Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar: Medication Safety – Complex Issues for A

1. Welcome to the • NQF Safe Practices for Better Healthcare • 2009 Update • Webinar: • Medication Safety – Complex Issues for All (Safe Practices 17-18) • Hosted by NQF and TMIT Attendee dial-in instructions: Toll-free Call-in number (US/Canada): 1-866-764-6260 (direct number, no code needed) To join the online webinar, go to: www.safetyleaders.org Online Access Password: Webinar1 (case-sensitive)

2. Welcome and Overview of the Medication Management Chapter of the 2009 NQF Safe Practices Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program Safe Practices Webinar June 18, 2009

3. Panelists Charles Denham Peter Angood Michael Cohen Mary Andrawis Jeffrey Schnipper Patti O’Regan

4. Culture Consent & Disclosure Consent & Disclosure Work Force Information Management & Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices Culture SP 1

5. Culture CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices] • Leadership Structures & Systems • Culture Measurement, Feedback and Interventions • Teamwork Training and Team Interventions • Identification and Mitigation of Risks and Hazards Team Training & Team Interv. ID Mitigation Risk & Hazards Structures & Systems Culture Meas, F.B, & Interv. Consent & Disclosure Consent & Disclosure CHAPTER 3: Informed Consent & Disclosure • Informed Consent • Life Sustaining Treatment • Disclosure • Care of the Caregiver Disclosure Care of Caregiver Informed Consent Life Sustaining Treatment Work Force CHAPTER 6: Medication Management • Medication Reconciliation • Pharmacist Leadership Structures and Systems NEW: • Previous practices including Pharmacist Role, High-Alert Medications, Standardized Medication Labeling & Packaging, and Unit-Dose Medications are bundled into the Pharmacist Leadership Structures and Systems practice. • Medication Reconciliation updated with expanded Additional Specifications and Example Implementation Approaches. CHAPTER 4: Workforce • Nursing Workforce • Direct Caregivers • ICU Care 2009 NQF Report Nursing Workforce Direct Caregivers ICU Care Legend: CHAPTER 5: Information Management & Continuity of Care • Critical Care Information • Order Read-back and Abbreviations • Labeling Studies • Discharge Systems • Safe Adoption of Integrated Clinical Systems including CPOE Information Management & Continuity of Care No Material Changes Labeling Studies Critical Care Info. Material Changes Discharge System CPOE Read-back & Abbrev. New Medication Management CHAPTER 6: Medication Management • Medication Reconciliation • Pharmacist Leadership Role Including: High-Alert Med. & Unit Dose Standardized Medication Labeling & Packaging Med Recon. Pharmacist Systems Leadership High Alert, Std Labeling/Pkg, & Unit Dose CHAPTER 7: Hospital Associated Infections • UTI Prevention • MDRO Prevention • Care of the Ventilated Patient & VAP, • Central Venous Catheter Related Blood Stream Infection Prevention • Surgical Site Infection Prevention • Hand Hygiene • Influenza Prevention Healthcare Associated Infections UTI Prevention MDRO Prevention VAP Prevention Hand Hygiene Influenza Prevention Central V. Cath BSI Prevention Sx Site Inf. Prevention CHAPTER 8: • Wrong Site, Wrong Procedure, Wrong Person Surgery Prevention • Falls Prevention • Organ Donorship • Pressure Ulcer Prevention • DVT/VTE Prevention • Anticoagulation Therapy • Gycemic Control • Contrast Media-Induced Renal Failure Prevention • Pediatric Imaging Condition, Site, and Risk Specific Practices Falls Prevention Organ Donation Anticoag Therapy DVT/VTE Prevention Pediatric Imaging Press. Ulcer Prevention Wrong site Sx Prevention Glycemic Control Contrast Media Use

6. Challenges of Policy Development for Medication Management Peter B. Angood, MD, FRCS(C), FACS, FCCM Senior Advisor, Patient Safety National Quality Forum Safe Practices Webinar June 18, 2009

7. Medication Safety Overview, Evolution, and Current Issues Michael Cohen, RPh, MS, ScD President, Institute for Safe Medication Practices (ISMP) Safe Practices Webinar June 18, 2009

8. Epidemiological ReviewIOM  Preventing Medication Errors • Medications harm too many Americans • At least 1.5 million people per year • Hospitals • 400,000 preventable ADEs per year • About 1 medication error per patient per day • Outpatient setting • Also frequent, though data less solid • 530,000 ADEs/year in Medicare patients

9. Event types reported to Pa-PSRS

10. Hospital Drug Distribution Systems • Pre-1960s - floor stock system • Locked narcotic safes/boxes (keys) with manual counts • 1960s – individual patient prescriptions; 3-to-5-day supply, nurses “poured” own meds • 1970s – unit-dose distribution; IV admixtures • Errors much more visible • More pharmacist oversight of drug distribution process • 1980s-’90s – Clinical pharmacy practice • 1990s – present - automated dispensing, robotics, bar-coding, outsourcing for order review

11. Early Studies

12. Historic events in medication safety

13. Clinical consequences of a product-related error

17. Communication of Drug Information • “Look-alike”/“sound-alike” drug names combined with poor order communication, including during digital transmission • Dangerous abbreviations and dose designations • Suffixes misunderstood or omitted • Confusion related to OTC brand name extensions • Unsafe practices depicted in journal advertising • Name confusion with medical terminology or laboratory nomenclature • Same established name, different substance internationally • More than one trademark for brand item

19. Use of mixed-case (tall-man) characters • Dobutamine 400 mg • Dopamine 500 mg • chlorpropamide 100 mg • chlorpromazine 100 mg • hydralazine 50 mg • hydroxyzine 50 mg • doBUTamine • doPAmine • chlorproPAMIDE • chlorproMAZINE • hydrALAzine • hydrOXYzine

20. Example of error due to lackof Patient Information

21. Sound-alike • Brand names • FEMARA (letrozole) & FemHRT • SEROPHENE (clomiphene) and SARAFEM (fluoxetine) • INVANZ (morphine extended release) or AVINZA (ertapenem injection) • Nonproprietary names • tamoxifen or tomoxetine (now atomoxetine) • fomepizole or omeprazole • torsemide or furosemide Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

22. Some changes to brand name as a result of medication errors • Losec (confused with Lasix) is now Prilosec • Levoxine (confused with Lanoxin) is now Levoxyl • Mazicon (confused with Mivacron) is now Romazicon • Pediaprofen (confused with Pediapred) is now Children’s Motrin • Altocor (confused with Advocor) is now Altoprev • Reminyl (confused with Amaryl) is now Razadyne • Omacor (confused with Amicar) is now Lovaza

23. Nonproprietary Name Changes • amrinone or amiodarone (now inamrinone) • tamoxifen or tomoxetine (now atomoxetine) • fomepizole or omeprazole (fomepizole was 4-methylpyrazole [4-MP] and concern was for confusion with 6-MP [mercaptopurine] • torsemide or furosemide (torsemide was originally torosemide)

24. Oral orders “Read-back” vs. “Repeat-back” • The receiver of the order should write down the complete order or enter it into a computer • Then the receiver should read it back • Receive confirmation from the individual who gave the order

26. Look-alike packaging

29. Lilly insulin color differentiation

30. United States Before and after – both are same strength

31. High-Alert Medications • Small number of medications that have a high risk of causing injury if misused • Errors may or may not be more common with these than with other medications, but the consequences of errors may be devastating

32. Leading Products in Harmful Medication Errors, CY 2005 MEDMARX annual report 2007

36. Medication Errors Reporting Program (MERP) Operated by theUnited States Pharmacopeia in Cooperation with theInstitute for Safe Medication Practices www.ismp.org Pennsylvania Patient Safety Reporting Program ISMP is a federally certified Patient Safety Organization

37. Actionable Items • Be proactive, not reactive. Learn from experience of other organizations. Medication safety officer/team. • Focus on unsafe practices/at risk behaviors (e.g., unlabelled containers, sharing insulin pens, abbreviating drug names, patient weight conversions, etc.) • Implement technologies (smart pumps, bedside bar-code scanning, follow automated dispensing cabinet guidelines, e-Rx, etc.) • Standardize drug concentrations, units of measure, etc. • Encourage error reporting – internal and external (see “ISMP Med Safety Alert! Pump up the volume – tips for increasing reporting. Feb 9, 2006 “) http://www.ismp.org/Newsletters/acutecare/articles/20060209.asp

38. Perspectives on the Importance of the Pharmacist Leadership Safe Practice in the Hospital Environment Mary Andrawis, PharmD, MPH Director, Clinical Guidelines and Quality Improvement American Society of Health-System Pharmacists (ASHP) Safe Practices Webinar June 18, 2009

39. The Pharmacist’s Mission • To help patients make the best use of medicines • Extensively trained to ensure safe and evidence-based use of medications • Expanded role to meet the need for comprehensive medication management

40. Literature clearly demonstrates improved patient outcomes, fewer adverse events, andreduced costs when pharmacists are involved in care.

41. Safe Practice 18: Pharmacist Leadership Structures and Systems “Pharmacy leaders should have an active role on the administrative leadership team that reflects their authority and accountability for medication management systems performance across the organization.”

42. Health-System Administrative Team Pharmacy Leader

43. Items of Impact on Care • Organizational decision-making. Involve pharmacy leaders with integral system decisions. • Direct communication.Engage pharmacy leaders with the organizations’ leadership team and the Board. ASHP Statement on the Roles and Responsibilities of the Pharmacy Executive [PDF]

44. Items of Impact on Care • Medication Safety Committee.Create a committee led by pharmacy leaders to review errors. • Walk-rounds.Evaluate medication processes and get front-line staff input on medication safety. ASHP Guidelines on Preventing Medication Errors in the Hospital [PDF]

45. Items of Impact on Care • Technology Readiness Planning.Call on pharmacy to play central role in planning and implementation of technologies that affect medication use. ASHP Statement on Bar-Code-Enabled Medication Administration Technology [PDF]

46. Items of Impact on Care • Pharmacists on Clinical Teams.Place clinical pharmacists on rounds to optimize safe and evidence-based selection and monitoring of medications. ASHP–SHM Joint Statement on Hospitalist–Pharmacist Collaboration [PDF]

47. Utilize your pharmacy leaders to get: • better patient outcomes • fewermedicationerrors, and • lowercosts. • Examples of Pharmacists’ Impact

48. Where the Rubber Meets the Road: Implementation of Medication Reconciliation at the Practitioner Level Jeffrey Schnipper, MD, MPH, FHM Director of Clinical Research, BWH Hospitalist Service; Associate Physician, Division of General Medicine, Brigham and Women's Hospital; Assistant Professor of Medicine, Harvard Medical School Safe Practices Webinar June 18, 2009

49. Goals of This Talk • To review the experience at Partners regarding medication reconciliation • Which patients are at highest risk • Benefits of Health Information Technology-based solutions • Other lessons learned • To discuss various ways to approach solutions for medication reconciliation

50. Classifying and Predicting Errors of Inpatient Medication Reconciliation Jennifer R. Pippins, MD, Tejal K. Gandhi, MD, MPH, Claus Hamann, MD, MS, Chima D. Ndumele, MPH, Stephanie A. Labonville, Pharm D, BCPS, Ellen K. Diedrichsen, Pharm D, Marcy G. Carty, MD, MPH, Andrew S. Karson, MD, MPH, Ishir Bhan, MD, Christopher M. Coley, MD, Catherine L. Liang, MPH, Alexander Turchin, MD, MS, Patricia McCarthy, PA, MHA, and Jeffrey L. Schnipper, MD, MPH J Gen Intern Med 2008;23(9):1414-22