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Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
October 14, 2010, Session TH-16
David Benjamin, Ph.D., FASHRMFay A. Rozovsky, JD, MPH, DFASHRM
Medication Error Risk Reduction: Communication Lessons from
Claims Data
Objectives• Describe the common communication
failures found in medication errors.• Identify Critical Success Factors for risk
reduction in medication management communication.
• Apply practical tools to reduce medication risk communication exposures.
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"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.“National Coordinating Council for Medication. Error Reporting & Prevention (NCCMERP.org – 3/13/2010)
Medication Error - NCCMERP
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Classes of Drugs are Involved in Common Medication Errors
• Antibiotics: 19-30%• Analgesics: 7-30%• Cardiovascular: 8-18%• Concentrated electrolytes: 1-10%• Antineoplastic drugs: 7-8%• Sedatives: 4-8%• Anticoagulants: 1.3-3% (1000U Heparin)
Source: Agency for Healthcare Research and Quality (AHRQ) sponsored studies
Classes of Drugs Appearing Twice During 1996-98 in
PHICO’s Closed Claims Project*• Antibiotics• Anticoagulants• Antirheumatics• Tranquilizers• Concentrated electrolytes
• Insulin• Oral Antidiabetics• Antihypertensives• Opiates• Fibrinolytics
*Benjamin, DM and Pendrak, RF. : Medication Errors: An Analysis Comparing PHICO’s Closed Claims Data and PHICO’s Event Reporting Trending System (PERTS).
J Clin Pharmacol 2003;43:754-759.
Medication Errors Appearing in PHICO’s 1998 Closed Claims*
• Allergic/Adverse Reaction (25%)
• Contraindicated drug administered (22%)
• IM Technique Issue (10%)
• Incorrect dose (10%)
• Wrong Patient (3%)• Wrong route (3%) • Labeling/dispensing
error (1%) • Not classified: eg,
failure to monitor or prescribe
*Benjamin, DM and Pendrak, RF. : Medication Errors: An Analysis Comparing PHICO’s Closed Claims Data and PHICO’s Event Reporting Trending System (PERTS). J Clin Pharmacology 2003;43:754‐759.
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
The Lessons Drawn fromClaims Data
Communication Failure is Key• Communication Breakdowns among care
providers and with patients/families• Failure to Communicate• Inadequate Communications• Untimely Communications • Inaccurate Communications
Failure to obtain informed consent to use of Rx
Transcription Errors “Look-Alike” - “Sound Alike” Names
Confusion Over:Drug Names or Handwriting
• Larocin 250 mg vs. Lanoxin 0.250 mg (Larocin changed to Larotid after mix-up)
• Losec changed to Prilosec after confusion with Lasix
• Heparin 1000U sc q 4 hrs Can’t abbreviate Units, you risk a ten-fold OD!
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
More Sound-alike - Look-alike Drugs• Amicar• Cardura• Darvocet• Effexor• hydrocodone• MS Contin• Tramadol• Zestril• Zocor• Oxycontin• hydroxyzine• lorazepam
• Omacar• Coumadin• Percocet• Effexor XR• oxycodone• Oxycontin• trazodone• Zyprexa• Zyrtec• oxycodone• hydralazine• alprazolam
Common Medication Errors Linked to Communication Issues
• Wrong Drug• Wrong Dose• Wrong Route (of administration)• Wrong Patient• Wrong Time (or omission)• Ambiguous/Illegible Rx->Transcription Error• Inadequate Monitoring (e.g., lack of proper follow-up)• Joint Commission Pt Safety Goal: Must reconcile
medications across a continuum of care
Types of Adverse Drug Reactions (ADRs) Frequently Encountered
• Overmedication - too much or too many• Side Effect - an undesirable drug effect• Secondary Effect - additional drug effects• Allergic Reactions - e.g., to antibiotics• Idiosyncratic - rare• Maternal-Fetal - in utero or during nursing• Drug-Drug Interactions - ADME • Alternative Medical Products & OTC drugs
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Faulty Communications With Other Services
• Hand-Offs - Communication Errors. When Patients are Transferred to Other Services, Units or Facilities; last set of orders were not carried out.
• Chart Does not Move Along With Patient.• Failure to reconcile medications.
Proximal Causes of Medication Errors • Lack of Knowledge About the Drug• Lack of Information About the Patient• Rule Violations• Slips and Memory Lapses• Transcription Errors• Faulty Drug Identification• Dosing Errors• Infusion Pump/Parenteral Delivery Error• Inadequate Monitoring• Preparation Errors
Leape, LL et al, System Analysis of Adverse Drug Events, JAMA, 1995;274:35-43.
Lack of Knowledge About the DrugInadequate knowledge of :• Indications• Dosage• Routes of Administration• Chemical Incompatibilities or
Drug Interactions
…and the failure to ask for assistance.
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Lack of Information About the Patient
• Allergies or Sensitivities• Current Diagnosis• Secondary Diagnoses• Concomitant Medications• Use of herbal supplements • Prior Medical History• The patient’s culture, cognitive
ability and language
Care Provider-Patient CommunicationPatient relied on American Sign Language. Requested ASL interpreter. Doctor refused to obtain interpreter. Prescribed medication for rheumatoid condition. Patient’s condition worsened. Still, the doctor refused to secure an interpreter.
Patient went to a different rheumatologist. Learned that the medication was inappropriate for her condition.
Patient sued 1st specialist for lack of informed consent & violation of laws requiring language interpreter accommodation. Patient won.
Family Care Giver CommunicationElderly grandmother took her four year-old grandson to the asthma clinic. Nurse educator instructed grandmother how to administer asthma meds, including use of a nebulizer. Nurse checked-off on the educational summary “Caregiver understood instructions.”
Child came back through the Emergency Department with a full-blown asthma attack. When asked to repeat steps in the administration of the medication, it was clear that the elderly woman did not understand how to manage the drugs.
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Health Literacy & Communication
• Font Size too small on the instruction sheet or bottle.
• Instructions written for a grade 8 comprehension level - patient is at grade 4 reading level.
• Prescription label and instructions printed in Spanish – but the patient is illiterate.
• Instructions contain contradictory information.
Beware “e” Communication Risks• CPOE challenges.• Ergonomic factors in e-Prescribing.• System “upgrades” and “patches.”• Texting in drop down menus in an EHR or EMR
setting.• Conflicting eMAR inputs into the system – “dueling
Blackberry’s.”• Shifting to “paper” following a system glitch.
The Up Side of CPOE
• MD computerized order entry decreased serious medication errors 55%.
• Potential undetected Adverse Drug Experiences (ADE) declined 84%.
Bates et al JAMA 1998;280:1311-1316
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Still Problems With CPOE• CPOE Software Differ.• In 2003, the USP found that 57.9% of CPOE involved Lack of
Knowledge.• Computer Entry ranked as the 4th leading cause of errors in
2003.• 67% of errors occurred during the prescribing phase.• 56.5% of all computer entry errors resulted from distraction• Joint Commission Pt Safety Goal: Must reconcile medications
across a continuum of care.
Case StudyA 63 yo white male has been receiving enalapril for one year for the treatment of his hypertension. Last week, he experienced some difficulty swallowing and discomfort in the back of his throat. He called his doctor and was told to go to the emergency room at the local hospital. Upon arrival in the ER, the patient was experiencing some mild breathing difficulty and was treated with Benadryl, 50 mg, IM and oxygen by mask. Within 30 minutes, the patient was breathing more comfortably and was admitted to a general medical floor for observation.
The next morning, the patient’s wife arrived with a bag of the patient’s “other medications”, which she said she administered to her husband every day. The nurse called the admitting physician and received permission to administer the patient’s other meds, during the course of which, she also administered another dose of enalapril.
The patient was discharged later that day. The day following discharge, the patient suffered an episode of acute angioneurotic edema with dysphagia, lip swelling, airway obstruction, and expired before paramedics could respond.
Conduct a Root Cause Analysis and determine:
What “System Errors” (shown on next slide) Occurred?
What can be done to prevent a recurrence?
Case Study Continued
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Portrait of a Poor Prescription
Source: AMA Website
The Correct Drug was . . .• Final Answer: Isordil not
Plendil which was dispensed and caused fatal hypotension for which both the MD and RPh were held jointly liable for almost $500,000.
Critical Success Factors:Medication Communication
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
CSF - Ability & CompetenciesAbility in terms ofVerbal skillsVisual capabilityPhysical dexterityMental capabilityHealth literacy
Competencies in terms ofTyping skillsUse of CPOEFormulary eMAR systemWriting medication ordersManaging medication orders
CSF - Environment of Rx“Sterile Cockpit”
ApproachTo Focused
Communication
Ergonomically“Friendly”
Human Factors“Qualified”
• Nature of the proposed treatment or procedure.• Reasonably Foreseeable material risks.• Appropriate alternative treatments or procedures.• Foreseeable risks if patient is or becomes pregnant.• Special instructions re: food, drink, lifestyles, eg, no
Chianti with MAOIs.• Tell patients to call if: rash, dark urine, or anything
unexpected occurs.• Pt should repeat critical info; Ask pt for questions.
*Benjamin, DM. Reducing Medication Errors and Increasing Patient Safety: Case Studies in Clinical Pharmacology. Pharmacol 2003;43:768-783
CSF - Drug Information to Provide to the Patient*
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
CSF -Take a Complete Drug History Including Alternative Medical Products
• “Natural Products”, e.g., St. John’s Wort is an MAOI & Reduces serum Digoxin levels.
• Kava Kava causes liver damage.• Herbals, e.g., Ephedrine-containing.• Food Supplements, e.g., L-Tryptophan.• Androgenic Supplements - Heart Failure.• Vitamins & Minerals in Excessive Doses, e.g.,
>10,000 IU Vitamin A/day--> Toxicity.• OTC Drugs.
CSF- Orders and InstructionsNo ambiguity in medication order.Clear instructions for administration – leaving no room for interpretation.Orders are issued in a timely manner.Orders are clear on timing for administration of Rx.Systems check – no overriding of protocol or software regimen.
Verify along the medication management continuumTeach-Back Read back
CSF - Risk Avoidance & ControlRisk Avoidance Plan – All patient/LTC resident prescriptions checked for Rx intolerance, sensitivity, allergy, drug-drug interaction, food-drug interaction.
Systems Safety Net – when the “e” system fails, all pharmacy personnel know how to use the paper-based back-up system. Chain of Command – anyone may use it when there is a concern about a medication order or use.
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
CSF – Rx Reconciliation
LTC
Assisted Living
Patient’s HomeHome Health
Agency
Urgent Care
Hospital
Pharmacy
MD Practice
AmbulatoryCare
Dentists & Optometrists
For each Rx“Communication
Bridge”
CSF – Ask the “Right” Questions“Have you been taking your medication?” “Tell me what medication you have
been taking? •“Do you use any medications that do not require a prescription?•Do you use supplements?•Do you take vitamins?•Do you use any homemade or specially made medication?
Drill down questions to effect good Rx communication!
…like the drill down questions in the informed consent process.
CSF - Discharge InstructionsCompletion of a “Discharge Time Out”• Verbal abilities• Health literacy• Mental capabilities• Regimen adherence capability• Ability to pay for medication• Ability to pay for accompanying dietary changes• Demonstrated competencies for use of Rx!
WHEN IN DOUBT: A Critical Success Factor is to clarify and confirm. When necessary, use the Rx Chain of Command!
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Risk Management Strategiesand Tools for Effective Rx Communication
Keep an Eye on Rx TrendsNew Class of Medication or New Off Label Use of Established Rx
New Medication Delivery Method
New Rx Delivery System or Software Program
Post-Marketing Surveillance Reports MedWatch
Post-Marketing Surveillance Reports MedWatch; Rx Literature.
Monitor the Professional Literature & Reputable Websites
Watch for Internal TrendsNear Misses
Revolving DoorRe-Admissions
P & T CommitteeData
Incident Reports
New eMAR software +
devices
New computer orhandheld devices
New agency or staff personnel
…and Rx Communication
Issues
Revised RxFormulary
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Act on Rx TrendsRx Surveillance & Risk Identification
Complaints Literature ADE Reports Claims Data
Rx Risk Control
Analyze Evaluate Risk Action
Rx Risk Communication
In-Service Rounds Pharm Alerts Pt Updates
Tools to Design to FacilitateRx CSFs
Demonstrated RxCompetencies
Education
Design Your OwnMedication Inventory
Intake Tool
Discharge Summary Medication Checklist
Tool
Specific to your organization
Tools in the Handout
PatientCommunicationTime Out Tool
Staff GuideOn
Health Literacy
Medications Interventions
Checklist
Clinical ResearchADR – ADE
Instruction Tool
It is all about COMMUNICATION!
Medication Error Risk Reduction: Communication Lessons from Claims DataBenjamin - Rozovsky
October, 2010
ASHRM 30th Annual Education Program
Conclusion
Conclusion• Claims Data and Research Data – consistent pattern
persists of a breakdown in communication at critical junctures of the medication order and administration process.
• Technology – while it may be useful, it will not resolve the Rx communication issues.
• Education – persistent drumbeat on what to do for everyone in the medication order management and administration process.
Contact Information
Fay A. Rozovsky, JD, MPHThe Rozovsky Group, Inc.(860) [email protected]
David Benjamin, [email protected]
Contact us if you have any questions.