Conference Report Published by CareFusion Center for Safety and Clinical Excellence
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- Bu səhifədəki naviqasiya:
- Verbal order not read back
- Figure 2. Old and New Labeling for IV Heparin Figure 3. Use of Abbreviation “U” for “units” Figure 4. This is your Brain on Call
- New Admission! Mrs. Smith fell Angry patient wants "real doctor" LOOK GOOD ON ROUNDS
- Figure 4. Telephone order not read back
- Improper manufacturer labeling
- Preservatives
- ISMP Medication Safety Self Assessment®
- Overall medication errors vs. anticoagulant errors
- Averted programming errors
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Unsafe abbreviations Use of “U” for "unit" can lead to 6U being confused with 60, 4U with 44 and 25cc/hr with 25 units/hr (Figure 3). Confusing 1000U with 10,000 can easily lead to a 10-fold over- dose. This type of mistake can be prevented by use of a smart pump drug library.
“Read back” is one of the National Patient Safety Goals. The order shown in Figure 4 was transcribed so that “10U” was legible as “10 units,” but the order was not read back to the prescriber. Read back, it would have been apparent that for a patient with a blood sugar of 324, the correct medication would be insulin, not heparin.
Confusing “HEPARIN” and “HESpan” is common. Hetastarch, the generic name for Hespan, can be confused if the product is referred to as Hespan. The “h,” “e” and “p” are all in the same sequence. If a bag of heparin is accidentally placed in the storage location for hetastarch (Hespan), which is used for volume replacement for shock, selection of the wrong bag could lead to a fatal error. A patient who needs hespan can be in shock because of hemorrhaging. Administering heparin to such a patient is fatal. The error has also happened the other way around, i.e., hetastarch administered in place of heparin.
Vials of 100-unit heparin flush and 100- unit insulin are often found together on top of medication carts and counters, contribut- ing to mix-ups. Someone could mistakenly pick up the wrong vial, causing a fatal event. There is a need to minimize or eliminate the availability of heparin flushes, to use unit- dose heparin syringes and to standardize on a single concentration for newborns where it is used for vascular catheter patency, e.g., a 1-unit syringe. Figure 2. Old and New Labeling for IV Heparin Figure 3. Use of Abbreviation “U” for “units” Figure 4. This is your Brain on Call Discharge Mr. Jones urinate > daily Grand rounds in 10 min! Coffee deficiency Salvage marriage Check ptt, adjust UFH gtt Check GFR before DVT ppx Notice low plts on exaparin RN calling about colace Conference presentation Call rheum consult Follow duty hours Discharge prescriptions New Admission! Mrs. Smith fell Angry patient wants "real doctor" LOOK GOOD ON ROUNDS FINISH NOTES BEEP! BEEP!
BEEP! BEEP!
BEEP! Review medications Why is Nunez altered?
Executive Summary Conference Report
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Improper manufacturer labeling
A label can show the concentration of drug per mL but not indicate the total amount of drug in the vials. If a 10-mL vial is labeled "5,000 units/mL," a nurse may read this as a 5,000 unit total, when it actually totals 50,000 units.
Heparin containing benzyl alcohol as a pre- servative has caused toxicity in newborns. Dosing errors Dosing errors can occur if patient weight is not estimated or not verified or if an incor- rect nomogram used, e.g., acute cardiac syn- drome vs. DVT vs. stroke. Many calculation errors are listed in the reports sent to ISMP. These include math- ematical errors in determining the volume of heparin to use for a bolus or the rate of infusion and miscalculation of the amount of heparin to add to total parenteral nutrition (TPN) solutions. Dosing errors with infusion pumps can occur when an infusion pump is used to deliver a bolus dose and then not adjusted to a continuous infusion rate, (e.g., admin- istering a 5,000- to 10,000-unit bolus by increasing the infusion rate but forgetting to change the rate back to a 1,000 unit/hr infusion). Other pump programming errors include programming concentration or rate incorrectly. Fortunately, the introduction of smart pumps has helped to address these types of errors. ISMP Medication Safety Self Assessment®
A free ISMP Medication Safety Self Assessment® for Antithrombotic Therapy for Hospitals is available at www.ismp.org 2 .
More than 400 hospitals completed this self- assessment during the first quarter of 2008. The self-assessment was put together with experts from all over the country in hema- tology, pharmacy practice and nursing. The text lays out the system enhancements that need to be in place, system issues that need to be addressed in order to deliver heparin safely. Hospitals can enter their data, moni- tor it over time and compare their perfor- mance to organizations nationwide.
Heparin errors are both common and a matter of public concern. There are many ways to improve the safety of heparin use in hospitals. The healthcare industry needs to be proactive, not reactive, in taking action to address the many issues that contribute to heparin errors. The necessary informa- tion is available from many sources. Paying attention and acting on this information will play a major role in addressing problems and improving the safety and quality of heparin therapy and patient care.
1. Pederson CA, Gumpper KF: ASHP National survey on informatics: Assessment of the adoption and use of pharmacy informatics in US hospitals. Am J Health Syst Pharm, 2008; 65:2244-64. 2. ISMP Medication Safety Self Assessment for Antithrombotic Therapy in Hospitals. Retrieved October 22, 2008 from http://www.ismp.org/selfassessments/ asa2006/Intro.asp. 3. ISMP websites: http://www.ismp.org and http://www. consumermedsafety.org.
PROCEEDINGS
9th Invited Conference: Improving Heparin Safety 13
Executive Summary Conference Report Key points • Adverse drug event surveillance at Brigham and Women’s Hospital (BWH) showed that in cardiovascular patients, anticoagulants are the drug class most frequently associated with adverse drug reactions and the second most frequent cause of medication errors. • Unfractionated heparin (UFH) was associated with the greatest number of anticoagulant medication errors, with infusion pump and parenteral delivery problems as the most frequent causes of these errors. • Of the anticoagulant errors, 1.5% of the events prolonged hospitalization and 6.2% required medical intervention. • Continuous quality improvement (CQI) data from smart infusion devices showed that averted UFH overdoses accounted for 29.0% of intercepted UFH medication errors. Dosing errors ranged from 30-999 mL/hr (3,000-99,900 units/hr). Averted UFH underdoses accounted for 20.6% of intercepted UFH medication errors. Dosing errors ranged from 0.1-2.7 mL/hr (10-270 units/hr). • Almost two-thirds of UFH averted errors occurred between noon and 4 p.m., or close to the time of the principal nursing-shift change at 3 p.m. Averted errors were less common on Fridays and during weekends. • For those facilities using smart pump technology, CQI data of infusion-related medication errors should be reviewed promptly to identify opportunities to improve anticoagulant medi- cation safety. Adverse drug events (ADE) consist of adverse drug reactions (ADR) and medication errors that result in harm. ADEs can increase costs, generate adverse publicity, compro- mise patient trust and demoralize hospital staff
1-7 . Analysis of ADEs in specific disease- state populations or medication classes in the hospital setting has been limited 8-12 .
Anticoagulation in the hospitalized patient is cited as frequently being associated with medication errors 3-5
. As part of the Drug Safety Surveillance Program at BWH, ADEs in cardiovascular patients were reviewed, errors with anticoag- ulant medications analyzed and the impact of smart pump technology evaluated 12-14 . Smart pumps with dose-error-reduction software (DERS) may reduce the number of these med- ication errors.
In the cardiovascular patients reviewed, ADRs and medication errors occurred with equal frequency (51.1% and 49.1%, respec- tively). Anticoagulants were the drug class most frequently associated with ADRs includ- ing elevations in laboratory monitoring tests, thrombocytopenia and hemorrhage. Anticoagulants were the second most fre- quent source of medication errors 12 . A review of all anticoagulant errors showed that antico- agulants accounted for 1.72 medication errors per 10,000 patient days 13 . Anticoagulation therapy accounted for 67% of anticoagulant medication errors, while 33% were associated with prophylaxis.
Among anticoagulant drugs, unfraction- ated heparin (UFH) was associated with the greatest number of events followed by war- farin, low molecular weight heparin (LMWH), argatroban and lepirudin. The medication error rate for anticoagulants in general was 1.67 per 1,000 patients treated and for UFH, 1.27 events per 1,000 patients treated. Wrong rate or frequency were the most commonly reported errors associated with anticoagulant administration, and most of these were asso- ciated with UFH administration. Infusion pump and parenteral delivery problems were the most frequent proximate cause of anticoagulant medication errors (Figure 1). These errors were only associ- ated with heparin administration. While no deaths were attributed to any of the anti- coagulant errors, 1.5% of the events pro- longed hospitalization and 6.2% required medical intervention. Many events required an increase in laboratory monitoring but caused no patient harm. Heparin Medication Safety: Impact of Smart Infusion Technology John Fanikos, RPh, MBA, Assistant Director of Pharmacy, Brigham and Woman’s Hospital, Boston, MA
Executive Summary Conference Report
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Averted programming errors The Alaris® System with Guardrails® soft- ware from CareFusion Health (formerly known as the Medley™ Medication Safety System) was implemented at our hospital. This is a smart (computerized) infusion device with a hospital-determined drug library and dose- error-reduction software (DERS). The software drug library contains a list of parenteral medi- cations, their admixture concentrations and approved dosage ranges. If an infusion were programmed for an IV infusion rate or dose that exceeded approved ranges, the soft- ware would generate an alert that must be addressed before infusion could begin. Averted errors were identified by continu- ous quality improvement (CQI) data show- ing that a clinician responded to an alert by reprogramming or cancelling and infusion. Over a 16-month period, CQI logs in the safety software documented 7,395 averted errors, 858 (11.6%) of which were triggered by anti- coagulant therapy 14 . Of 14,012 heparin doses administered to 3,674 patients, UFH infusion programming in 246 patients generated 501 alerts that were subsequently reprogrammed or the infusion cancelled, i.e., averted errors. “Dose Above Maximum” overdoses accounted for 29.0% of UFH averted errors, and “Dose Below Minimum” underdoses, for 20.6%. UFH averted overdoses ranged from 30-999 mL/hr (3,000-99,900 units/hr) and averted under- doses from 0.1-2.7 mL/hr (10-270 units/hr). The infusion safety software captured all cases of reprogramming in response to an alert (Figure 2). CQI data showed a 100- fold potential overdose in 40 averted errors (28.5%), 10-fold potential overdose in 40 averted errors (28.5%) and a greater-than-100- fold potential overdose in 10 (6.5%) averted errors. A 100-fold potential underdose would have occurred in 39 (25.2%) and a 10-fold potential underdose in 26 (16.8%) averted errors. Programming errors were frequently duplicated. In 72.8% of averted errors, one alert was sufficient to have the user reprogram the device. However, in 27.2% of averted errors, the user repeated the error in response to the alert, i.e., reprogrammed the device with the same incorrect entry. The highest percentage (18.2%) of avert- ed errors occurred between 2 p.m. and 4 p.m., and the next-highest (12.7%) between noon and 2 p.m. (Figure 3). These periods coincide with the nursing shift change at 3 p.m. Averted errors were equally common during weekdays Monday through Thursday and had the lowest occurrence on Fridays and during weekends. Discussion Among cardiovascular patients, ADRs and medication errors are most commonly asso- ciated with routinely utilized medications. Anticoagulant therapy, specifically UFH, was a common culprit and perhaps the best tar- get for error-prevention strategies and early recognition of ADRs and medication errors. UFH’s broad indications, widespread use, laboratory monitoring and frequent dosing changes make ADEs a common occurrence 9-10
. CQI data showed that heparin medication errors occurred most commonly during drug administration. Infusion device programming errors were identified as the most frequent cause of heparin errors, which influenced the decision to purchase smart infusion devices. Following implementation of these devices, CQI data generated by the safety software showed that programming errors involving incorrect infusion rates or doses are common. Possible explanations for incorrect program- ming included transcription errors associ- ated with misplaced zero(s) and/or decimal points, and transposition of rate and dose. CQI data showed that smart infusion technology helped to avert such errors, thereby reduc- ing opportunities for anticoagulation over- or underdosing. A recent study has shown the difficulties in achieving and maintaining therapeutic anti- coagulation with UFH 15 . Smart infusion tech- nology may help to achieve these goals by helping to alert staff to incorrect infusion rates and doses. A recently published, prospective, randomized, time-series trial assessed infu- sion safety devices in critically ill patients. Investigators concluded that the smart pumps could detect IV medication errors and poten- tial ADEs 16 .
between 2 p.m. and 4 p.m., a period associ- ated with a relatively high rate of admis- sions and transfers, nursing shift change and typically the height of medical staff prescrib- Infusion pump
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10% 5% 0% 23% 19% 13% 12% 8% 8% 3% 3% 2% 2% 2% 2% 2% Pe rc en t Cause Figure 1. Causes of Anticoagulant Errors 15
Executive Summary Conference Report 9th Invited Conference: Improving Heparin Safety ing. Averted errors occurred with equal fre- quency during weekdays but with less fre- quency on Fridays and during weekends. Past studies have found higher medication error rates at the time of hospital admission and during transfer between facilities. 17-18
Recent studies have suggested a higher patient mortality rate on weekends and cor- related nurse staffing levels to quality of care. 19-20
More research is required to deter- mine possible associations between these variables and effective drug use, especially with complex medications such as antico- agulants.
CQI data from BWH smart pumps provide a real-life illustration of IV UFH-related poten- tial ADEs occurring during the routine care of patients and may provide guidance for resource allocation to improve practice to pre- vent or avoid future events. Smart pump CQI data on infusion medication errors should be reviewed promptly to identify opportunities for rapid response to improve anticoagulant medication safety.
1. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34. 2. Chyka PA. How many deaths occur annually from adverse drug reactions in the United States? Am J Med 2000;109:122-30. 3. Johnson JA, Bootman JL. Drug –related morbidity and mortality: A cost of illness model. Arch Intern Med 1995;155:1949-56. 4. Bates DW, Spell N, Cullen DJ, et al. The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. 5. Claussen DC, Pestotnik SL, Evans RS, et al. Adverse events in hospitalized patients. Excessive length of stay, extra costs and attributable mortality. JAMA 1997;277:301-6. 6. Grant SM. Who’s to blame for tragic error? Am J Nurs 1999; 99 (9). 7. Brink S. 1995 best hospitals. Tragedy at Dana-Farber. US News & World Report 119(4): 53-4, 56, 1995 Jul 24. 8. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48. 9. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114-20. 10. Simpson JH, Lynch R, Grant J, et al. Reducing medica- tion errors in the neonatal intensive care unit. Arch Dis Child Neonatal Ed 2004;89:480-2. 11. Mehta RH, Alexander JH, Van de Werf F, et al. Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. JAMA 2005; 293:1746-50. 12. Fanikos J, Cina JL, Baroletti S, et al. Adverse events in hospitalized cardiac patients. Am J Cardiol 2007; 20:1465-9. 13. Fanikos J, Stapinski C, Kucher N, et al. Medication errors associated with anticoagulant therapy in the hospital. Am J Cardiol 2004; 94:532-5. 14. Fanikos J, Fiumara K, Baroletti S, et al. Impact of smart infusion technology on administration of anticoagu- lants (unfractionated heparin, argatroban, lepirudin, and bivalirudin . Amer J of Cardiol 2007;(99);7:1002 - 5. 15. Hylek EM, Regan S, Henault LE, et al. Challenges to the effective use of unfractionated heparin in the hospital- ized management of acute thrombosis. Arch Intern Med 2003;163:621-7. 16. Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med 2005;33:522- 40. 17. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admis- sion. Arch Int Med 2005; 165:424-9. 18. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuation in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Int Med 2004; 164:545-50. 19. Bell CM, Redelemeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001;345:663-8. 20. Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002;346:1715-22. Yüklə 1 Mb. Dostları ilə paylaş:
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