Las Vegas—Pharmacists can more easily help make improvements in their health care settings by working in multidisciplinary teams, according to a session on safety and quality pearls presented at the American Society of Health-System Pharmacists 2012 Midyear Clinical Meeting.

“We [as pharmacists] sometimes have tunnel vision,” said Lt. Col. Jorge Carrillo, PharmD, the deputy director of the Military Vaccine Agency, in Falls Church, Va., who organized the pearls session. It’s important to work in multidisciplinary teams, and consider several strategies to solve a problem, he told Pharmacy Practice News.

During the session, pharmacists detailed efforts to improve medication and patient safety, ranging from reducing distractions during medication administration and optimizing the delivery of high-risk medications via infusion pumps, to better educating staff on storage requirements for replacement drugs during shortages. For many of the improvement projects described below, pharmacists worked in conjunction with nurses, information technology specialists or other health care workers to effect change.


Less Distractions Equals Fewer Med Errors

Giving nurses protected time to administer medications without interruptions reduced the number of medication administration errors linked to disruptions by half, pharmacists at the Cleveland Clinic have found.

From January to June 2011, researchers observed that 47% of medication administration errors reported through the Cleveland Clinic’s voluntary reporting system for two nursing units were caused, at least in part, by workflow disruptions, according to Alina Bulgar, PharmD, PhD, the hospital’s coordinator of medication regulatory and accreditation services. Each medication administration had an average 4.1 interruptions or distractions such as phone calls, conversations with patients or staff, missing medications or noise.

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The Cleveland Clinic has cut medication distractions in half via the use of signs and badges that signal that drug administration is occurring.

Dr. Bulgar and her colleagues created a set of interventions to reduce distractions and raise staff awareness that medication administration was in progress. The measures, tested in two nursing units, included 45-minute “medication pass time-outs” at common medication administration times (9 a.m., 1 p.m. and 9 p.m.), during which nurses could turn off their wireless phones and have calls triaged by the health unit coordinator and an assistant nurse manager or charge nurse; red badges with the words “medication pass” on red lanyards on the computers on wheels that nurses used during medication delivery; and “do not disturb” signs to be put on patient room doors when nurses were administering medications. The pharmacy team used tape to mark off a “quiet zone” on the floor surrounding automated dispensing cabinets. The team also developed educational resources, including an information sheet for patients and families that explained the medication administration process and asked them to refrain from asking nurses social and personal questions during that time. They also created a medication administration checklist for nurses.

After the intervention, data from January to June 2012 showed that only 20% of medication errors had workflow disruptions as a cause or contributing factor, and each medication administration averaged two interruptions or distractions. The biggest success has been a decrease in “significant interruptions from other personnel,” Dr. Bulgar said. She added that the overall number of medication errors has decreased since implementing the interventions, “although more research is needed to determine if there is a direct correlation.”

five additional units now follow that process, she said, and the pharmacy-nursing team is rolling it out throughout the main hospital and affiliated regional hospitals.


The work was funded by the Cardinal Health Foundation.


Education, Formulary Changes Decrease Naloxone Overuse

A pharmacy-led multidisciplinary team at a small Massachusetts health system has reduced the frequency of narcotic oversedation requiring naloxone administration.

Nicole Clark, PharmD, BCPS, the pharmacy clinical manager for Hallmark Health Systems, Inc., in Medford, a two-community hospital system comprising 340 inpatient beds, and her colleagues noticed an uptick in naloxone usage, from two to five instances per quarter, to 10 instances. In all 10 cases, patients had been receiving hydromorphone for pain.

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“One-size-fits–all” dosing regimens programmed in patient-controlled analgesia units can lead to overuse of narcotics for pain.

A pharmacy-led multidisciplinary medication safety subcommittee that was formed to look into the issue realized that they had “one-size-fits–all” dosing recommendations for patient-controlled analgesia (PCA). The committee’s fix was to establish three dosing groups for morphine, hydromorphone and fentanyl PCAs: patients who were over the age of 64 years, had sleep apnea or weighed less than 50 kg; patients who were opioid-tolerant; and patients not in one of these other groups (the majority of patients). They also created a series of six online education sessions on pain management, with narrated slides, interactive case studies and a podcast. They held a “Pain Day,” offering a half hour of continuing education credit for participation, including games and activities related to pain management. The group also organized a physician grand rounds education session on acute pain management.

The team also recommended a change to the formulary, eliminating 4-mg injections of hydromorphone and adding 1-mg injections of the drug to allow for more incremental dosing. They recommended changing the hydromorphone order strings for physicians to include only the most appropriate doses and frequencies, and posted a visual medication safety alert in each unit that compares dosing of hydromorphone with that of other medications, including morphine, to illustrate the potency differences of the medications. All recommendations were approved by the Pharmacy & Therapeutics Committee before implementation, Dr. Clark noted.

Post-intervention, the health system is averaging seven naloxone events per quarter, and the team is still in the process of making improvements.

Dr. Clark said, “What we thought was going to be a temporary multidisciplinary team has now become a very important group in our health system working toward improving safety and quality.” She added that the team is updating PCA nursing documentation to improve methods of assessing sedation, including utilizing the Pasero Opioid-Induced Sedation Scale (POSS). Once this is completed, the group will incorporate POSS into all pain assessments. The team also is looking at appropriate use of fentanyl patches.


Replacement Drug Log Alerts Staff to Substitutions During Drug Shortages

The pharmacy team at Connecticut’s Bristol Hospital has streamlined their process of ordering and storing replacement drugs during shortages.

The work started following a recent shortage of gemcitabine, when the team found their usual powdered vials of the drug in short supply and ordered a vial in solution as an alternative. Although the product was shipped to the pharmacy on ice, whoever opened the package placed the medication at room temperature. A keen-eyed pharmacy technician caught the error and brought it to clinical manager Brenda Egan, PharmD, BCPS. Unfortunately, the integrity of the product was compromised because of the incorrect storage, so it was thrown out. When Dr. Egan looked at the product, she noticed that the vial in solution had “store in refrigerator” in small letters on the package, whereas their powdered vials had “store at room temperature” in large letters.

Monitoring replacement drugs can be tricky, Dr. Egan noted. Not only might they have different storage requirements, but they also may come in different vial sizes or formulations (powdered vials vs. solutions) or in ampules instead of syringes, or vice versa. Inconsistencies in drug labeling, as evidenced by the gemcitabine issue, also can be problematic.

To address these potential causes of errors, Dr. Egan and her colleagues assigned a purchaser to identify all substitute drugs and signal when they are coming in for delivery, and a pharmacist to take charge of the final verification process. They also created a drug replacement log of the usual drugs and their substitutes, with the substitutes’ concentrations, storage requirements, clinical considerations, caregiver notifications and bar-code information, as well as the need for any education.

Using the chart has become “hard-wired into our routine,” Dr. Egan said. “It’s a very low-tech regimen that has helped us tremendously.”


Near-Miss Tracking Promotes Patient Safety

Tracking near misses that could have resulted in medication errors is helping one hospital pharmacy in Massachusetts fine-tune its operations.

The pharmacy team at Saint Vincent Hospital, in Worcester, wanted to create an environment where pharmacists would feel comfortable reporting near misses and speaking up about safety concerns without fear of being punished, said Jules Trahan, PharmD, a medication safety fellow at the hospital.

Near misses caught on patient floors generally result in a call from the nurses, Dr. Trahan said, but “we hear very little about” issues happening in the pharmacy. She noted that staff members “feel like they will get themselves or their co-workers in trouble. They don’t want to tattle, so they tend to hide those events.”

The pharmacy created a paper near-miss tracker chart, with spaces for days and two- to four-hour time blocks during the week. Pharmacy staff was asked to put a tally mark in the chart each time they caught a near-miss event. Trackers were placed in four areas of the pharmacy: the inventory/medication storage area, the pharmacist workstation, the IV room and the verification area.

To promote the trackers’ importance to staff, leaders used a “Swiss cheese” analogy, demonstrating how each event reported provides an opportunity to study a hole in the pharmacy process and make staff workloads easier. Pharmacy staff members were compliant in using the anonymous charts, Dr. Trahan said, but they expressed frustration at not being able to report what types of errors they caught, so the grids were revised to include check-off boxes for six to eight types of common near-miss events, including inventory/medication storage (medication stocked in wrong bin (look-alike sound-alike drugs), pharmacist workstation (medication ordered for wrong patient), verification area (incorrect strength of correct medication), etc.

The trackers report about 30 near misses a week, Dr. Trahan said. Because they showed more near misses during the evening shift and Mondays and Tuesdays, the pharmacy scheduled additional staff to work those shifts.


Mining Error Data Improves Administration Accuracy

Investigating medication administration errors led leaders at Novant Health to make significant changes in its infusion pump procedures.

Novant Health data from 2010 showed that 20% of medication administration errors were related to infusion pumps, said Elizabeth McGowan Rebo, PharmD, a medication safety manager for Novant, a group of 13 hospitals, 100 outpatient facilities and 364 physician practices in Virginia, North Carolina, South Carolina and Georgia. The pumps did not have wireless upgrade options, had limited drug libraries and dubious dose-range guardrails, were not integrated with medication administration systems, and lacked reporting capabilities. Additionally, there were dosing errors because staff members were recording incorrect patient weights (sometimes because of pound/kilogram mix-ups) or recording height as whatever patients told them rather than verifying it.

Table. Improvements With New Infusion Pump Procedures at Novant Health
Parameter Before Changes After Changes
Rate that high-risk medications delivered via infusion pumps were given in the correct dose at the correct rate under proper safety guidelines 83% 98%
Rate of accurate height and weight measurements 45% 61%

Novant’s corporate medication team set out to improve two parameters: the rate that high-risk medications delivered via infusion pumps are given in the correct dose at the correct rate of administration with providers using proper safety guidelines, and the rate that patients in acute care facilities and group practices have an accurate height and weight recorded if the information is relevant to medication administration.

To improve these parameters, the team updated the health system’s drug libraries, standardized drug concentrations corporation-wide, implemented a nursing-pharmacy double-check for high-risk infusions and conducted bedside education for nurses on the use of pumps. Team members also added a mandatory hard stop to records to indicate how height/weight was measured, and obtained additional tools to record patients’ height and weight accurately.

From August to October 2012, the system improved both parameters (Table). Dr. Rebo noted that the team is still tracking data and is looking to upgrade to wireless pumps.