1 Patient Safety Curriculum Practical Approaches to Patient

1 Patient Safety Curriculum Practical Approaches to Patient Safety Module II Medication Safety, Systems & Communication

2 Patient Safety Curriculum Module II Practical Approaches to Patient Safety • Prescription and medication safety • Communication issues – tracking and follow-up – communication skills • Transcultural issues

3 Types of Medication Errors (>40 steps from doctor to patient) • Prescribing errors – wrong drug – wrong dose • Transcription errors (miscommunication) • Dispensing errors • Administration errors – – wrong drug wrong route wrong time improper syringe or IV prep

4 Common Causes of Medication Errors · Incomplete patient information · Unavailable drug information · Miscommunication of drug orders · Environmental factors and distractions · Labeling problems Source: AHA Quality Advisory 1999 http: //www. hospitalconnect. com/Desktop. Servlet

5 Common Causes of Medication Errors Incomplete Patient Information • Diagnoses • Lab values • Allergies Unavailable Drug Information • Drug contraindications • Other medications – Duplicate prescriptions – Drug interactions

6 Common Causes of Medication Errors Miscommunication of Drug Orders • Written prescriptions • Look-alike names • Sound-alike names • Misuse of decimal points and zeroes • Inappropriate abbreviations • Misuse of metric and apothecary measures • Ambiguous or incomplete orders

7 Common Causes of Medication Errors Environmental Factors and Distractions • Noise, interruptions – transcription errors – multitasking • Fatigue • Work overload • Poor lighting • Stocking and storage problems

8 Common Causes of Medication Errors Packaging and Labeling Problems Look-alike packaging Hard-to-read labels Source: Institute for Safe Medication Practices 2000. (Photos used with permission)

9 Common Causes of Medication Errors When the Patient Leaves the Office • Dispensing error at pharmacy • Failure to read or understand labeling and product information • Drug (e. g. , OTCs) or food interactions • Non-adherence – Prescription not filled or refilled – wrong dose, wrong time – improper administration (e. g. , asthma inhalers)

10 Solutions for Look-alike or Sound-alike Names • Don’t rely solely on memory • Tips for error prevention – tell the patient/caregiver what it is and why you are prescribing it – provide both generic and brand names on handwritten prescriptions – consider e. Pocrates, MDPad, i. Scribe for Palm Pilot – Computerized Physician Order Entry (CPOE) systems Source: Cohen M. Medication Errors 1999. Joint Commission on Accreditation of Healthcare Organizations 2001; National Coordinating Council for Medication Errors Reporting and Prevention 2001.

11 Solutions for Look-alike or Sound-alike Names For Verbal or Telephone Orders • Spell out the name of the drug – E. g. , “X” and “Z” are common sound-alikes • Ask listener to repeat the drug name, dosage, and frequency —“Hear Back” Source: National Coordinating Council for Medication Error Reporting and Prevention 2001.

12 Danger of Handwritten Prescriptions • Virtually all prescriptions are handwritten • >30% of pharmacies investigated (n = 245) filled prescriptions for potentially lethal drug combinations • Computerized pharmacy orders increase safety – allergy alerts – interaction alerts – tracking and record-keeping functions Source: Schiff GD, Rucker TD. Computerized Prescribing, JAMA, 1998. Cavuto NJ, et al. Pharmacies and prevention of potentially fatal drug interactions, JAMA, 1996.

13 Solutions for Measures and Administration Orders • Symbols and abbreviations can be dangerous – Q. D. Q. I. D. Q. O. D. – Never use “U” for “unit, ” easily confused with “ 0” and “ 4” – Write the indication with “prn” meds • Triple check dose, form (e. g. , XL, CR, SR), and frequency • Use leading zeroes, but not trailing zeroes – 0. 5 NOT. 5 – 5 NOT 5. 0 • If you must write, do so legibly! Source: Cohen M. Medication Errors 1999.

14 Group Discussion • What do you see in your practice? • How do you deal with it? – What or who helps? (maximize) – What or who hinders? (remedy or removal)

15 Medication Errors at Home • Patients or caregivers are in control • Pharmacists are your partners • Information and education are critical – is labeling/information easy to read? – is labeling/information easy to understand? – how do you know?

16 Systems & Communication Tracking and Follow-Up What happens when… • you hand off to another physician? • the patient goes home? • the patient switches health plans? • the patient moves to a different state? How do you know?

17 Systems & Communication Dealing with Handoffs Handoff = Opportunity for Error • Miscommunication – – especially with verbal communications listening skills are critical: “Hear Back”! due to distractions (e. g. , noise, interruptions) due to fatigue and stress

18 Systems & Communication Tracking and Follow-Up Reducing the Risk of Error • information must follow the patient

19 Systems & Communication Continuity of Care and Safety High Risk • Chronic conditions – complex care – many providers • • Changing health plans/employers Vulnerable populations Cultural/language issues Post-screening – for cancer, cardiovascular disease, etc.

20 Systems & Communication Electronic Medical Records • Tremendous potential – rapid, seamless communication; easy retrieval – automatic interaction and allergy checking • Barriers to adoption – patient privacy – money – reimbursement – training – proprietary systems that can’t communicate with each other

22 Systems & Communication Skills • Sometimes we see or hear what we expect, not what’s really there – slips and lapses due to conditioning biases • Every link in a chain of communications harbors a latent failure – put it in writing

23 Systems & Communication Skills Many Ways to Communicate • Speaking – face-to-face – via telephone • Writing – on a chart, sign-out, or prescription pad – in a letter or fax – via computer (e-mail) • Sign language • Body language

24 Systems & Communication Transcultural Issues Cultural Diversity Adds Complexity • Language barriers: “once” vs. once • Health belief models • Social styles and moral values • Religious beliefs and practices • Economic considerations

25 Systems & Communication Language Barriers • Access to translators – “language banks”: AT&T, etc. – multicultural staff – judicious use of family members as translators • Qualifications – ability to translate medical terminology – competence with dialects • Expense/reimbursement – another unfunded mandate – an issue that will not go away

26 Systems & Communication Health Belief Models • Diverse views on health and wellness – perceptions of distinguishing physical attributes – how the human body works and stays well • Attitudes toward physical intervention – drawing or receiving blood; surgery – laying on of hands • “Alternative” therapies – home remedies – physical therapies (e. g. , acupuncture) – diet

27 Systems & Communication Social Styles and Moral Values • Trust • Eye contact – propriety • Touch – modesty • Social interactions – within family systems – between males and females – between different age groups

28 Systems & Communication Religious Belief and Practices • Fasting • Prayer • Reverence for elders, family, and ancestors

30 Systems & Communication Transcultural Issues Group Discussion • What do you see and hear in your practice? • How do you deal with it? – What or who helps? (maximize) – What or who hinders? (remedy or removal)

31 Module II - Conclusion • Prescription and medication safety – look-alike and sound-alike drug names – decimals, zeroes, and abbreviations – CPOE and pharmacist consults can reduce errors • Tracking and follow-up – chronic conditions present problems – complete, accurate charting and confirmation – electronic medical record systems can help • Transcultural issues – more than language