6 Policy
Pharmacy Practice News • August 2015
Compliance
I SURVIVED
cases and indicated that 40% would have likely been readmitted had we not followed up with the patients.” Dr. Shane offered several additional performance improvements that can boost medication safety: • Work with IT to ensure barcode medication administration and infusion device integration • Have proactive systems in place for dealing with drug shortages • Use lidded bins to reduce look-alike/ sound-alike dispensing errors.
continued from page 1
not want to hear me speak very much,” Dr. Shane said. “They want to hear it from front-line staff.” Preparing a slide deck can help staffers highlight the steps that pharmacy has taken to reduce medication error risks, she added during the webinar, which also included a presentation by Darryl S. Rich, PharmD, MBA, a medication safety specialist at the ISMP. Dr. Shane based her observations on the “many, many surveys” that she has experienced over the years as well as on TJC’s December visit to Cedars-Sinai. One thing that stood out during that week-long trial, she noted, was the shift in surveyors’ focus toward team-based care and pharmacists as team members. “We have pharmacists involved in the progression-of-care rounds,” Dr. Shane said, adding that surveyors “were very positive about seeing the pharmacists’ engagement. From my historical perspective, this was very encouraging. The Joint Commission has become more cognizant of our role in ensuring the safety of the medication-use process.” Dr. Shane outlined some of pharmacy’s initiatives to improve performance at medication risk points, with an emphasis on high-risk medications (Table). One involved opioids. “We’ve gone to Dilaudid [hydromorphone] as our preferred opioid,” she said, “and have added a statement to the medication order in our electronic medical record indicating that it is seven times more potent than morphine. We have also removed the 4-mg dose as an order option.” In the postoperative setting, she said, a performance improvement initiative has focused on ensuring monitoring of patients to reduce the risk for respiratory depression related to opioids.
Periodic Reviews Is Key Using red bins with warning stickers is one strategy for reducing risks posed by high-alert medications.
Also, pulse oximetry has been implemented for individuals using patientcontrolled analgesia. Medication reconciliation is another area receiving close scrutiny. “We’re doing a lot of work in transitions of care,” Dr. Shane commented. The current focus, she added, is on obtaining patients’ medication histories and involving pharmacists and technicians with the care team in ensuring that drugs aren’t omitted or incorrectly continued during handoffs across different levels of care, as well as at discharge and post-discharge. “We’re doing a fair amount of work in post-discharge follow-up,” Dr. Shane added. “Actually, we have a process where we have physicians validate whether patients would potentially have been readmitted had we not called, and we’ve had some favorable results.” Dr. Shane elaborated on the results in a follow-up email: “We haven’t performed a controlled study, so reduction in readmits has not been evaluated. However ... of the patients we called and where pharmacists identified significant drug-related problems, the physicians reviewed these
Dr. Rich offered a number of suggestions for meeting TJC’s medication management standards, including conducting periodic reviews of all areas where medications are used. “Do your own medication tracers,” he advised. “Go to those areas that you never go to.” Indeed, during TJC’s Cedars-Sinai survey in December, tracers were performed throughout the week, including ones related to vaccine storage and emergency medications. The surveyors’ high-risk tracer focused on chemotherapy. In the pharmacy department, Dr. Shane said surveyors were interested in “having us articulate what we do to ensure the safety and sterility of our compounding process for these hazardous substances.” Then they came back up to the unit and had the pharmacists, nurses and other team members “really focus on administration and safety, including how the infusion devices operate.” (See Table for some compounding safety tips.) During the weeklong survey, Dr. Shane was allowed to participate in the surveyors’ daily morning debriefing sessions. “That was invaluable,” she affirmed, “because it gave me insights into what the surveyors were interested in.” It also gave her a sense of what was important to focus on and get the word out to her staff.
Future Areas of Scrutiny
Table. Strategies To Ensure Safety With High-Alert Medications • Use of commercially available products whenever possible (e.g., heparin 25,000 units/250-mL bags) • Limit and/or standard concentrations available (e.g., heparin, neuromuscular-blocking agents)
Storage in Pharmacy Areas • Red bins/tape used to store high-alert medications in pharmacy department areas (heparin, concentrated KCl vials, chemotherapy agents)
Order & Transcription • Hospital protocols or order sets for heparin and argatroban infusions and patient-controlled analgesia • Pharmacist dual verification for parenteral chemotherapy
Preparation & Dispensing • Pharmacist independent double-checks (e.g., compounded parenteral chemotherapy, heparin infusions) Source: Rita Shane, PharmD, FASHP
“Looking into the crystal ball,” Dr. Rich predicted increased TJC emphasis on antimicrobial stewardship programs, safe opioid use and reducing errors related to health information technology, 81% of which, he said, are medication related, according to a 2012 study by the Pennsylvania Patient Safety Authority (http://goo.gl/dwkpfn). He also suggested keeping on top of “hot patient safety issues” that appear in the media (box). “Just remember,” he warned, “that surveyors are in their hotel the night before your survey, and if something appears in the news, they’re going to be asking you about it the next day. It could be an event that occurred 10 states away, but if it is health care– related they’re going to be wanting to know what you’ve done about that.” Deb Saine, BSPharm, MS, FASHP, a coauthor of the “Medication Safety Offi-
Darryl Rich’s Checklist for TJC Preparedness ✔ Periodically review all areas where medications are used.
✔ Conduct your own tracer audits. ✔ Go to the areas where you rarely visit.
✔ Be sure to address hot patient safety issues in the media.
✔ Work with your TJC Coordinator. ✔ Don’t panic—focus on big issues, not the obscure.
✔ Focus on direct impact areas of performance, which are likely to create immediate risks to patient safety. (The risks often stem from a lack of processes to offset the threats.)
✔ Make sure you have strategies in place for resolving issues that arise during audits.
✔ Take a well-thought–out, proactive approach to risk assessment.
✔ Encourage multidisciplinary input from front-line staff.
✔ Focus not only on meeting the letter of TJC requirements, but also the intent—especially the medication safety intent.
✔ Read TJC Standards FAQ (www. jointcommission.org/standards_ information/jcfaq.aspx). TJC, the Joint Commission Source: www.jointcommission.org
cer’s Handbook,” said health systems reap huge benefits from TJC’s focus on patient safety—a goal that is “front and center” in the group’s mission, she noted. Dr. Saine also gave kudos to TJC for not taking a top-down approach to process improvement. “Practitioner feedback and recommendations, including front-line pharmacists, are included in development of medication management standards and National Patient Safety Goals,” she pointed out. This dynamic process “encourages us to be forward-thinking and to raise the bar for our standards of practice,” said Ms. Saine, who is a senior lean management engineer at Valley Physician Enterprise, a part of Valley Health headquartered in Winchester, Va. “The standards (and the processes) for medication management span the entire organization—they drive the conversations for medication safety across departments, and expose opportunities for collaboration that might not otherwise exist in the absence of accreditation. This is a key value of the [Joint Commission] accreditation process.” —Bruce Buckley None of the sources reported any relevant financial conflicts of interest.