Clinical 29
Pharmacy Practice News • December 2014
Medication Safety Table 1. Self-Assessment Tools Available Online
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However, there are still too many errors and “there’s still a lot we don’t know about how to design safe medication use processes,” she said. “That’s why prospective techniques are needed.” Self-Assessments in Bite-Sized Pieces. A good place for organizations to begin examining their own processes before an error occurs is by conducting one of several self-assessments available online, Ms. Paparella suggested (Table 1). With roughly 300 items, the ISMP’s own tool may feel like a daunting project, but Ms. Paparella said it can be completed in segments. Those results can spur more rigorous evaluations, she said. “What we’ve heard from organizations is that gathering teams to discuss the self-assessment results, either in part or in whole, can help really important information emerge,” Ms. Paparella noted. Electronic Systems a Data Trove. In addition to the insights gleaned from self-assessments, organizations can identify errors and error-prone processes by looking at data collected in electronic health records (EHRs), computerized prescriber order entry (CPOE) systems and newer devices, some of which offer data reporting functions, Ms. Paparella said. For example, CPOEs and EHRs can be queried to list alerts that have come up when entering medication orders, or instances of medications discontinued soon after ordering. Additionally, trigger tools can indicate use of rescue medications, orders for STAT laboratory tests or acute changes in patient care, she explained. “These are important clues that are often overlooked and can tell us about missed doses or prescribing errors,” Ms. Paparella noted. “But many organizations are not yet taking advantage of these sources.” James Hoffman, PharmD, MS, a medication outcomes and safety officer and an associate member of the Pharmaceutical Sciences Department at St. Jude Children’s Research Hospital in Memphis, Tenn., agreed that proliferating use of automated systems in the medication use process is a potential boon to error prevention initiatives. He said the question remains as to how these new technologies should be optimally leveraged. “There are apps, trigger tools, IV workflow products and barcode management software that all provide data that need to somehow be mined to identify events,” said Dr. Hoffman, who recently presented a study examining whether rapid changes in dosing and drug discontinuations can be used as surrogate markers of drug errors at the American Medical Informatics Association’s 2014 Annual Symposium, held in
Assessment Tool
URL
ISMP Medication Safety Self-Assessments
ismp.org/selfassessments/default.asp
American Hospital Association Leadership Assessment for Patient Safety
aha.org/aha/content/2002/pdf/ conwaytool.pdf
Agency for Healthcare Research and Quality Hospital Patient Survey on Safety Culture
ahrq.gov/qual/patientsafetyculture
Tubing Misconnections Self-Assessment for Healthcare Facilities
ismp.org/selfassessments/tubing misconnections/default.asp
International Medication Safety Self-Assessment for Oncology
mssa.ismp-canada.org/oncology
Opioid Knowledge Self-Assessment
patientsafetyauthority.org/educationaltools/patientsafetytools/opioids/ documents/assessment.pdf
‘There’s still a lot we don’t know about how to design safe medication use processes. That’s why prospective techniques are needed.’ —Susan Paparella, MSN, RN
Table 2. External Sources of Risk Identification Category
Source
URL
Error reporting programs
The Joint Commission Sentinel Event Alerts
jointcommission.org/sentinel_event.aspx
Pennsylvania Patient Safety Reporting System
papsrs.state.pa.us/PSA
Professional publications
ISMP publications (ismp.org); ISMP Quarterly Action Agendas
ismp.org/newsletters/acutecare/ actionagendas.aspx
Discussion boards
Medication Safety Officers Society Listserve
medsafetyofficer.org/forums/ msos-discussion-board
Washington, DC. “My hope is that vendors will include more capabilities to identify errors as part of their products.” Engage With Staff. A lower-tech way of gathering information on errors or error-prone processes is to speak with staff, Ms. Paparella said. “Who knows better than front-line workers where the existing hazards are?” she pointed out. Safety briefs, shift changes, staff meetings or walkarounds are all opportunities to engage with staff and to find out whether there are elements of the medication use process that are challenging, Ms. Paparella explained. “Ask about mistakes or near-mistakes they have made, or workarounds they have developed.” Pharmacist Interventions Important. While pharmacists tend to think of order reviews and related interventions as “part of their job,” Ms. Paparella said data from these reviews and interventions can be collected and used to inform the risk evaluation process. Whether they are collected electroni-
cally or manually, the data can identify order sets that need to be modified or prescribers who “may not be appreciating the therapeutic nuances of certain medications,” she said. In the outpatient setting, conducting random audits and comparing willcall orders with medication labels can uncover errors in labeling and packaging, as well as other points of vulnerability in the pharmacy workflow, Ms. Paparella added. Don’t Wait for an Error To Happen! Organizations need to consider errors that have not occurred internally when they decide what processes to scrutinize, Ms. Paparella said. It’s thus helpful to carefully review information on errors that have occurred at other institutions (Table 2). Dr. Hoffman agreed, cautioning against a belief “that error can never happen here.” Organizations, he noted, “need to embrace the idea of making improvements in their own process-
es based on reports of errors at other [facilities],” he said. “Be proactive, and don’t wait for things to happen at your hospital or health system.” Do a Deep Dive. After error-prone processes are identified, they should be closely examined, Ms. Paparella said. One methodology she said is particularly effective is the failure mode and effects analysis (FMEA). FMEA helps organizations identify ways by which a process might fail, factors that might cause it to fail, the potential consequences of failure and ways to improve the safety of the process, Ms. Paparella explained. FMEA tools are available through organizations such as The Institute for Healthcare Improvement (http://app.ihi.org/Workspace/tools/fmea). “FMEA takes time to learn, but it can be really helpful in guiding you to the right questions to ask about a process, and it can identify most of the safety gaps in a process,” she said. Because it is a time-consuming method, Ms. Paparella suggested prioritizing highalert medications for FMEA evaluations. She also suggested narrowing the focus of an analysis to look at sub-processes in the use of a medication. Such an approach, she noted, will increase the likelihood that an analysis will produce results. “You can end up getting bound up with the complexity of bigger processes,” she said. “So, looking at sub-processes will likely get you more actionable results.” Organizations should also prioritize analyzing processes for use of medications and devices that are new to the formulary and the organization, because providers can be unfamiliar with their handling, administration and use, she said. “There are important questions you should be asking about your processes up front and before dispensing new medications or using new devices. “For example, do you have the structural and technological resources in place to administer the new medication? Do your pumps have the appropriate tubing to deliver all of the agents you administer? Risk assessment is about creating a learning culture.” —David Wild Ms. Paparella and Dr. Hoffman reported no relevant financial conflicts of interest.
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