9 th Annual Pharmacy Informatics Conference Managing Health

9 th Annual Pharmacy Informatics Conference Managing Health IT Related Patient Safety Issues Danielle Kato, Pharm. D Pharmacist Consultant Informatics Patient Safety March 2018

Say what? What is your generic term for a sweetened carbonated beverage? Soda Pop Coke Soft drink Joshua Katz, Department of Statistics, NC State University VETERANS HEALTH ADMINISTRATION 1

What is your generic term for a sweetened carbonated beverage? VETERANS HEALTH ADMINISTRATION Joshua Katz, Department of Statistics, NC State University 2

Say what? How do you pronounce “crayon”? 2 syllables, “cray-ahn” 2 syllables, “cray-awn”, there the second syllable rhymes with “dawn” 1 syllable, “cran” as in “man” I pronounce it the same as “crown” Joshua Katz, Department of Statistics, NC State University VETERANS HEALTH ADMINISTRATION 3

How do you pronounce “crayon”? VETERANS HEALTH ADMINISTRATION Joshua Katz, Department of Statistics, NC State University 4

Objectives • Describe the mission of the Informatics Patient Safety Office • Define the term “e-Iatrogenesis” • Describe the safety domains of Health Information Technology (IT) • Evaluate Health IT issues with respect to patient safety VETERANS HEALTH ADMINISTRATION 5

Informatics Patient Safety Office Mission: Foster a culture of safety within Health IT (HIT) to protect the patient VETERANS HEALTH ADMINISTRATION 6

Informatics Patient Safety Office Aligned to Office of Health Informatics (OHI) – Health Informatics Division Collaborations with – National Center for Patient Safety – Pharmacy Benefit Management – Patient Care Services – Office of Information and Technology (OIT) – And YOU VETERANS HEALTH ADMINISTRATION 7

Patient Safety “The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare” National Patient Safety Foundation http: //www. npsf. org/ VETERANS HEALTH ADMINISTRATION 8

e-Iatrogenesis “patient harm caused at least in part by the application of health information technology” Weiner et al, JAMIA 2007 • e-Iatrogenic events – Associated to any aspect of a comprehensive HIT system – Involve errors of commission or omission VETERANS HEALTH ADMINISTRATION 9

Health IT Safety (HITS) Framework Singh H, Sittig DF. BMJ Qual Saf 2016; 25: 226– 232. 10

Health IT Safety Domains Safe HIT Integrity Availability Confidentiality Safe use of HIT Using HIT for safer care Usability Correct Use Complete Use Identify Monitor Intervention VETERANS HEALTH ADMINISTRATION Adapted from: Singh H, Sittig DF. BMJ Qual Saf 2016; 25: 226– 232. 11

Safe Health IT | Domain 1 Address safety concerns that are unique and specific to technology • Data Availability - accessible and usable upon demand by authorized individuals • Data Quality and Integrity – accurate and not altered or destroyed in any unauthorized manner • Data Confidentiality – available or disclosed to authorized persons or processes VETERANS HEALTH ADMINISTRATION 12

Using Health IT Safely | Domain 2 Optimize the Safe Use of Technology • Complete/Correct health IT use – features are implemented and used as intended • Health IT system usability – features are designed and implemented effectively, efficiently, and to satisfaction of intended users to minimize potential for harm VETERANS HEALTH ADMINISTRATION 13

Using HIT for Safer Care | Domain 3 Use technology to monitor and improve patient safety • Safety Surveillance, Optimization, and Reporting – Mechanisms in place to monitor, detect, and report on the safety and safe use of HIT – Optimize the use of HIT to improve quality and safety VETERANS HEALTH ADMINISTRATION 14

Practice: which HIT Safety Domain? Scenario 1 During outpatient prescription verification, the checking pharmacist discovered multiple strengths of Lisinopril in the patient’s bottle for Lisinopril 10 mg. It was discovered the user that refilled the outpatient automation canisters was scanning one bottle multiple times rather than each individual as intended by the technology’s design. VETERANS HEALTH ADMINISTRATION 15

Practice: which HIT Safety Domain? Scenario 1 During outpatient prescription verification, the checking pharmacist discovered multiple strengths of lisinopril in the patient’s bottle for Lisinopril 10 mg. It was discovered the user that refilled the outpatient automation canisters was scanning one bottle multiple times rather than each individual as intended by the technology’s design. Answer: Domain 2 – Safe use of HIT VETERANS HEALTH ADMINISTRATION 16

Practice: which HIT Safety Domain? Scenario 2 With the release of MOCHA 2. 1 b, Macros were provided to pharmacy informaticists that enable monitoring of order checks. With this information, the pharmacy informaticist is able to detect order check failures and take appropriate action to resolve the failures. VETERANS HEALTH ADMINISTRATION 17

Practice: which HIT Safety Domain? Scenario 2 With the release of MOCHA 2. 1 b, Macros were provided to pharmacy informaticists that enable Using HIT for this information, monitoring of order checks. With safer care the pharmacy informaticist is able to detect order Identify check failures and take. Monitor appropriate action to Intervention resolve the failures. Answer: Domain 3 – Using HIT for safer care VETERANS HEALTH ADMINISTRATION 18

Practice: which HIT Safety Domain? Scenario 3 When attempting to finish a medication order, the pharmacist is kicked out of Vist. A completely and given a $ZERROR and has to close the session before being able to log back in. The problematic order becomes locked. VETERANS HEALTH ADMINISTRATION 19

Practice: which HIT Safety Domain? Scenario 3 When attempting to finish a medication order, the pharmacist is kicked out Safe of HITVist. A completely and given a $ZERROR and. Integrity has to close the session Availability before being able to log back in. The problematic Confidentiality order becomes locked. Answer: Domain 1 – Safe HIT VETERANS HEALTH ADMINISTRATION 20

Identifying HIT Issues as “Patient Safety Related” Consider the Risk to the Patient • Severity – What is the harm or potential harm to the patient? • Frequency – How often does the issue occur? • Detectability – How easy is it for someone to notice that something is wrong? VETERANS HEALTH ADMINISTRATION 21

Identifying HIT Issues as “Patient Safety Related” Do I have a Patient Safety Incident with a Health IT Component? I’m hungry VETERANS HEALTH ADMINISTRATION I feel like I’m forgetting something important… Do I have a Health IT issue with a Patient Safety component? Who was I supposed to call back? 22

Patient Safety Incident with a Health IT Component? Health IT Issues with a Patient Safety Component? Patient Safety Incident Staff identifies “problem” with HIT Investigation by Patient Safety Manager (PSM) “Problem” brought to informaticist Identification of HIT as root cause or contributing factor Informaticist investigates “problem” 23

Local Pathway National Pathway Patient Safety Incident Patient Safety Community aware of issue Investigation by Patient Safety Manager (PSM) Identification of HIT as root cause or contributing factor PSM submits RCA to NCPS Issue has national Health IT implications Patient Safety Community/IPS Collaboration IPS leads investigative effort 24

Informaticist investigates problem and determines need for Help Desk Ticket entered and marked for Patient Safety review IPS monitors tickets for patient safety matters Validated patient safety issues entered into IPS database IPS Analyst contacts ticket submitter for additional information Health IT patient safety issue is analyzed and risk evaluated Recommendations for resolution of confirmed issues are developed, documented, and monitored 25

Health IT Issue Affects Patient Safety VETERANS HEALTH ADMINISTRATION 26

Informaticist investigates problem and determines need for Help Desk Ticket entered and marked for Patient Safety review IPS monitors tickets for patient safety matters Validated patient safety issues entered into IPS database IPS Analyst contacts ticket submitter for additional information Health IT patient safety issue is analyzed and risk evaluated Recommendations for resolution of confirmed issues are developed, documented, and monitored 27

Informaticist investigates problem and determines need for Help Desk Ticket entered and marked for Patient Safety review Contact Informatics Patient Safety directly with an issue https: //vaww. vaco. portal. va. gov/sites/OHIA/IPSPublic/default. aspx IPS monitors tickets for patient safety matters Validated patient safety issues entered into IPS database IPS Analyst contacts ticket submitter for additional information Health IT patient safety issue is analyzed and risk evaluated Recommendations for resolution of confirmed issues are developed, documented, and monitored 28

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Informaticist investigates problem and determines need for Help Desk Ticket entered and marked for Patient Safety review IPS monitors tickets for patient safety matters Validated patient safety issues entered into IPS database IPS Analyst contacts ticket submitter for additional information Health IT patient safety issue is analyzed and risk evaluated Recommendations for resolution of confirmed issues are developed, documented, and monitored 32

Case Scenario 1 continued… You need to determine if other prescriptions for Lisinopril 10 mg were filled since the last time that canister was replenished. You discover that three patients received prescriptions… VETERANS HEALTH ADMINISTRATION 33

Case Scenario 2 continued…. • Your MOCHA reports reveal that order checks could not be performed on several medications • Several exceeds max dosage order checks for ZINC 50 MG (FROM SULFATE) CAP VETERANS HEALTH ADMINISTRATION 34

Recent Developments… NCPS PSAT for Health IT • Patient Safety Assessment Tool (PSAT) • Joint Commission Sentinel Event Alert (SEA) #54: Safe Use of Health IT – Culture – Process Improvement – Leadership • PSAT statements map to SEA #54 recommendations VETERANS HEALTH ADMINISTRATION 35

PSAT Example VETERANS HEALTH ADMINISTRATION 36

Questions VETERANS HEALTH ADMINISTRATION 37