Patient Safety--Medications 2

“Curmudge, we could be a lot more authoritative in our discussion of medications if you were a pharmacist.”

“That’s true, Jaded Julie, but when I was younger most drug stores were one-man operations with a small pharmacy in back, a retail section, and a soda fountain in front. I didn’t want to spend my professional career selling Coca-Cola and Band-Aids. Besides, I was always mystified at how a pharmacist could decipher the illegible handwriting on a prescription.”

“Speaking of sources of medication errors, like illegible handwriting, perhaps we should mention some of the system elements that influence safe medication use: (1)
Patient information (allergies, diagnosis)
Drug information
Drug labeling and packaging
Drug storage and distribution
Environmental factors (poor lighting, interruptions)
Staff competency.”

“Problems can occur in each of those areas. In addition, there are several errors of omission on the part of the pharmacist, physician, or patient that can lead to adverse events. These are individual performance deficiencies: (1)
Failure to detect a disease state contraindication
Failure to detect a drug interaction or allergy
Failure to prescribe the correct dose
Failure to monitor drugs with narrow therapeutic indices.”

“Curmudge, an alert patient and a nurse who is up to date in her profession might be able to head off several of these failures.”

“Also with regard to their individual performance, I hope that all health care professionals know and practice the ‘5 rights’ of medication administration.”

“I presume, Curmudge, that you mean the right patient, the right drug, the right time, the right dose, and the right route.”

“What’s this ‘right route’ stuff? Do they need a map?”

“Oh, that means where in the patient you administer the med, like intramuscular (IM) vs. intravenous (IV). That’s almost always indicated, although everyone should already know that you don’t stick a suppository in the patient’s ear.”

“I think we have alarmed our readers sufficiently. Perhaps we should now mention some of the actions that are taken to minimize adverse medication events. These fall into the category of mistake-proofing (2), although there may be ways to circumvent some of them. Perhaps we could call those mistake-less-likely.”

“I read the AHRQ publication, Curmudge, and picked out some of the mistake-proofing examples applied to medications:
· Pyxis systems to control access to medications
· ‘Tall man’ labels with unusual placement of capital letters to distinguish between look-alike or sound-alike meds. CeleBREX and CeleXA are examples.
· Storage of high-risk medications in red containers
· An orange smock saying, ‘Don’t interrupt me,’ for the nurse delivering meds to patients
· Oral syringes that will not fit into IV tubing so that oral meds cannot be administered intravenously
· In-line hooks for hanging IV bags to make it easy to identify which line comes from which bag. This can also be achieved by color coding each line with a cyalume light.
· Computerized physician order entry. Mistake-proofing features depend on the software. Problems with illegible handwriting are eliminated. Note that programs are available for physicians who want to improve their handwriting (3).
· Machine-made unit doses with bar codes to match medication with patient
· Standard abbreviations, acronyms, and symbols. JCAHO has an official ‘do not use’ list, and Affinity’s list of unacceptable abbreviations is shown in Policy 00803.”

“That’s a good list, Julie, but our ultimate goal is to implant a culture of safety in everyone’s brain. We must use Lean tools to continuously improve the safety of every aspect of our medication processes. As stated by Huminski (4), ‘We are perfecting the medication delivery system to be safe for every patient, every time.’”

Affinity’s Kaizen Curmudgeon

(1)http://www.medscape.com/viewprogram/7099_pnt
(2)http://www.ahrq.gov/qual/mistakeproof/mistakeproofing.pdf
(3)http://handwritingsuccess.com
(4)http://blog.hin.com/?p=391