532055
research-article2014
AJMXXX10.1177/1062860614532055American Journal of Medical QualityVanderford et al
Q-Tip
Implementation of Pharmacy to Dose: Reducing Near Miss Medication Errors
American Journal of Medical Quality 2014, Vol. 29(4) 360 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614532055 ajmq.sagepub.com
Cheryl E. Vanderford, MPAS, PA-C,1 Katherine M. McKinney, MD, MS,1,2 and John T. Emmons, PharmD1 James F. Pelegano, MD, MS, Valerie P. Pracilio, MPH, CPPS, and Martin Wegman, Section Editors Medication errors are a threat to patient safety, yet near miss events are frequently underreported. At the Lexington Veterans Affairs Medical Center, medication errors are tracked utilizing the electronic patient event reporting system. Starting in August 2012, the pharmacy department initiated a more robust process to improve reporting of medication errors generated from computerized physician order entry in the computerized patient record system. Analysis of these data revealed that a majority of near miss events were related to antibiotic orders, with a percentage of these near miss events being attributable to inappropriate renal dosing. An interdisciplinary team including pharmacists, physicians, medical informatics, and quality department staff conducted a lean process improvement project utilizing failure modes and effects analysis methods to assess and mitigate near miss medication errors. Inpatient antibiotic orders were targeted for intervention because of the potential severity of an actual dosing error and the relative probability of occurrence given frequent use of these medications. Data analysis revealed the most commonly ordered inpatient antibiotics to be vancomycin, levofloxacin, and piperacillin/tazobactam. Antibiotic order screens without renal dosing parameters and lack of electronically viewable dosing explanations between physicians and pharmacists were identified as primary failure modes. Potential factors affecting this vulnerability included having to exit medication order screens within the electronic record to determine a patient’s renal function, variable methods to calculate renal function, and lack of standardized medication order menus across clinical services. Voice of the customer analysis of inpatient physicians and pharmacists was conducted to define end user expectations. A pharmacy to dose orderable option within the electronic medical record was a common recommendation across services. As a small cycle of change, a pharmacy to dose option for vancomycin was chosen for pilot implementation, given the importance of renally based dosage of this medication. A pharmacy-driven vancomycin-dosing protocol was developed via an iterative process incorporating feedback from physicians and staff pharmacists prior to implementation. A baseline frequency of vancomycin renal dosing errors was established through review of the 3-month time frame prior to pilot implementation. Since implementation, vancomycin-related dosing
errors over a 3-month time frame have been reduced by 94% when compared to the baseline error rate. Postimplementation voice of the customer interviews revealed that pharmacists and physicians felt that the use of pharmacy to dose was both efficient and more accurate than physician-driven dosing of vancomycin. An anonymous postimplementation survey of pharmacy staff also was conducted to assess perceptions of the impact of the pharmacy to dose process upon internal pharmacy workflow. Overall response from pharmacy staff was positive, with pharmacists agreeing that the pharmacy to dose protocol positively affected their workload, improved efficiency, and was successfully implemented. Both physician and pharmacy staff expressed a desire to expand the pharmacy to dose protocol to other medications. Given the success of this pilot with vancomycin, our team now plans to expand the pharmacy to dose orderable option and protocol to include levofloxacin and piperacillin/tazobactam. Continued monitoring of near miss events and active surveillance for unintended consequences will be utilized to guide sustainment. Authors’ Note The contents of this article do not represent the views of the Department of Veterans Affairs or the United States Government.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Ms Vanderford received funding from the VA/NCPS Patient Safety Fellowship. This material is the result of work supported with resources and the use of facilities at the Lexington, KY, VA Medical Center. 1
Lexington Veterans Affairs Medical Center, Lexington, KY University of Kentucky, Lexington, KY
2
Corresponding Author: Cheryl E. Vanderford, Lexington Veterans Affairs Medical Center, 1101 Veterans Drive, C203B, Lexington, KY 40502-2236. Email: [email protected]
Downloaded from ajm.sagepub.com at UNIV OF CONNECTICUT on June 21, 2015
research-article2014
AJMXXX10.1177/1062860614532055American Journal of Medical QualityVanderford et al
Q-Tip
Implementation of Pharmacy to Dose: Reducing Near Miss Medication Errors
American Journal of Medical Quality 2014, Vol. 29(4) 360 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614532055 ajmq.sagepub.com
Cheryl E. Vanderford, MPAS, PA-C,1 Katherine M. McKinney, MD, MS,1,2 and John T. Emmons, PharmD1 James F. Pelegano, MD, MS, Valerie P. Pracilio, MPH, CPPS, and Martin Wegman, Section Editors Medication errors are a threat to patient safety, yet near miss events are frequently underreported. At the Lexington Veterans Affairs Medical Center, medication errors are tracked utilizing the electronic patient event reporting system. Starting in August 2012, the pharmacy department initiated a more robust process to improve reporting of medication errors generated from computerized physician order entry in the computerized patient record system. Analysis of these data revealed that a majority of near miss events were related to antibiotic orders, with a percentage of these near miss events being attributable to inappropriate renal dosing. An interdisciplinary team including pharmacists, physicians, medical informatics, and quality department staff conducted a lean process improvement project utilizing failure modes and effects analysis methods to assess and mitigate near miss medication errors. Inpatient antibiotic orders were targeted for intervention because of the potential severity of an actual dosing error and the relative probability of occurrence given frequent use of these medications. Data analysis revealed the most commonly ordered inpatient antibiotics to be vancomycin, levofloxacin, and piperacillin/tazobactam. Antibiotic order screens without renal dosing parameters and lack of electronically viewable dosing explanations between physicians and pharmacists were identified as primary failure modes. Potential factors affecting this vulnerability included having to exit medication order screens within the electronic record to determine a patient’s renal function, variable methods to calculate renal function, and lack of standardized medication order menus across clinical services. Voice of the customer analysis of inpatient physicians and pharmacists was conducted to define end user expectations. A pharmacy to dose orderable option within the electronic medical record was a common recommendation across services. As a small cycle of change, a pharmacy to dose option for vancomycin was chosen for pilot implementation, given the importance of renally based dosage of this medication. A pharmacy-driven vancomycin-dosing protocol was developed via an iterative process incorporating feedback from physicians and staff pharmacists prior to implementation. A baseline frequency of vancomycin renal dosing errors was established through review of the 3-month time frame prior to pilot implementation. Since implementation, vancomycin-related dosing
errors over a 3-month time frame have been reduced by 94% when compared to the baseline error rate. Postimplementation voice of the customer interviews revealed that pharmacists and physicians felt that the use of pharmacy to dose was both efficient and more accurate than physician-driven dosing of vancomycin. An anonymous postimplementation survey of pharmacy staff also was conducted to assess perceptions of the impact of the pharmacy to dose process upon internal pharmacy workflow. Overall response from pharmacy staff was positive, with pharmacists agreeing that the pharmacy to dose protocol positively affected their workload, improved efficiency, and was successfully implemented. Both physician and pharmacy staff expressed a desire to expand the pharmacy to dose protocol to other medications. Given the success of this pilot with vancomycin, our team now plans to expand the pharmacy to dose orderable option and protocol to include levofloxacin and piperacillin/tazobactam. Continued monitoring of near miss events and active surveillance for unintended consequences will be utilized to guide sustainment. Authors’ Note The contents of this article do not represent the views of the Department of Veterans Affairs or the United States Government.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Ms Vanderford received funding from the VA/NCPS Patient Safety Fellowship. This material is the result of work supported with resources and the use of facilities at the Lexington, KY, VA Medical Center. 1
Lexington Veterans Affairs Medical Center, Lexington, KY University of Kentucky, Lexington, KY
2
Corresponding Author: Cheryl E. Vanderford, Lexington Veterans Affairs Medical Center, 1101 Veterans Drive, C203B, Lexington, KY 40502-2236. Email: [email protected]
Downloaded from ajm.sagepub.com at UNIV OF CONNECTICUT on June 21, 2015
