APSF Medication Safety



I don't think anybody would have suspected this little child that given day coming in for very elective surgery a very healthy child would not leave the hospital alive little boy that was scheduled for elective ear surgery unfortunately when the surgeon went to inject what he thought was lidocaine with the loot epinephrine he ended up on ejected concentrated 1 to 1000 epinephrine when we started doing CPR and the child not come right back I began to feel I don't say a sense of panic but a sense of dread I think everybody in that room felt like they were trying to swallow a basketball he just it was it was really difficult to see a child just before your very eyes died the national coordination council for medication error reporting and prevention defines a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional patient or consumer the National Quality forum with support from the agency for Healthcare Research and quality has identified evidence-based practices that can work to decrease or prevent adverse events and medical errors these safe practices for better healthcare include medication use and emphasize the role of pharmacy involvement and leadership and the importance of standardized medication labeling and packaging medication administration errors continue to be a major source of harm to hospitalized patients while there is relatively sparse information about the extent of drug errors made by anesthesia professionals there are data suggesting that such errors occur in one form or another is often as once in every 133 anesthetics medications most involved with harmful intravenous drug errors include neuromuscular blocking drugs opioids antibiotics benzodiazepines epinephrine heparin and insulin medication errors account for approximately 4% of the cases in the a SI closed claims database of the 205 claims 24% were substitution errors reflecting an unintended administration of a different drug than planned drugs most often involved in this so called drug swap error where epinephrine and neuromuscular blocking drugs in 18% of the reported drug errors the event was an insertion error in which a drug was administered that was not intended to be given at that time or any time in 31% of the cases the drug error was administration of an incorrect dose and in nearly 50% of the claims the drug administration error resulted in significant adverse effects on the patient proximal causes of these errors included lack of standardization absence of protocols production pressures and a lack of agreement as to best practices in the review of 896 drug errors reported to the Australian incident monitoring study syringe and drug preparation errors accounted for 452 of the reports and included syringe swaps where the drug was correctly labeled but given an error and a similar number of incidents where the wrong drug was selected or drug labeling errors were present the drugs most commonly involved were neuromuscular blocking drugs followed by opioids contributing factors to these errors included haste inattention drug labeling error communication failure and fatigue the outcomes of these medication error events included minor morbidity in 105 patients major morbidity in 40 patients awareness in 40 patients and death in three patients compared with all other adverse events medication errors were more likely to be judged preventable and due to inappropriate care additionally the likelihood of a payment was greater and the median payout was more than for other adverse events the operating room is a unique environment in which the anesthesia professional both selects draws up and administers a drug with no intervening checks and balances that would normally occur if a drug was administered outside the operating room furthermore the anesthesia professional is often handling look-alike ampules bottles syringes and labels in high acuity situations with multiple distractions unlike other areas of the hospital that currently have checks and balances for medication preparation and administration the o.r is lacking these safety mechanisms indeed the need for an administration of high-risk medications combined with high-volume use of many medications make safety dependent on flawless human performance this inevitably contributes to an environment where errors are highly likely to occur and equally likely to cause harm I don't care if you're the best nurse pharmacist doctor it doesn't matter of course you're gonna make errors you're human I think the fact that people say they are never could happen to them is one of the biggest problems that we have good people give potassium intravenously by mistake as a direct injection good people dispense paralyzing agents instead of in antibiotic it could happen to any one of us given the right set of circumstances and when you look at it 10 20 different things 20 different system elements had to go wrong in order for one of these cases to actually happen a PSF and other professional associations have long supported certain basic medication safety principles including labeling of all syringes reading the label before administering a medication and incorporating features such as distinctive drug labels and color coding as fundamental to correct selection and administration of drugs in the operating room nevertheless medication errors continue to occur and thus a PSF is challenging the effectiveness of these traditional methods a PSF believes that current processes of medication preparation and administration represent an opportunity to address system changes to help eliminate preventable adverse events that compromise patient safety therefore a PSF is advocating a new paradigm as the next step in creating change in medication preparation delivery and identification that offer the potential to enhance patient safety in the immediate future this new paradigm is denoted by the acronym STP C reflecting the role of standardization technology Pharmacy pre-mixed and prefilled and culture in addressing medication safety in the operating room standardization examines drug dosages dosing units concentrations drug preparation methods and workplace design technology incorporates computer assisted identification and delivery via the application of automated information systems such as bar coding Pharmacy includes dedicating pharmacy resources to the operating room utilizing pre-mixed solutions and adopting prefilled syringes when possible culture encompasses a non-punitive system designed to recognize and report errors so that we may learn from adverse events and reduce the likelihood of recurrence due to the same or similar mechanism in fact the culture of identify blame and punish needs to be abandoned and replaced with a culture of accountability a PSF sponsored a multidisciplinary one-day conference on January 26 2010 that was attended by more than a hundred anesthesiologist nurse anesthetist nurses pharmacists hospital administrators liability insurance carriers as well as representatives of regulatory and accrediting agencies and Industry the attendees focused on the STP C paradigm and made specific recommendations for the application of this paradigm to medication safety in the operating room the full report of the conference was published in the spring 2010 issue of the AAP SF newsletter and is available on the AAP SF website the recommendations for standardization were high alert drugs such as phenol Efrain and epinephrine should be available in standardised concentrations and prepared by pharmacy when possible in a ready to use syringe for rapid administration or infusion form that is appropriate for adult and pediatric patients the Joint Commission national patient safety goal specifies the components of a fully compliant label that include the drug name in 12-point print tall man lettering the dose per milliliter total dose concentration expiration date barcode formats and ASTM color coding technology is the second part of the STP ce paradigm there are things that we could do with technology for example bar coding computerization of physician order entry prescriber order entry I think that in many cases the errors that we've seen wouldn't be able to happen taking advantage of modern information systems a modern computer support systems to be able to detect and intercept errors and support human decision-making in ways such that errors don't occur the recommendations for technology by the conference attendees included every anesthetize alok ation should have a mechanism to identify medications before drawing up or administering them such as a barcode reader as well as a mechanism to provide feedback clinical decision support and documentation documentation of drug administration and time could be provided by anesthesia information systems in the future other technology including voice recognition systems may supplant existing identification systems the recommendation of the conference attendees for the third part of the STP C paradigm Pharmacy prefilled and pre-mixed were to discontinue routine preparation of medications by the anesthesia professional at the point of care whenever possible instead consider the use of prefilled or pre-mixed solutions as provided by a satellite pharmacy or commercial vendor clinical pharmacist should be part of the perioperative and operating room team with an on-site operating room pharmacy when feasible pharmacist can provide drug preparation and distribution drug accountability in control and serve as a resource for drug information as well as providing regulatory oversight and financial oversight of drug-related expenditures additionally standardized prepared medication kits by case type should be used whenever possible the final component of the STP C paradigm addresses culture when I realized that the theater was my responsibility it was total devastation it's the biggest nightmare to hurt somebody I got a call from a contact of mine and he advised me to go immediately and resign because they were going to fire me that afternoon the word had been passed down from on high that that I was not to be hired under any circumstances so then I was I was really out in the cold the recommendations for incorporating a culture of change include establishing a just culture for reporting errors including near misses and discussion of lessons learned additionally establishing a culture of open communication cooperation and recognition of the benefits of STP see within and between institutions professional organizations and accrediting agencies one portion of the STP C paradigm was implemented at the Wake Forest University Baptist Medical Center utilizing standardization of intravenous infusion medications before the new paradigm anesthesia professionals prepared most of the intravenous medications at the point of care for use in the operating room after institution of the new paradigm the pharmacy was responsible for preparing standardized drug infusions and syringes for most drugs this eliminated the need for anesthesia professionals to prepare many of the drugs intended for intravenous delivery multiple concentrations of the same drugs such as phenol Efrain reflect a lack of standardization within a hospital environment after institution of the new paradigm there was only one standardized concentration available for the majority of intravenous medications including vasoactive drugs smart infusion pumps was standardized and limited drug libraries were instituted throughout the hospital it had been standard practice for infusion pumps to be switched upon transfer from the operating room to the intensive care unit because of non-standard concentrations and different types of infusion pumps following the institution of standardized drug concentrations and infusion pumps throughout the hospital the infusion pump now remains with the patient upon transfer from the operating room to the intensive our unit or vice versa there is no longer a need to change the infusion pump or medications finally mandatory training was an essential part of the institution and subsequent success of the new paradigm hospital-wide there were no exceptions all participated institution of this medication preparation and delivery paradigm on a hospital-wide basis illustrates the successful introduction of a process that offers the likelihood of improving medication safety and creating both clinicians satisfaction and operational efficiency in addition standardization in this manner is consistent with the Joint Commission's medication management standard requiring hospitals to standardize and limit the number of drug concentrations available to meet patient care needs a PSF urges anesthesia professionals nurses hospital administrators and pharmacists to consider adoption of those components of the STP C paradigm that offer the likelihood of improving medication safety in their operating rooms as well as hospital wide for successful implementation of the STP C paradigm it's likely that anesthesia professionals will need to surrender some independence and hospitals will need to invest in necessary resources ApS F believes the dividends will be the improvement in medication safety delivery in the operating room this educational video may be viewed on the AP SF website and a complimentary copy of the DVD may be requested by completing the information for

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