errors
Commission error AND Control failure
How errors occur ?
Selection
Dilution
Calculation
…
Check
Double-check
…
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Order of magnitude of dispensing errors by healthcare professionals ?
A. 0.01%
B. 0.1%
C. 1%
D. 10%
Quiz
Order of magnitude of dispensing errors by healthcare professionals ?
A. 0.01%
B. 0.1%
C. 1%
D. 10%
Quiz - answer
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74%
20%6%
Selection error
Repartition error
Counting error
Garnerin P, Eur J Clin Pharmacol 2007;63:769
Error rate = 3 %
Dispensing errors(experimental)
Performance of controls to catch errors ?Example: double-check of dispensed drugs ?
A. 70%
B. 85%
C. 95%
D. 99%
Quiz
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Performance of controls to catch errors ?Example: double-check of dispensed drugs ?
A. 70%
B. 85%
C. 95%
D. 99%
Quiz - answer
Introduction of errors during unit dose dispensing
Detection ability during human-performed control:
Pharmacists: 87.7%
Nurses: 82.1%
Facchinetti NJ, Med Care 1999;37:39-43
Limited performance of controls
Efficacy ≈ 85%(known value in the industry)
Do not be too confident with the double-checks !
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« On the 6th day, God created man … »
Human reliability
… but God was tired, and hiscreation was not perfect …
In hospitals, many high-riskactivities are based on humanreliability, which is limited
“Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities , and application of that knowledge in clinical settings.”
Human factors
Clinical Human factor Group, http://chfg.org
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“We cannot change the human condition,
but we can change the conditions under
which humans work.”
James Reason
“We cannot change the human condition,
but we can change the conditions under
which humans work.”
James Reason
Implement strategies to
How to improve the safety ?
Reduce the frequencyof errors
Increase the reliabilityof controls
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1. Avoid reliance on memory2. Simplify3. Standardize4. Use constraints and forcing functions5. Use protocols & checklists wisely6. Improve information access7. Reduce handoffs8. Increase feedback
Human factors principles to progress
http://www.who.int/patientsafety/research/online_course/en/
There is a role for IT and automation !
• Technology• Constraints• Forcing functions
High
• Standardisation• Redundancies• Check-lists
Medium
• Procedures• Education• Vigilance
Low
Hierarchy of risk reductionstrategies
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Medication safety: 3P’s
Process Persons Products
Information technologies
(IT)
Non - IT
In-house production
(BPF)
Presentation(RTU, design)
Patients
Tools
Research
Healthcareprofessionals
Hospital pharmacy and IT
Clinical pharmacyMedication process Production
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Medication process organisationIndividual (nominal) distribution
Prescription
Validation bya pharmacist
Patients dosespreparation
Doses delivery
Administration to patient ( )
Deliveryof packages
Orderingto the pharmacy
Distribution of packages
Medication process organisationGlobal distribution
Prescription
Dispensing
Administration to patient
Ward stock
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Individual distribution is more convenient in some conditions
Few prescription modifications (chronic care)
Pharmacy close to the wards
Individual or global ?
At the HUG, the global model was selected
Acute care in majority
Long distance between the pharmacyand some wards(multi-sites hospital)
The process of the future ?
Logisticinformation
system
EDI
Centralpharmacy
stock
Industrystock
Wardstock
Automateddispensing system
Bedsidescanning
Robotizeddistribution
CPOE
Distribution with scanning
Clinicalinformation
system
Smart Pumps
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Logisticinformation
system
Clinicalinformation
system
EDI
Centralpharmacy
stock
Industrystock
Wardstock
Automateddispensing system
Bedsidescanning
Robotizeddistribution
CPOE
Distribution with scanning
The process of the future ?HUG situation 2016
Smart Pumps
Gravimetric control is the only to have detectedall errors (> 30%, but lack of power to conclude)
Withoutdouble check
n=144
3
2
1
With visualdouble check
n=143
6
4
2
Gravimetriccontroln=151
5
5
0
Number of errors
Detected
Undetected
Carrez L, HUG, 2013
14/438 = 3% errors
Gravimetric controlImpact on the safety (simulation)
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Cytotoxic compoundingCytotoxic compounding
Cytotoxics: a special process
Electronicprescription
Bedsidescanning
Preparation withgravimetric control
+ Dose-banding
(2016)
Automatedpreparations
(2015)
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Automation
How to improve the safety in cytotoxic compounding ?
Reduce the frequencyof errors
Increase the reliabilityof controls
� In-process
� Gravimetriccontrol
� Post-process
� Quantitative analysis
Main objectivesDetect and avoid product errors [robust if scanning]
Detect and avoid dose errors
Standardize the method and the speed of preparation
Increase the traceability
Gravimetric control
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Robotized distributionRobotized distribution
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
Manual distribution
Scanning Robot (2011)
Robot (2015)
selectionaddition quantitymissing quantityother
Robotized distributionImpact on the safety
François O et al, HUG, 2015
0.93 % 0.94 %
0.48 %
0.13 %
n=5805 n=2437 n=4365 n=5564
Conveyor’s
improvement
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Robotized distribution Impact on the efficiency
François O et al, HUG, 2015
0
200
400
600
800
1000
1200
1400
1600
1800
Scanning Manual
distribution
Robot
WITH filling
Robot
WITHOUT filling
210 300 570 860
Pac
kage
s / h
our
Automated dispensing systemsAutomated dispensing systems
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Automated dispensing systemImpact on the safety (simulation)
Du Pasquier C, Riberdy L, HUG, 2003
0
0.5
1
1.5
2
2.5
3
Total Omission Selection Counting Repartition
Err
or ra
te [%
]
without with
0
5
10
15
20
Before (manual) Pilot with ADS After (manual)
Lines asked in emergency mode
Automated dispensing system Impact on the efficiency
%
Surgical ward, 28 beds
François O et al, HUG, 2013
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Automated dispensing system Nurses opinion on improvements
0%
0%
13%
22%
66%
no opinion
strongly …
disagree
agree
strongly agree
…improves medication traceability?
0%
0%
9%
22%
66%
no opinion
strongly …
disagree
agree
strongly agree
…improves the stock management ?
François O et al, HUG, 2015
3%
0%
3%
31%
63%
no opinion
strongly …
disagree
agree
strongly agree
…improves the safety of care?
Facilitators and barriers for successFacilitators and barriers for success
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Facilitators and barriers
FacilitatorsOrganisational stability
Implementation team leadership
Equipment availabilityand reliability
Flexible implementationtimelines
BarriersTechnical problems
Altered work practices
Weakened interpersonalcommunication
Poor access to computers
Logistics of training
Unsupportivemanagement team
Cost
Security
Hogan-Murphy D, Eur J Hosp Pharm 2015;22:358
Systematic review
ProcessTraining requirementsProcess flow (administration of drug before scanning, shortage of time)
TechnologyHardware (performance)
Software (delays in response)
Barcode (difficulties in reading)
ResistanceCommunicationChanging roleNegative perception of IT
Workaround
Van Onzenoort HA, Am J Health-Syst Pharm 2008;65:644Nanji KC, J Am Med Inform Assoc 2009;16:645
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The implementation of technologies is a real opportunity to re-engineer the whole processIf the technology is implemented without adaptingthe rest of the process, there is a high risk to create important problems (workaround, new risks, inefficiency,…)The use of process analysis tools isrecommended :
Proactive risk analysis (FMECA)ErgonomicsLEAN management
Re-engineering
Return on investment (ROI)Return on investment (ROI)
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Return on investment (ROI)
CostsInvestment
AcquisitionInstallation
Operation (annual)MaintenanceAmortization
BenefitsDirect purchase(e.g. drugs)
Direct staff costs
Efficiency(organizational costs)
Safety (less errors)
…
Partially based on estimations
ROI (years) = initial investment / annual balance
Return on investment (ROI)
Exemple: automated dispensing cabinets
Fictive numbers Investment [CHF] Operation(annual) [CHF]
Time for ROI
Acquisition costs + 45’000
Maintenance + 1’500
Amortization (8 years) + 6’250
Reduction stock value - 5’000
Reduction drug purchase (- 5%) - 7’500
Staff costs (technicians vs nurses) - 6’000
Safety (cost of errors) - 3’500
Total + 40’000 - 9’250 4.3 years
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Automation and robotisation are important strategies to optimize drug management
Safety, traceability and efficiency can be improved
The implementation must be intelligently and interdisciplinary decided and planified
These projects are very challenging and must be leadedby a competent and available team
A strategic vision should be elaborated by any hospital
Lessons learned
The world is changing…
We have to take the best to improve the
quality of care in hospitals
The world is changing…
We have to take the best to improve the
quality of care in hospitals
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Automation … time for adoption ?
Where are you ?
VISION
Vision without action is merely a dream.
Action without vision just passes the time.
Vision with action can change the world
Joël Barker