1 Medication Error Reduction Plan Program - Patientsafetycouncil.org

Medication Error Reduction Plan
Program
Loriann De Martini, Pharm.D.
Chief Pharmaceutical Consultant
Michael Alexander, M.Sc.
Pharmaceutical Consultant II
Michael Alexander
MERP Task Force Lead
Presentation Goals
• Provide an update on MERP program
• Provide information which may help you to
decrease medication errors
• Relate some important findings during MERP
surveys
• Provide overview of Med-SET project
• Provide CDPH with recommendations for
medication safety focus areas for next triennial
survey cycle starting January 2012
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MERP Survey Summary
January 2009 – December 2011
• 374 – Hospitals to be surveyed
• 368 – Exited surveys (98 %)
• 346 – Survey data received (94 %)
• 323 – Noted deficiencies (93 %)
• 23 – In compliance ( 7 %)
Data as of 01/23/2012
Common Deficiencies
• 68 % - Develop and implement P&Ps for safe
and effective use of medications [CCR 70263(c)(1)]
• 63 % - Conduct an annual review to assess
effectiveness of the implementation of MERP
[HSC 1339.63 (e)(2)]
• 46 % - Identify weakness or deficiencies that
could contribute to errors [HSC 1339.63 (e)(1)]
• 45 % - Include a multidisciplinary process to
regularly analyze all errors [HSC 1339.63 (e)(6)]
Issues:
• Fentanyl patches
• Droperidol
• Insulin
• IV infusion devices
• Smart pumps; PCAs
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Issues:
• Automated Dispensing Cabinets
• Discrepancies, overrides, profiling (e.g., Radiology,
PACU, ED)
• Emergency medications (MH, carts, boxes)
• Sealed, list of meds, exp. date
• Refrigerators (storage); warmers in OR
Issues:
• Lack of policies and procedures
• Policies and procedures not followed
• Recent medication deaths: heparin, morphine,
warfarin, fentanyl
Issues:
• Drawing up emergency medications correctly
• Preprinted orders – include parameters for dose
• Preprinted orders – include parameters for dose
changes
(e.g., norepinephrine, nitroprusside)
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Expired Drugs
• Operating room areas
• Transport boxes, kits
• Emergency department (succinylcholine?)
• Clinics
• Unit inspections
Malignant Hyperthermia
• Do nurses, pharmacists, physicians know how
to treat MH?
• Do nurses, pharmacists, physicians know where
to get drugs to treat MH?
• Do you have all of the MHAUS recommended
drugs in your cart?
Loriann DeMartini
Chief Pharmaceutical Consultant
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Department of Health and
Human Services
OFFICE OF
INSPECTOR GENERAL
ADVERSE EVENTS IN
HOSPITALS:
NATIONAL INCIDENCE
AMONG MEDICARE
BENEFICIARIES
11/2010
How the numbers add up
• 15,000
• 180,000
• 44
• 324
• Number 1 cause of adverse events
• 50
Department of Health and
Human Services
OFFICE OF
INSPECTOR GENERAL
HOSPTIAL INCIDENT
REPORTING
SYSTEMS
DO NOT CAPTURE
MOST PATIENT HARM
January 2012
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Office of Inspector General Report
• 14% of events are reported
• Reason – don’t see the outcome as an error
• 11% of events that led to death reported
• Medication = 38% of adverse events
• 13% reported
• Changes in mental status (delirium); excessive
bleeding, hypoglycemic event
Can Medication Safety System
Vulnerabilities be identified
proactively and objectively?
Medication Safety Event Tracking
Med SET
Launched September 2011
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Med SET
• Objectives/Goals:
• Collect, quantify, and analyze medication safety data.
• Goals:
• Identify medication safety system vulnerabilities and
their trends
• Use Med SET data to inform and educate internal and
external providers on medication safety issues
Med SET
• Data extracted from Statement of Deficiencies
• Long term care and hospitals
• Used MERP defined systems or procedures and
expanded - internal use only
• 12 categories with 85 sub-categories
• Compare different facility types
• Present level of harm
MERP
1. Prescribing
2. Prescription order
communication
3. Product labeling
4. Packaging and
nomenclature
5. Compounding
6. Dispensing
7. Distribution
8. Administration
9. Education
10.Monitoring
11.Use
Med SET
1. Prescribing
2. Prescription order communication
3. Product labeling, packaging and
nomenclature
4. Compounding
5. Dispensing
6. Distribution
7. Administration
8. Monitoring
9. Competency
10.Use
11.Technology
12.Transitions in care
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Med SET: Distribution
1. Expired, Unusable, or Recalled
2. Controlled Substances Accountability
3. High Risk/High Alert
4 Automated Dispensing Cabinet (ADC)
4. Automated Dispensing Cabinet (ADC)
5. Drug Storage
6. Accessibility of Drugs
7. Drug Storage Temperature
8. Emergency Kits and Carts
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Med SET: Next Steps
• Seek input from external stakeholders – Focus
Groups
• Finalize process
• Disseminate findings
• Develop recommendations to reduce system
vulnerabilities based on scope and severity
MERP Program
A story of collaboration
Collaboration: Its working…So
what's next?
What can we do to help you
reduce/eliminate medication errors?
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