Clinical Toxicology
ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20
Prevention of adverse drug events B. Farmer To cite this article: B. Farmer (2014) Prevention of adverse drug events, Clinical Toxicology, 52:6, 573-578, DOI: 10.3109/15563650.2014.909602 To link to this article: http://dx.doi.org/10.3109/15563650.2014.909602
Published online: 16 Apr 2014.
Submit your article to this journal
Article views: 257
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ictx20 Download by: [Ryerson University Library]
Date: 11 October 2016, At: 07:26
Clinical Toxicology (2014), 52, 573–578 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2014.909602
PROCEEDING OF THE 2013 AACT SYMPOSIUM ON ADVERSE DRUG EVENTS
Prevention of adverse drug events B. FARMER Division of Emergency Medicine, Weill-Cornell Medical College, New York, NY, USA
tions, fact sheets, toolkits, and newspaper articles related to best practices for improving specific aspects of patient and medication safety. As a patient safety expert, this is my “go-to” search tool when I am trying to find literature and other information related to patient safety. It is well organized and easy to search with “classic” articles at the top of each search. National experts (Michael Cohen from ISMP, Pat Croskerry, Peter Pronovost of the Central Line Checklist, David Bates, Tejal Gandhi, president of the National Patient Safety Foundation, amongst many others) serving on the editorial board and advisory panel for AHRQ Patient Safety Network chose the material presented on this website, including the “classic” articles/tools. The collection on this web site includes information from the Institute of Medicine, the Institute for Healthcare Improvement, the Institute for Safe Medication Practices, the Joint Commission, and many others. Initially, articles in the “Medication Safety” heading under the “Medication Errors/Preventable Adverse Drug Events” subheading were reviewed for common themes for error prevention based on each step of the medication process. Items and articles referring to medication reconciliation, epidemiology, error reporting, and analysis were not reviewed. The initial search of AHRQ’s Patient Safety Network’s Collections revealed 2462 items (1725 journal articles) under the Medication Safety heading. There were 3 subheadings under medication safety. The subheading of interest was Medication Errors/Preventable Adverse Drug Events, with 1748 items (1345 of the items were journal articles). There were 330 items (279 journal articles) related to ordering/ prescribing errors, 44 items (30 journal articles) for transcription errors, 105 items (73 journal articles) for dispensing errors, 379 (285 journal articles) for administration errors, and 24 items (20 journal articles) for monitoring errors and failures. Titles of these papers were reviewed in search of themes. Review of prevention of ordering/prescribing errors and transcribing errors revealed the following preventative method themes: use of computerized prescriber order entry (CPOE),3–5 use of decision support with CPOE,6,7 and use of clinical pharmacists.8–13 Review of articles related to the prevention of dispensing errors revealed the following themes: use of bar code technology14–18 and use of automated dispensing cabinets (ADCs).19,20 Review of
Background Adverse drug events (ADEs), defined as an injury involving medication use, occur commonly. ADEs include adverse drug reactions and medication errors. An adverse drug reaction is an adverse effect produced when using the drug correctly and is also known as a drug side effect. A medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”1 Medication errors are also classified as preventable ADEs. When ADEs do not result in patient injury, they are considered near misses or potential ADEs. Each part of the medication process has been targeted in order to prevent ADEs and potential ADEs. Prescription, transcription, dispensing, administration, and monitoring are the steps of the medication process. By targeting each one, the “rights” of medication administration are followed and safety is improved. The rights of medication administration include the right patient, drug, dose, route, time, and indication. The patient is then monitored for the right response.2 The purpose of this paper is to review and discuss some measures to prevent ADEs. It is based on my lecture from the American Academy of Clinical Toxicology Pre-Symposium at North American Congress of Clinical Toxicology 2013, “Adverse Drug Event Prevention – What Works?” and on my work on patient and medication safety. It is, therefore, not a complete review. This commentary is meant to provoke interest in learning more about the prevention of ADEs. Some topics to improve medication safety, such as improved medication reconciliation, will not be discussed. The Agency for Healthcare Research and Quality’s (AHRQ’s) Patient Safety Network collection and safety literature (psnet.ahrq.gov/collection.aspx) was searched for common preventative measures. The nation’s experts support this collection to improve patient safety, the medication process, and to prevent ADEs. This comprehensive web site contains evidence-based publications, clinical guidelines from safety, quality, and regulatory organizaReceived 8 March 2014; accepted 24 March 2014. Address correspondence to Dr. Brenna Farmer, Division of Emergency Medicine, Weill-Cornell Medical College, 525 E 68th Street, M-130, New York, NY 10065, USA. E-mail: [email protected]
573
574
B. Farmer
articles related to the prevention of administration errors revealed the following preventative techniques: use of bar code technology,14–18 use of intelligent infusion devices,21,22 and limiting interruptions.23,24 Review of articles related to monitoring errors and failures focused on the preventative techniques of computerized notices to remind practitioners about lab monitoring.25 Some themes didn’t fit into a specific part of the medication process, usually because they addressed multiple parts of the medication use process, including educational initiatives,26,27 and communication and teamwork.28–30 Therefore, ADE prevention can be broken down into the following themes: technological solutions, use of clinical pharmacists, communication/teamwork, and education initiatives. Technological solutions Technological solutions can be used for each part of the medication process to target different errors and improve medication safety. These solutions will be discussed in the order that they would appear during the medication administration process, beginning with CPOE. CPOE incorporation into the electronic health record leads to improvements and prevention of some errors at the prescribing phase of the medication process. It removes the need to interpret prescriber handwriting, as every order is typewritten, thereby, also reducing errors at the transcription phase of the medication process. Prescribing errors are reduced by 50–55% when CPOE is used.3–5 However, CPOE does not prevent human error in order entry. Such order entry errors include entry of weight in pounds instead of in kilograms leading to incorrect weight-based dosing of medications and incorrect entry of creatinine clearance leading to improper dosing of renally eliminated medications. New errors can also result from CPOE. Screen arrangements of drugs may lead to error as the most commonly prescribed drug may not appear at the top of the list, leading to providers choosing incorrect medication, incorrect dosage, or formulation.31 Examples include having continuous infusions listed before single or intermittently dosed medications or having long-acting formulations listed before short-acting formulations. In order to prevent look-alike/sound-alike prescribing errors, some CPOE systems use Tall Man lettering. Tall Man lettering is the process of capitalizing portions of letters that differ among orthographically similar drug names. For example, clonazePAM (klonoPIN®), cloNIDine, and cloZAPine would be written with Tall Man lettering in the CPOE.32 Use of Tall Man lettering is also recommended for pharmacy-generated labels, shelf labels, ADC selection screens, intelligent infusion pump screens, and for electronic Medication Administration Records (eMAR).32 Decision support is incorporated into CPOE. It usually means that a large database of medication information is available to aid order entry. Allergies and allergy crossreactions (e.g., a patient with penicillin allergy being prescribed a cephalosporin) may be checked, as well as possible drug interactions. Decision support also evaluates for
appropriate medication use, such as with the use of Beers’ Criteria for geriatric patients.7 While Beers’ Criteria has its shortcomings, other criteria/tools such as START and STOPP have not been studied as part of decision support for CPOE. These large databases can be individualized for hospital systems and can reflect the formulary of that system for both the inpatient and outpatient setting. Prescribers are alerted when a problem is identified. Depending on the sensitivity chosen by the hospital system, these alerts can fire too often, leading to alert fatigue. Providers start answering whatever they need to so that they “blow-by” or bypass the alert, without reading it, to get whatever order they want.6 Commonly, these databases may not be up to date, or lack dosing for a specific indication, such as antidote dosing. Prescribers that use hand-held devices can download other decision support tools, such as pharmacopeias, that may not put safe use warnings, contraindications, or adverse events on a screen that they will use to determine a prescribing dose, as has been shown with opioids.33 Of note, decision support can also be used to ensure adequate monitoring of patients taking medications that require laboratory checks for safe use (e.g., warfarin, potassium-wasting diuretics, cholesterol-lowering medications, and many others). A systematic review (excluding monitoring of anticoagulation) found that the laboratory alert process improved monitoring of medications at sites with lower baseline monitoring rates and when other team members such as pharmacists, not just prescribers, were targeted to receive monitoring alerts.25 ADCs with brand names such as Pyxis® and Omnicell® are storage cabinets holding unit- or single-dose medications. ADCs are often used in conjunction with CPOE and barcode medication administration (BCMA), but can also be used alone. To obtain a medication from the cabinet, a patient’s name must be selected followed by the medication needed. Prior to the medication being available for dispensing, a pharmacist will usually verify the drug order as appropriate. In a neonatal intensive care unit, ADCs reduced monthly dispensing errors from 5 to 0.19 Additionally, ADC display screens list medications in alphabetical order and use Tall Man lettering, as described earlier, to reduce the risk of look-alike/sound-alike errors. However, errors can be introduced into medication administration with this technology. Sometimes the machines have small, difficult-to-read screens, with poor resolution, and a medication’s full name may not be visible on the display screen. If Tall Man lettering is not used, look-alike errors can occur. If a drug is on the “override” list, a written physician order is not required to dispense the medication (e.g., in emergency situations such as giving D50W for hypoglycemia) and a pharmacist does not verify the order to ensure order accuracy and appropriateness. By removing the safety check of a pharmacist, a patient can be dispensed an incorrect drug. Additionally, the drawers for ADCs have to be stocked manually. If a drawer is stocked with an incorrect medication or a look-alike medication, dispensing errors can occur.20 Examples of this type of human error occurred with the heparin mix-ups at Indianapolis and in Los Angeles with Dennis Quaid’s newborn twins.34,35 Clinical Toxicology vol. 52 no. 6 2014
Prevention of adverse drug events 575 BCMA can be used alone or in conjunction with ADCs and other technologies to ensure the rights of medication administration. It requires a barcode on the unit dose medication and a barcode on the patient’s identification bracelet be scanned. In the neonatal intensive care unit, barcode administration reduced all administration errors by 47– 50%.17 Additionally, high-alert medication administration errors were reduced with the use of barcode administration by reducing opioid administration errors in a neonatal intensive care unit .18 Once they are familiar with the workflow using BCMA, nurses find that BCMA reduces the amount of time that they spend in administering medications. They are able to reallocate that extra time to other direct nursing patient-care.14 Unfortunately, as with the other forms of technological safety solutions, new errors can be introduced. For barcode administration to work properly, a drug has to be labeled correctly with a barcode and the label must be readable by the barcode scanner. If a drug is labeled incorrectly, a wrong drug administration may occur. If the scanner cannot read the drug’s barcode, the scanner will produce an error message and a nurse may have to find a “workaround” in order to administer the drug to the patient. Problems arising from the inability to read barcodes on medications and patients’ identification bands are known to be deterrents to the implementation of BCMA. Workarounds with BCMA, such as nurses scanning the medications at the computer cart, rather than at the bedside, or carrying multiple patients’ medications around after scanning at the medication cart, could lead to wrong patient-wrong drug administration.16 For multidose vials, some workarounds could lead to new errors. These workarounds include taking the barcode off the multidose vial, placing it on top of the medication cabinet, and scanning it in the hallway or at the ADC rather than at the patient’s bedside when the patient’s ID band is scanned.15,16 Drug shortages have also caused problems with this safety check. When a drug dosage is on shortage, an alternative must be found. In some cases, that alternative could be giving two tablets of a lower dosage so that the patient gets the correct dose. Barcode administration inventory data must be set to recognize that substitution, or the prescriber must prescribe the drug as two lower-dose tablets so that an error screen or alert does not occur. Use of barcodes also occurs in outpatient pharmacies. Pharmacy technicians are able to use barcodes to ensure that correct medications are dispensed to patients. Intelligent infusion pumps for medication administration allow for correct administration of infused medications in the clinical setting. These pumps contain drug libraries (specific to the hospital formulary) of all the different medications, the differing concentrations for administration, as well as the different ways to administer the medications (bolus versus continuous infusion). For instance, medications may be more concentrated when given via a central venous catheter than when given via a peripheral venous catheter or when given to an adult patient rather than to a pediatric patient (e.g., norepinephrine adult dosing mcg/min vs. pediatric dosing of mcg/kg/min). These drug libraries are unchangeable when on the floor or unit. The pumps must be removed from the floor and sent to Copyright © Informa Healthcare USA, Inc. 2014
biomedical engineering in order to add a new formulary medication or for updates when an infused medication administration guideline is changed.21,22 Errors occur when workarounds are used, which usually means that an alternate method of drug administration is being employed instead of the smart pump being used. “Run-away” pumps can also occur, resulting in a medication being administered too quickly leading to an overdose. Use of clinical pharmacists Specialty or clinical pharmacists who are part of the clinical team caring for a patient can reduce ADEs and save money. These pharmacists provide education to prescribers while doing rounds with clinical teams, and can intervene quickly to prevent errors.9 Clinical pharmacists are used in two ways: in a specific ward (i.e., ICU) and with a specific team (e.g., medical teams caring for patients throughout a hospital). These pharmacists are patient care team members familiar with the patient’s condition and can aid the rest of the team in appropriate drug and dose selection based on comorbidities, renal function, and other medications prescribed to the patient. In the intensive care unit, clinical pharmacists reduced ADEs by 66%, leading to $270,000 in hospital savings in one study.9 In the pediatric intensive care unit, clinical pharmacists reduced medication errors by up to 80%, and on pediatric hospital wards, they reduced potential ADEs by 94%.10,11 One area of the hospital where clinical pharmacists can make a huge impact is the emergency department (ED). The ED has an increased risk of ADEs for many reasons, including lack of familiarity with patient history, little continuity of care, overcrowding, and increased number of admitted patients awaiting hospital rooms. These admitted patients lead to increased medication orders and increased numbers of medications to administer, particularly when CPOE is used.12 ED clinical pharmacists prevent ADEs in many ways. They provide consultation when prescribers have questions regarding medication choice, dose, and interactions. ED nurses can also approach these pharmacists with administration questions for unfamiliar medications. ED pharmacists can review all medication orders to ensure that appropriate medication is prescribed for a patient and can verify orders placed to diminish the need for “overrides.”12 In one study involving 3 EDs, ED clinical pharmacists were able to make 2200 interventions to prevent ADEs, leading to $488,000 in potential savings.13 Another study compared errors that occurred when no ED clinical pharmacist was present with those that occurred when an ED clinical pharmacist was present. Without an ED clinical pharmacist, there were 16 errors per 100 medication orders. With an ED pharmacist, there were only 5 errors per 100 medication orders, leading to a 67% reduction of medication errors.8 Other fixes Limiting interruptions Some safety experts and advocates have evaluated the possibility of using “no-interruption” zones or vests when
576
B. Farmer
a medication is to be given to a patient. Some advocate a “no-interruption bundle” which includes the no-interruption zone or vest, redirecting phone calls to another nurse and signs and other postings to patients and family members not to interrupt the nurse while she or he is preparing medications for administration. This idea stems from the use of a safety measure in the airline industry known as the “sterile cockpit principle.” During take-off, landing, travel to and from 10,000 feet, and taxiing on the runway, pilots only discuss take-off and landing procedures with no other extraneous conversation. This is an example of using crew resource management to improve safety.36 In a hospital, the no-interruption zones are meant to curb the number of times a nurse is interrupted when attempting to administer a medication to a patient.23 Every time a nurse is interrupted during the process, there is a 12% increase in error.24 However, opponents advocate for interruptions to occur so that the error does not cause harm. These opponents recommend a “see something, say something” approach. An interruption can also serve to let the nurse know of a change in plan of care leading to a change in medications. A systematic review evaluating the effectiveness of limiting interruptions found only weak and limited scientific evidence to support its use for reducing medication errors.37 This was due to poor research methodologies and limited statistical analysis in the studies and the fact that no randomized controlled trials were found. Most of the studies in the systematic review had multiple interventions to limit interruptions, which the authors also felt was a weakness of these studies.37 The authors could not endorse one specific method or separate out the best method to limit interruptions. While it is true that the traditional rigorous scientific methodologies were not present in the articles included in the review, it is important to note that some studies did result in limiting interruptions and medication administration errors using qualitative methods. Qualitative methods are traditionally used to improve patient and medication safety.23,38–43 Use of multiple methods to target a single problem adds redundancy to plug holes in the Swiss Cheese Model of Error to improve safety.44 Teamwork/Communication Improvement in communication can prevent ADEs. Both written and verbal communication should be standardized. Written communication is standardized through the use of CPOE, as described earlier. Specific language should be used, and certain abbreviations such as those on the Joint Commission’s “Do Not Use” list45 or the ISMP’s list of error-prone abbreviations46 should be avoided to prevent confusion. Tall Man lettering, a use of mixed-case letters, aids in visual perception of medication names and should be used in all displays of drug names (CPOE, ADCs, intelligent infusion pump libraries, eMARs, etc.) to prevent confusion with look-alike/sound-alike drugs.47,48 Verbal communication should involve a closed loop format and be done in a standard order with communication tools such as SBAR (situation, background, assessment, and recommendation) or others. This standard communication can reduce errors and unexpected patient deaths.28 Closed
loop communication is a standardized sender–receiver– sender pathway to ensure the correctness of verbal orders. An example of closed loop communication would be a physician asking a nurse to give epinephrine 0.3 mg intramuscularly for a patient in anaphylaxis. The nurse would state back to the physician, “Epinephrine 0.3 mg intramuscular.” The physician then confirms the order, “Epinephrine 0.3mg intramuscular.” Once the emergent situation is over, a written computer order should be entered to again confirm the order initially stated. In addition, team training can improve communication. According to one study, resident physicians were unlikely to challenge an attending doctor’s prescribing decision, even if they felt uncomfortable or did not understand the choice and reason for a particular medication. These prescribers were also likely not to change another physician’s prescription based on perceived “prescribing etiquette.” If they perceived pressure from a nurse, prescribers were also likely to add prescriptions.49 As part of team training, every provider knows his or her role (leader, follower) and the goal of the team. Team training provides specific communication skills and tools to empower providers, of all hierarchical levels, to voice a concern to the leader when they see a problem. One such tool is the use of “CUS” words for raising concerns when problems or potential errors are noted, in an escalating pattern. This tool is promoted through the Team STEPPS team training program sponsored by AHRQ. The leader is taught to recognize these “CUS” words and to stop and take appropriate steps to avoid an error. The follower can state that he or she is “concerned” about a potential problem. If there is no response, the follower then tells the leader that he or she is “uncomfortable” with the order. If there is again no response, the follower states that he or she notes a “safety” issue. At this point, the leader is supposed to stop and listen fully to the potential problem.50 In one study, after team training in a neonatal intensive care unit, the nurses felt much more comfortable challenging a medication error written by a senior neonatologist. Challenges increased from 38% to 77%.30 After team training was implemented at a trauma center, pediatric trauma patients experienced a reduction in ADEs, particularly prescribing and administration errors.29 Education Lastly, educational interventions can sometimes reduce ADEs. A study in the neonatal intensive care unit demonstrated that tutorials, ward-based teaching, and feedback reduced medication errors from 20% to 3%.26 Another study on resident physicians’ training in emergency medicine demonstrated that a short review of dosing calculations led to decreased calculation errors. After the educational session, 70% of answers to the dosing scenarios were correct, whereas prior to the educational intervention,27 48% of answers were correct.
Summary ADE prevention is a major component of medication safety. Each part of the medication process has been targeted to Clinical Toxicology vol. 52 no. 6 2014
Prevention of adverse drug events 577 achieve safe use of medications and prevent ADEs. Technological solutions such as CPOE, decision support, BCMA, use of ADCs, and use of intelligent infusion pumps support the “rights” of medication administration. These technologies have resulted in a reduction of ADEs. The use of clinical pharmacists, improved verbal and written communication, team training with an emphasis on improved communication skills, and educational initiatives can also contribute to ADE prevention above and beyond the use of technology. This commentary has, hopefully, peaked interest in ADE prevention.
15.
16.
17.
18.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
19.
20. 21.
References 1. National Coordinating Council for Medication Error Reporting and Prevention. About medication errors: medication error category index. Available at: http://www.nccmerp.org/aboutMedErrors.html Last accessed 6 November 2013. 2. Elliot M, Liu Y. The nine rights of medication administration: an overview. Br J Nurs 2010; 19:300–305. 3. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280:1311–1316. 4. Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med 2004; 164: 785–792. 5. Lykowski G, Mahoney D. Computerized provider order entry improves workflow and outcomes. Nurs Manage 2004; 35:40G–H. 6. Miller AM, Boro MS, Korman NE, Davoren JB. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downstream of CPOE alerts. J Am Med Inform Assoc 2011; 18:i45–50. 7. Monane M, Matthias DM, Nagle BA, Kelly MA. Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. JAMA 1998; 280:1249–1252. 8. Brown JN, Barnes CL, Beasley B, Cisneros R, Pound M, Herring C. Effect of pharmacists on medication errors in an emergency department. Am J Health Syst Pharm 2008; 65:330–333. 9. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267–270. 10. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114–2120. 11. Kaushal R, Bates D, Mckenna KJ, et al. Ward-based clinical pharmacists and serious medication errors in pediatric inpatients. Paper presented at: Proceedings of the Annual Meeting of the National Academy of Health; 28 Jun 2003, 2003; Nashville, TN. 12. Patanwala AE, Warholak TL, Sanders AB, Erstad BL. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med 2010; 55:522–526. 13. Runy LA. Emergency department. Pharmacists in the ED help reduce errors. Hosp Health Netw 2008; 82:12–14. 14. Dwibedi N, Sansgiry SS, Frost CP, Dasgupta A, Jacob SM, Tipton JA, Shippy AA. Effect of bar-code-assisted medication administration on Copyright © Informa Healthcare USA, Inc. 2014
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33. 34.
nurses’ activities in an intensive care unit: a time-motion study. Am J Health Syst Pharm 2011; 68:1026–1031. Early C, Riha C, Martin J, Lowdon KW, Harvey EM. Scanning for safety: an integrated approach to improved bar-code medication administration. Comput Inform Nurs 2011; 29:TC45–52. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008; 15:408–423. Morriss FH Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN, et al. Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. J Pediatr 2009; 154:363–368, 368 e361. Morriss FH Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code-assisted medication administration system. Am J Health Syst Pharm 2011; 68:57–62. Gard JW, Starnes HM, Morrow EL, Sanchez PJ, Perlman JM. Reducing antimicrobial dosing errors in a neonatal intensive care unit. Am J Health Syst Pharm 1995; 52:1508, 1512–1503. Grissinger M. Safeguards for Using and designing automated dispensing cabinets. PT 2012; 37:490–530. Rothschild JM, Keohane CA, Cook EF, Orav EJ, Burdick E, Thompson S, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med 2005; 33:533–540. Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit. Qual Saf Health Care 2010; 19:430–434. Anthony I, Wienick C, Bauer C, Daly B, Anthony MK. No interruptions please: impact of a no interruption zone on medication safety in intensive care units. Crit Care Nurse 2010; 30:21–29. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of Interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170:683–690. Fischer SH, Tjia J, Field TS. Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review. J Am Med Inform Assoc 2010; 17:631–636. Campino A, Lopez-Herrera MC, Lopez-de-Heredia I, Valls-i-Soler A. An educational strategy to reduce medication errors in a neonatal intensive care unit. Acta Paediatr 2009; 98:782–785. Nelson LS, Gordon PE, Simmons MD, Goldberg WL, Howland MA, Hoffman RS. The benefit of house officereducation on proper medication dosage calculation and ordering. Acad Emerg Med 2000; 7: 1311–1316. De Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse-physician communication and reduces unexpected death. Resuscitation 2013; 84:1192–1196. Kalina M, Tinkoff G, Gleason W, Veneri P, Fulda G. A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center. Pediatr Emerg Care 2009; 25:444–446. Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Netw 2013; 32:26–33. doi:10.1891/0730-0832.32.1.26. Villamanan E, Larrubia Y, Ruano M, Vélez M, Armada E, Herrero A, Álvarez-Sala R. Potential medication errors associated with CPOE. Int J Clin Pharm 2013; 35:577–583. Institute of Safe Medication Practices. FDA and ISMP Lists of Look-Alike Drug Names and Recommended Tall Man Letters. 2011. Available at: https://www.ismp.org/tools/tallmanletters.pdf. Accessed 20 February 2014. Lapoint J, Perrone J, Nelson LS. A missed opportunity for safe opioid use using electronic pharmacopeia. J Med Toxicol 2013:85. Kim T, Webber T. Third baby dies after error at Indiana hospital. USA Today. 20 September 2006. Available at: http://usatoday30.usatoday. com/news/nation/2006-09-20-baby-deaths_x.htm?csp ⫽ 34. Accessed 7 March 2014.
578
B. Farmer
35. The Associated Press. Dennis Quaid’s twins among three newborns given drug overdose. 21 November 2007. Fox News. Available at: http://www.foxnews.com/story/2007/11/21/dennis-quaid-twinsamong-three-newborns-given-drug-overdose/. Accessed 7 March 2014. 36. Fore AM, Sculli GL, Albee D, Neily J. Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. J Nurs Manag 2013; 21:106–111. 37. Raban MZ, Westbrook JI. Are interventions to limit interruptions and errors during medication administration effective: a systematic review. BMJ Qual Saf 2014; 23:414–421. 38. Conrad C, Fields W, McNamara T, Cone M, Atkins P. Medication room madness: calming the chaos. J Nurs Care Qual 2010; 25:137–144. 39. Freeman R, McKee S, Lee-Lehner B, Pesenecker J. Reducing interruptions to improve medication safety. J Nurs Care Qual 2013; 28:176–185. 40. Kliger J, Blegen MA, Gootee D, O’Neil E. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Jt Comm J Qual Pt Safety 2009; 35: 604–612. 41. Kliger J, Singer S, Hoffman F, O’Neil E. Spreading a medication administration intervention organizationwide in six hospitals. Jt Comm J Qual Pt Safety 2012; 38:51–60.
42. Nguyen EE, Connolly PM, Wong V. Medication safety initiative in reducing medication errors. J Nurs Care Qual 2010; 25:224–230. 43. Relihan E, O’Brien V, O’Hara S, Silke B. The impact of a set of interventions to reduce interruptions and distraction to nurses during medication administration. BMJ Qual Saf 2010; 19:e52. 44. Reason J. Human Error. New York, NY: Cambridge University Press; 1990. 45. ISMP’s List of Error-prone abbreviations, symbols, and dose designations. ISMP 2013. Available at: https://www.ismp.org/tools/ errorproneabbreviations.pdf. Accessed 22 February 2014. 46. The Joint Commission. Facts about the official “do not use” list. Available at: http://www.jointcommission.org/assets/1/18/Do_Not_ Use_List.pdf. Accessed 22 February 2014. 47. Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of capital (“Tall Man”) letters using eye movement data. Soc Sci Med 2004; 59:2597–2601. 48. Darker IT, Gerret D, Filik R, Purdy KJ, Gale AG. The Influence of “Tall Man” lettering on errors of visual perception in the recognition of written drug names. Ergonomics 2011; 54:21–33. 49. Lewis PJ, Tully MP. Uncomfortable prescribing decisions in hospitals: the impact of teamwork. J R Soc Med 2009; 102:481–488. 50. TeamSTEPPS training program. http://www.teamstepps.ahrq.gov. Last Accessed 22 February 2014.
Clinical Toxicology vol. 52 no. 6 2014
ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20
Prevention of adverse drug events B. Farmer To cite this article: B. Farmer (2014) Prevention of adverse drug events, Clinical Toxicology, 52:6, 573-578, DOI: 10.3109/15563650.2014.909602 To link to this article: http://dx.doi.org/10.3109/15563650.2014.909602
Published online: 16 Apr 2014.
Submit your article to this journal
Article views: 257
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ictx20 Download by: [Ryerson University Library]
Date: 11 October 2016, At: 07:26
Clinical Toxicology (2014), 52, 573–578 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2014.909602
PROCEEDING OF THE 2013 AACT SYMPOSIUM ON ADVERSE DRUG EVENTS
Prevention of adverse drug events B. FARMER Division of Emergency Medicine, Weill-Cornell Medical College, New York, NY, USA
tions, fact sheets, toolkits, and newspaper articles related to best practices for improving specific aspects of patient and medication safety. As a patient safety expert, this is my “go-to” search tool when I am trying to find literature and other information related to patient safety. It is well organized and easy to search with “classic” articles at the top of each search. National experts (Michael Cohen from ISMP, Pat Croskerry, Peter Pronovost of the Central Line Checklist, David Bates, Tejal Gandhi, president of the National Patient Safety Foundation, amongst many others) serving on the editorial board and advisory panel for AHRQ Patient Safety Network chose the material presented on this website, including the “classic” articles/tools. The collection on this web site includes information from the Institute of Medicine, the Institute for Healthcare Improvement, the Institute for Safe Medication Practices, the Joint Commission, and many others. Initially, articles in the “Medication Safety” heading under the “Medication Errors/Preventable Adverse Drug Events” subheading were reviewed for common themes for error prevention based on each step of the medication process. Items and articles referring to medication reconciliation, epidemiology, error reporting, and analysis were not reviewed. The initial search of AHRQ’s Patient Safety Network’s Collections revealed 2462 items (1725 journal articles) under the Medication Safety heading. There were 3 subheadings under medication safety. The subheading of interest was Medication Errors/Preventable Adverse Drug Events, with 1748 items (1345 of the items were journal articles). There were 330 items (279 journal articles) related to ordering/ prescribing errors, 44 items (30 journal articles) for transcription errors, 105 items (73 journal articles) for dispensing errors, 379 (285 journal articles) for administration errors, and 24 items (20 journal articles) for monitoring errors and failures. Titles of these papers were reviewed in search of themes. Review of prevention of ordering/prescribing errors and transcribing errors revealed the following preventative method themes: use of computerized prescriber order entry (CPOE),3–5 use of decision support with CPOE,6,7 and use of clinical pharmacists.8–13 Review of articles related to the prevention of dispensing errors revealed the following themes: use of bar code technology14–18 and use of automated dispensing cabinets (ADCs).19,20 Review of
Background Adverse drug events (ADEs), defined as an injury involving medication use, occur commonly. ADEs include adverse drug reactions and medication errors. An adverse drug reaction is an adverse effect produced when using the drug correctly and is also known as a drug side effect. A medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”1 Medication errors are also classified as preventable ADEs. When ADEs do not result in patient injury, they are considered near misses or potential ADEs. Each part of the medication process has been targeted in order to prevent ADEs and potential ADEs. Prescription, transcription, dispensing, administration, and monitoring are the steps of the medication process. By targeting each one, the “rights” of medication administration are followed and safety is improved. The rights of medication administration include the right patient, drug, dose, route, time, and indication. The patient is then monitored for the right response.2 The purpose of this paper is to review and discuss some measures to prevent ADEs. It is based on my lecture from the American Academy of Clinical Toxicology Pre-Symposium at North American Congress of Clinical Toxicology 2013, “Adverse Drug Event Prevention – What Works?” and on my work on patient and medication safety. It is, therefore, not a complete review. This commentary is meant to provoke interest in learning more about the prevention of ADEs. Some topics to improve medication safety, such as improved medication reconciliation, will not be discussed. The Agency for Healthcare Research and Quality’s (AHRQ’s) Patient Safety Network collection and safety literature (psnet.ahrq.gov/collection.aspx) was searched for common preventative measures. The nation’s experts support this collection to improve patient safety, the medication process, and to prevent ADEs. This comprehensive web site contains evidence-based publications, clinical guidelines from safety, quality, and regulatory organizaReceived 8 March 2014; accepted 24 March 2014. Address correspondence to Dr. Brenna Farmer, Division of Emergency Medicine, Weill-Cornell Medical College, 525 E 68th Street, M-130, New York, NY 10065, USA. E-mail: [email protected]
573
574
B. Farmer
articles related to the prevention of administration errors revealed the following preventative techniques: use of bar code technology,14–18 use of intelligent infusion devices,21,22 and limiting interruptions.23,24 Review of articles related to monitoring errors and failures focused on the preventative techniques of computerized notices to remind practitioners about lab monitoring.25 Some themes didn’t fit into a specific part of the medication process, usually because they addressed multiple parts of the medication use process, including educational initiatives,26,27 and communication and teamwork.28–30 Therefore, ADE prevention can be broken down into the following themes: technological solutions, use of clinical pharmacists, communication/teamwork, and education initiatives. Technological solutions Technological solutions can be used for each part of the medication process to target different errors and improve medication safety. These solutions will be discussed in the order that they would appear during the medication administration process, beginning with CPOE. CPOE incorporation into the electronic health record leads to improvements and prevention of some errors at the prescribing phase of the medication process. It removes the need to interpret prescriber handwriting, as every order is typewritten, thereby, also reducing errors at the transcription phase of the medication process. Prescribing errors are reduced by 50–55% when CPOE is used.3–5 However, CPOE does not prevent human error in order entry. Such order entry errors include entry of weight in pounds instead of in kilograms leading to incorrect weight-based dosing of medications and incorrect entry of creatinine clearance leading to improper dosing of renally eliminated medications. New errors can also result from CPOE. Screen arrangements of drugs may lead to error as the most commonly prescribed drug may not appear at the top of the list, leading to providers choosing incorrect medication, incorrect dosage, or formulation.31 Examples include having continuous infusions listed before single or intermittently dosed medications or having long-acting formulations listed before short-acting formulations. In order to prevent look-alike/sound-alike prescribing errors, some CPOE systems use Tall Man lettering. Tall Man lettering is the process of capitalizing portions of letters that differ among orthographically similar drug names. For example, clonazePAM (klonoPIN®), cloNIDine, and cloZAPine would be written with Tall Man lettering in the CPOE.32 Use of Tall Man lettering is also recommended for pharmacy-generated labels, shelf labels, ADC selection screens, intelligent infusion pump screens, and for electronic Medication Administration Records (eMAR).32 Decision support is incorporated into CPOE. It usually means that a large database of medication information is available to aid order entry. Allergies and allergy crossreactions (e.g., a patient with penicillin allergy being prescribed a cephalosporin) may be checked, as well as possible drug interactions. Decision support also evaluates for
appropriate medication use, such as with the use of Beers’ Criteria for geriatric patients.7 While Beers’ Criteria has its shortcomings, other criteria/tools such as START and STOPP have not been studied as part of decision support for CPOE. These large databases can be individualized for hospital systems and can reflect the formulary of that system for both the inpatient and outpatient setting. Prescribers are alerted when a problem is identified. Depending on the sensitivity chosen by the hospital system, these alerts can fire too often, leading to alert fatigue. Providers start answering whatever they need to so that they “blow-by” or bypass the alert, without reading it, to get whatever order they want.6 Commonly, these databases may not be up to date, or lack dosing for a specific indication, such as antidote dosing. Prescribers that use hand-held devices can download other decision support tools, such as pharmacopeias, that may not put safe use warnings, contraindications, or adverse events on a screen that they will use to determine a prescribing dose, as has been shown with opioids.33 Of note, decision support can also be used to ensure adequate monitoring of patients taking medications that require laboratory checks for safe use (e.g., warfarin, potassium-wasting diuretics, cholesterol-lowering medications, and many others). A systematic review (excluding monitoring of anticoagulation) found that the laboratory alert process improved monitoring of medications at sites with lower baseline monitoring rates and when other team members such as pharmacists, not just prescribers, were targeted to receive monitoring alerts.25 ADCs with brand names such as Pyxis® and Omnicell® are storage cabinets holding unit- or single-dose medications. ADCs are often used in conjunction with CPOE and barcode medication administration (BCMA), but can also be used alone. To obtain a medication from the cabinet, a patient’s name must be selected followed by the medication needed. Prior to the medication being available for dispensing, a pharmacist will usually verify the drug order as appropriate. In a neonatal intensive care unit, ADCs reduced monthly dispensing errors from 5 to 0.19 Additionally, ADC display screens list medications in alphabetical order and use Tall Man lettering, as described earlier, to reduce the risk of look-alike/sound-alike errors. However, errors can be introduced into medication administration with this technology. Sometimes the machines have small, difficult-to-read screens, with poor resolution, and a medication’s full name may not be visible on the display screen. If Tall Man lettering is not used, look-alike errors can occur. If a drug is on the “override” list, a written physician order is not required to dispense the medication (e.g., in emergency situations such as giving D50W for hypoglycemia) and a pharmacist does not verify the order to ensure order accuracy and appropriateness. By removing the safety check of a pharmacist, a patient can be dispensed an incorrect drug. Additionally, the drawers for ADCs have to be stocked manually. If a drawer is stocked with an incorrect medication or a look-alike medication, dispensing errors can occur.20 Examples of this type of human error occurred with the heparin mix-ups at Indianapolis and in Los Angeles with Dennis Quaid’s newborn twins.34,35 Clinical Toxicology vol. 52 no. 6 2014
Prevention of adverse drug events 575 BCMA can be used alone or in conjunction with ADCs and other technologies to ensure the rights of medication administration. It requires a barcode on the unit dose medication and a barcode on the patient’s identification bracelet be scanned. In the neonatal intensive care unit, barcode administration reduced all administration errors by 47– 50%.17 Additionally, high-alert medication administration errors were reduced with the use of barcode administration by reducing opioid administration errors in a neonatal intensive care unit .18 Once they are familiar with the workflow using BCMA, nurses find that BCMA reduces the amount of time that they spend in administering medications. They are able to reallocate that extra time to other direct nursing patient-care.14 Unfortunately, as with the other forms of technological safety solutions, new errors can be introduced. For barcode administration to work properly, a drug has to be labeled correctly with a barcode and the label must be readable by the barcode scanner. If a drug is labeled incorrectly, a wrong drug administration may occur. If the scanner cannot read the drug’s barcode, the scanner will produce an error message and a nurse may have to find a “workaround” in order to administer the drug to the patient. Problems arising from the inability to read barcodes on medications and patients’ identification bands are known to be deterrents to the implementation of BCMA. Workarounds with BCMA, such as nurses scanning the medications at the computer cart, rather than at the bedside, or carrying multiple patients’ medications around after scanning at the medication cart, could lead to wrong patient-wrong drug administration.16 For multidose vials, some workarounds could lead to new errors. These workarounds include taking the barcode off the multidose vial, placing it on top of the medication cabinet, and scanning it in the hallway or at the ADC rather than at the patient’s bedside when the patient’s ID band is scanned.15,16 Drug shortages have also caused problems with this safety check. When a drug dosage is on shortage, an alternative must be found. In some cases, that alternative could be giving two tablets of a lower dosage so that the patient gets the correct dose. Barcode administration inventory data must be set to recognize that substitution, or the prescriber must prescribe the drug as two lower-dose tablets so that an error screen or alert does not occur. Use of barcodes also occurs in outpatient pharmacies. Pharmacy technicians are able to use barcodes to ensure that correct medications are dispensed to patients. Intelligent infusion pumps for medication administration allow for correct administration of infused medications in the clinical setting. These pumps contain drug libraries (specific to the hospital formulary) of all the different medications, the differing concentrations for administration, as well as the different ways to administer the medications (bolus versus continuous infusion). For instance, medications may be more concentrated when given via a central venous catheter than when given via a peripheral venous catheter or when given to an adult patient rather than to a pediatric patient (e.g., norepinephrine adult dosing mcg/min vs. pediatric dosing of mcg/kg/min). These drug libraries are unchangeable when on the floor or unit. The pumps must be removed from the floor and sent to Copyright © Informa Healthcare USA, Inc. 2014
biomedical engineering in order to add a new formulary medication or for updates when an infused medication administration guideline is changed.21,22 Errors occur when workarounds are used, which usually means that an alternate method of drug administration is being employed instead of the smart pump being used. “Run-away” pumps can also occur, resulting in a medication being administered too quickly leading to an overdose. Use of clinical pharmacists Specialty or clinical pharmacists who are part of the clinical team caring for a patient can reduce ADEs and save money. These pharmacists provide education to prescribers while doing rounds with clinical teams, and can intervene quickly to prevent errors.9 Clinical pharmacists are used in two ways: in a specific ward (i.e., ICU) and with a specific team (e.g., medical teams caring for patients throughout a hospital). These pharmacists are patient care team members familiar with the patient’s condition and can aid the rest of the team in appropriate drug and dose selection based on comorbidities, renal function, and other medications prescribed to the patient. In the intensive care unit, clinical pharmacists reduced ADEs by 66%, leading to $270,000 in hospital savings in one study.9 In the pediatric intensive care unit, clinical pharmacists reduced medication errors by up to 80%, and on pediatric hospital wards, they reduced potential ADEs by 94%.10,11 One area of the hospital where clinical pharmacists can make a huge impact is the emergency department (ED). The ED has an increased risk of ADEs for many reasons, including lack of familiarity with patient history, little continuity of care, overcrowding, and increased number of admitted patients awaiting hospital rooms. These admitted patients lead to increased medication orders and increased numbers of medications to administer, particularly when CPOE is used.12 ED clinical pharmacists prevent ADEs in many ways. They provide consultation when prescribers have questions regarding medication choice, dose, and interactions. ED nurses can also approach these pharmacists with administration questions for unfamiliar medications. ED pharmacists can review all medication orders to ensure that appropriate medication is prescribed for a patient and can verify orders placed to diminish the need for “overrides.”12 In one study involving 3 EDs, ED clinical pharmacists were able to make 2200 interventions to prevent ADEs, leading to $488,000 in potential savings.13 Another study compared errors that occurred when no ED clinical pharmacist was present with those that occurred when an ED clinical pharmacist was present. Without an ED clinical pharmacist, there were 16 errors per 100 medication orders. With an ED pharmacist, there were only 5 errors per 100 medication orders, leading to a 67% reduction of medication errors.8 Other fixes Limiting interruptions Some safety experts and advocates have evaluated the possibility of using “no-interruption” zones or vests when
576
B. Farmer
a medication is to be given to a patient. Some advocate a “no-interruption bundle” which includes the no-interruption zone or vest, redirecting phone calls to another nurse and signs and other postings to patients and family members not to interrupt the nurse while she or he is preparing medications for administration. This idea stems from the use of a safety measure in the airline industry known as the “sterile cockpit principle.” During take-off, landing, travel to and from 10,000 feet, and taxiing on the runway, pilots only discuss take-off and landing procedures with no other extraneous conversation. This is an example of using crew resource management to improve safety.36 In a hospital, the no-interruption zones are meant to curb the number of times a nurse is interrupted when attempting to administer a medication to a patient.23 Every time a nurse is interrupted during the process, there is a 12% increase in error.24 However, opponents advocate for interruptions to occur so that the error does not cause harm. These opponents recommend a “see something, say something” approach. An interruption can also serve to let the nurse know of a change in plan of care leading to a change in medications. A systematic review evaluating the effectiveness of limiting interruptions found only weak and limited scientific evidence to support its use for reducing medication errors.37 This was due to poor research methodologies and limited statistical analysis in the studies and the fact that no randomized controlled trials were found. Most of the studies in the systematic review had multiple interventions to limit interruptions, which the authors also felt was a weakness of these studies.37 The authors could not endorse one specific method or separate out the best method to limit interruptions. While it is true that the traditional rigorous scientific methodologies were not present in the articles included in the review, it is important to note that some studies did result in limiting interruptions and medication administration errors using qualitative methods. Qualitative methods are traditionally used to improve patient and medication safety.23,38–43 Use of multiple methods to target a single problem adds redundancy to plug holes in the Swiss Cheese Model of Error to improve safety.44 Teamwork/Communication Improvement in communication can prevent ADEs. Both written and verbal communication should be standardized. Written communication is standardized through the use of CPOE, as described earlier. Specific language should be used, and certain abbreviations such as those on the Joint Commission’s “Do Not Use” list45 or the ISMP’s list of error-prone abbreviations46 should be avoided to prevent confusion. Tall Man lettering, a use of mixed-case letters, aids in visual perception of medication names and should be used in all displays of drug names (CPOE, ADCs, intelligent infusion pump libraries, eMARs, etc.) to prevent confusion with look-alike/sound-alike drugs.47,48 Verbal communication should involve a closed loop format and be done in a standard order with communication tools such as SBAR (situation, background, assessment, and recommendation) or others. This standard communication can reduce errors and unexpected patient deaths.28 Closed
loop communication is a standardized sender–receiver– sender pathway to ensure the correctness of verbal orders. An example of closed loop communication would be a physician asking a nurse to give epinephrine 0.3 mg intramuscularly for a patient in anaphylaxis. The nurse would state back to the physician, “Epinephrine 0.3 mg intramuscular.” The physician then confirms the order, “Epinephrine 0.3mg intramuscular.” Once the emergent situation is over, a written computer order should be entered to again confirm the order initially stated. In addition, team training can improve communication. According to one study, resident physicians were unlikely to challenge an attending doctor’s prescribing decision, even if they felt uncomfortable or did not understand the choice and reason for a particular medication. These prescribers were also likely not to change another physician’s prescription based on perceived “prescribing etiquette.” If they perceived pressure from a nurse, prescribers were also likely to add prescriptions.49 As part of team training, every provider knows his or her role (leader, follower) and the goal of the team. Team training provides specific communication skills and tools to empower providers, of all hierarchical levels, to voice a concern to the leader when they see a problem. One such tool is the use of “CUS” words for raising concerns when problems or potential errors are noted, in an escalating pattern. This tool is promoted through the Team STEPPS team training program sponsored by AHRQ. The leader is taught to recognize these “CUS” words and to stop and take appropriate steps to avoid an error. The follower can state that he or she is “concerned” about a potential problem. If there is no response, the follower then tells the leader that he or she is “uncomfortable” with the order. If there is again no response, the follower states that he or she notes a “safety” issue. At this point, the leader is supposed to stop and listen fully to the potential problem.50 In one study, after team training in a neonatal intensive care unit, the nurses felt much more comfortable challenging a medication error written by a senior neonatologist. Challenges increased from 38% to 77%.30 After team training was implemented at a trauma center, pediatric trauma patients experienced a reduction in ADEs, particularly prescribing and administration errors.29 Education Lastly, educational interventions can sometimes reduce ADEs. A study in the neonatal intensive care unit demonstrated that tutorials, ward-based teaching, and feedback reduced medication errors from 20% to 3%.26 Another study on resident physicians’ training in emergency medicine demonstrated that a short review of dosing calculations led to decreased calculation errors. After the educational session, 70% of answers to the dosing scenarios were correct, whereas prior to the educational intervention,27 48% of answers were correct.
Summary ADE prevention is a major component of medication safety. Each part of the medication process has been targeted to Clinical Toxicology vol. 52 no. 6 2014
Prevention of adverse drug events 577 achieve safe use of medications and prevent ADEs. Technological solutions such as CPOE, decision support, BCMA, use of ADCs, and use of intelligent infusion pumps support the “rights” of medication administration. These technologies have resulted in a reduction of ADEs. The use of clinical pharmacists, improved verbal and written communication, team training with an emphasis on improved communication skills, and educational initiatives can also contribute to ADE prevention above and beyond the use of technology. This commentary has, hopefully, peaked interest in ADE prevention.
15.
16.
17.
18.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
19.
20. 21.
References 1. National Coordinating Council for Medication Error Reporting and Prevention. About medication errors: medication error category index. Available at: http://www.nccmerp.org/aboutMedErrors.html Last accessed 6 November 2013. 2. Elliot M, Liu Y. The nine rights of medication administration: an overview. Br J Nurs 2010; 19:300–305. 3. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280:1311–1316. 4. Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med 2004; 164: 785–792. 5. Lykowski G, Mahoney D. Computerized provider order entry improves workflow and outcomes. Nurs Manage 2004; 35:40G–H. 6. Miller AM, Boro MS, Korman NE, Davoren JB. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downstream of CPOE alerts. J Am Med Inform Assoc 2011; 18:i45–50. 7. Monane M, Matthias DM, Nagle BA, Kelly MA. Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. JAMA 1998; 280:1249–1252. 8. Brown JN, Barnes CL, Beasley B, Cisneros R, Pound M, Herring C. Effect of pharmacists on medication errors in an emergency department. Am J Health Syst Pharm 2008; 65:330–333. 9. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267–270. 10. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114–2120. 11. Kaushal R, Bates D, Mckenna KJ, et al. Ward-based clinical pharmacists and serious medication errors in pediatric inpatients. Paper presented at: Proceedings of the Annual Meeting of the National Academy of Health; 28 Jun 2003, 2003; Nashville, TN. 12. Patanwala AE, Warholak TL, Sanders AB, Erstad BL. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med 2010; 55:522–526. 13. Runy LA. Emergency department. Pharmacists in the ED help reduce errors. Hosp Health Netw 2008; 82:12–14. 14. Dwibedi N, Sansgiry SS, Frost CP, Dasgupta A, Jacob SM, Tipton JA, Shippy AA. Effect of bar-code-assisted medication administration on Copyright © Informa Healthcare USA, Inc. 2014
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33. 34.
nurses’ activities in an intensive care unit: a time-motion study. Am J Health Syst Pharm 2011; 68:1026–1031. Early C, Riha C, Martin J, Lowdon KW, Harvey EM. Scanning for safety: an integrated approach to improved bar-code medication administration. Comput Inform Nurs 2011; 29:TC45–52. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008; 15:408–423. Morriss FH Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN, et al. Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. J Pediatr 2009; 154:363–368, 368 e361. Morriss FH Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code-assisted medication administration system. Am J Health Syst Pharm 2011; 68:57–62. Gard JW, Starnes HM, Morrow EL, Sanchez PJ, Perlman JM. Reducing antimicrobial dosing errors in a neonatal intensive care unit. Am J Health Syst Pharm 1995; 52:1508, 1512–1503. Grissinger M. Safeguards for Using and designing automated dispensing cabinets. PT 2012; 37:490–530. Rothschild JM, Keohane CA, Cook EF, Orav EJ, Burdick E, Thompson S, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med 2005; 33:533–540. Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit. Qual Saf Health Care 2010; 19:430–434. Anthony I, Wienick C, Bauer C, Daly B, Anthony MK. No interruptions please: impact of a no interruption zone on medication safety in intensive care units. Crit Care Nurse 2010; 30:21–29. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of Interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170:683–690. Fischer SH, Tjia J, Field TS. Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review. J Am Med Inform Assoc 2010; 17:631–636. Campino A, Lopez-Herrera MC, Lopez-de-Heredia I, Valls-i-Soler A. An educational strategy to reduce medication errors in a neonatal intensive care unit. Acta Paediatr 2009; 98:782–785. Nelson LS, Gordon PE, Simmons MD, Goldberg WL, Howland MA, Hoffman RS. The benefit of house officereducation on proper medication dosage calculation and ordering. Acad Emerg Med 2000; 7: 1311–1316. De Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse-physician communication and reduces unexpected death. Resuscitation 2013; 84:1192–1196. Kalina M, Tinkoff G, Gleason W, Veneri P, Fulda G. A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center. Pediatr Emerg Care 2009; 25:444–446. Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Netw 2013; 32:26–33. doi:10.1891/0730-0832.32.1.26. Villamanan E, Larrubia Y, Ruano M, Vélez M, Armada E, Herrero A, Álvarez-Sala R. Potential medication errors associated with CPOE. Int J Clin Pharm 2013; 35:577–583. Institute of Safe Medication Practices. FDA and ISMP Lists of Look-Alike Drug Names and Recommended Tall Man Letters. 2011. Available at: https://www.ismp.org/tools/tallmanletters.pdf. Accessed 20 February 2014. Lapoint J, Perrone J, Nelson LS. A missed opportunity for safe opioid use using electronic pharmacopeia. J Med Toxicol 2013:85. Kim T, Webber T. Third baby dies after error at Indiana hospital. USA Today. 20 September 2006. Available at: http://usatoday30.usatoday. com/news/nation/2006-09-20-baby-deaths_x.htm?csp ⫽ 34. Accessed 7 March 2014.
578
B. Farmer
35. The Associated Press. Dennis Quaid’s twins among three newborns given drug overdose. 21 November 2007. Fox News. Available at: http://www.foxnews.com/story/2007/11/21/dennis-quaid-twinsamong-three-newborns-given-drug-overdose/. Accessed 7 March 2014. 36. Fore AM, Sculli GL, Albee D, Neily J. Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. J Nurs Manag 2013; 21:106–111. 37. Raban MZ, Westbrook JI. Are interventions to limit interruptions and errors during medication administration effective: a systematic review. BMJ Qual Saf 2014; 23:414–421. 38. Conrad C, Fields W, McNamara T, Cone M, Atkins P. Medication room madness: calming the chaos. J Nurs Care Qual 2010; 25:137–144. 39. Freeman R, McKee S, Lee-Lehner B, Pesenecker J. Reducing interruptions to improve medication safety. J Nurs Care Qual 2013; 28:176–185. 40. Kliger J, Blegen MA, Gootee D, O’Neil E. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Jt Comm J Qual Pt Safety 2009; 35: 604–612. 41. Kliger J, Singer S, Hoffman F, O’Neil E. Spreading a medication administration intervention organizationwide in six hospitals. Jt Comm J Qual Pt Safety 2012; 38:51–60.
42. Nguyen EE, Connolly PM, Wong V. Medication safety initiative in reducing medication errors. J Nurs Care Qual 2010; 25:224–230. 43. Relihan E, O’Brien V, O’Hara S, Silke B. The impact of a set of interventions to reduce interruptions and distraction to nurses during medication administration. BMJ Qual Saf 2010; 19:e52. 44. Reason J. Human Error. New York, NY: Cambridge University Press; 1990. 45. ISMP’s List of Error-prone abbreviations, symbols, and dose designations. ISMP 2013. Available at: https://www.ismp.org/tools/ errorproneabbreviations.pdf. Accessed 22 February 2014. 46. The Joint Commission. Facts about the official “do not use” list. Available at: http://www.jointcommission.org/assets/1/18/Do_Not_ Use_List.pdf. Accessed 22 February 2014. 47. Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of capital (“Tall Man”) letters using eye movement data. Soc Sci Med 2004; 59:2597–2601. 48. Darker IT, Gerret D, Filik R, Purdy KJ, Gale AG. The Influence of “Tall Man” lettering on errors of visual perception in the recognition of written drug names. Ergonomics 2011; 54:21–33. 49. Lewis PJ, Tully MP. Uncomfortable prescribing decisions in hospitals: the impact of teamwork. J R Soc Med 2009; 102:481–488. 50. TeamSTEPPS training program. http://www.teamstepps.ahrq.gov. Last Accessed 22 February 2014.
Clinical Toxicology vol. 52 no. 6 2014
