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How to Avoid Catastrophic Medication Errors

By Ted Stucka, PhD

Where has the summer gone? That seemed to be the consensus at my “Last Summer Barbeque of the Year” barbeque last week. It was a strange summer in central NY as we had either heat/no rain or rain and no heat. We did have some great sweet corn from one of my fields but overall the summer went by way too quickly for most of us.

The neighbors found time to talk about the latest local gossip. On this occasion, our local hospital was the subject. Recently, newspapers were filled with articles concerning a lawsuit about a near-fatal drug mishap. It is alleged that a nurse accidentally administered the wrong drug. Most of the comments approximated “How stupid could they be?” and “How could that happen?”

As always I started to enumerate the many causes of medication errors. I explained to these folks that errors can occur for many types of procedures or issues, from seemingly simple to very complex. Then my non-clinician friends began to speculate “How hard can it be to give a drug?” I quickly pointed out the various ways that things can go wrong. I told them about the look-alike sound-alike scenario. Then I explained to the group that a simple mispronunciation of a word, a missed allergy, an unreported drug a patient is taking at home, even a practice or protocol bypassed entirely can all lead to a serious if not fatal medical misadventure.

I went on to explain that “Some drugs are just very toxic and need special handling to mix, make or administer. Many of these agents are rarely used and special handling instructions can get ignored or go unnoticed. All these nuances of error can cause serious problems, especially if you are not accustomed to using them. In a busy pharmacy environment it is likely that the pharmacist gets distracted or interrupted when filling them. All it takes is a moment of diverted attention. With these classes of drugs, such as neoplastic agents, the more reminders a pharmacist has on how to handle them, available on-demand, is the best way to prevent errors. To ensure that the staff stops, looks and knows what to do, is the best way to avoid any medicinal mishap.

I continued on, “There are likely more ways to cause an error than to prevent one. Errors can happen anywhere in the order process, from inception to administration. Each step in the process (prescribing, verification, dispensing/compounding, storing and finally administration) is a new and different stage in the medication process for the error to occur. One of the best ways to stop these types of errors is to make a proactive risk assessment and have in place protocols and procedures that determine how drugs are to be used before the problem arises.

After all, if you are aware of the step where a potential problem can or has happened then that is the place where the appropriate prophylactic measures must be implemented.    An electronic system that alerts users at the appropriate point, can go a long way in preventing any issue from arising at any given stage in the process.

It’s been my experience that every hospital has problem drug or two that are vulnerable to errors. When you identify those drugs you need to make sure that those drugs are handled with an extra amount of care. The best part about a good electronic medication software is the ability to customize your warnings. In this way, we can take our ideas and tailor them to be more proactive about resolving medication errors before they happen.

An effective EHR can allow users to identify and isolate those special, problematic drugs and give them clear and concise instructions as to how they want the drug handled. Flexibility and customization can help everyone be aware that this drug needs special attention. The best part is the software can then notify the user where in the chain of events the issue happens.

For problems such as a “look alike, sound alike” users can put their special warning at time of order entry (for the prescriber and for the verifier) so the drug is entered properly. They can do this again at the time of drug fill – so they can take that extra second to check it, making sure they have the correct drug or yet again at the time of compounding with warnings such as “after mixing, check for particulars. If present discard and redo”. And lastly when the nurse goes to administer the drug a special warning or note can be tailored to appear explaining just what needs to be checked prior to administering it to the patient.   The availability of drug images in conjunction with bar code scanning can reinforce and enhance 5 rights checking.

A comprehensive EHR that allows for customization can identify and require certain drugs to have a second person check and verify that the drug is correct as well. By having the additional clinician enter their password into the system before the drug is delivered or administered.

Taking a user out of their comfort zone for a few seconds by requiring their special attention is one of the best ways to prevent any error. With electronic health record software you can tailor warnings to the prescriber, pharmacist, technician or administering personnel, ensuring that each receives enough information that is vital to helping prevent a medical misadventure. Sometimes it’s the little help that these pop-ups give you make all the difference between safety and disaster.

Weeding through CQM requirements for your EHR

By Penny Casebolt RN, MSN, MHA

I spent my last few weekends working in my flower garden attempting to conquer the weeds and re-establish order. When I began planting in the Spring, I took the time to design and strategize a plan and visualized my end product as one complete, beautiful flower garden with little maintenance required. Needless to say the reality is far different. In the middle of the bed I placed a large stone obelisk with intent to find the perfect climbing flower to wind from the base to the top and become a focal point in the garden. Well, as usual life got busy and the perfect flower never materialized, which means that now I am stuck having to weed around an object without purpose (something I would embrace more if the temperature was say – 70 instead of 98). As I was weeding I was reminded of work in the office this past week- a weeding of a different sort.

A group of us are working with our clients on identifying the fields needed to capture and transmit the data required for clinical quality measures (CQMs). For 2014 the CQMs for eligible hospitals involve reporting on 16 of 29 approved quality measures. Within these 16 CQMs there must be measures encompassing at least three (3) of the National Quality Strategy domains such as Care Coordination or Clinical Processes and Effectiveness. For Stage 2 it is not enough to simply report the measure was ordered rather a completed picture of implementation is captured as discrete data. For example one well known quality measure is Venous Thromboembolism Prophylaxis (VTE) with documentation of prophylaxis started day of or day after hospitalization. Designing discrete data fields to capture the ordering or not of a VTE prophylaxis such as low molecular weight heparin or graduated compression stockings for a patient is not problematic. Beyond the ordering of the intervention the application or administration of the intervention must also be captured as a discrete data field that is available for export to a MU report.

Here is where the weeding comes in. Providers order and nurses implement. Nursing documentation is a vital component in obtaining the discrete data for Stage 2. Was the compression stocking applied within the required timeframe or not? If not what was the reason?   This documentation will come from nursing. But I ask you, dear readers, has anyone looked at a nursing form lately?

Developing and designing nursing documentation that provides a tool to collect relevant data as well as one for the nurse to assess and document interventions is not easy. Nursing forms are constantly added to in order to capture that newest piece of information someone wants. And even with the best of intentions in mind when the form was designed, in time elements of it can become like my obelisk -a great idea at the time but one that simply ends up being simply an obtrusive structure. With so many check boxes and drop-downs to wade through it is daunting to try and navigate quickly through the documentation. Eligible hospitals working on Stage 2 probably have well established forms and workflows nurses have been using. Frequently these forms were not designed with specific discrete data elements to be pulled into meaningful use reports in mind as they were meant to be for nursing use while providing clinical care.

As our group evaluated where the data elements would pull from for these CQMs it was apparent that changes to current nursing documentation must be made. I am sure most eligible hospitals are facing similar situations. As this work is done it is imperative that NURSING is involved. Changing an existing nursing form will impact the bedside nurse. These forms had a vision and strategy at the time of creation- even those with weeds creeping in. Reporting CQMs is a great initiative but we must be sure to remember that the aid and the positive input of nurses is essential in form redesign, as they are key stakeholders in providing the care that makes use of these data elements.

By the time I finished weeding my garden the original vision had re-emerged, plants that were not thriving were removed, and space was cleared so that new ones could grow. And I think we should face the task of form redesign for MU requirements with the same goal in mind.  Happy weeding.

Reflecting on Alert Fatigue

By Ted Stucka, PhD

I was reading a professional journal the other day and it described a medication error that resulted in a near death. At first glance it seemed that their Information system failed to detect a drug allergy that was known. The patient received the drug and had an anaphylactic reaction.

Fortunately for all, the patient was treated and survived the incident without any permanent injury. Checking for allergies is one of the basic fundamental tasks that any system can and must be able to do. As expected, an in-depth analysis of the incident took place. The allergy warnings did indeed trigger….and it was ignored. The pharmacist received an allergy warning….Overrode the warning, allowing the drug to be dispensed and ultimately given to the patient.

When questioned, the pharmacist was certain that no warning appeared and the fault lay in the system itself. The audit trail clearly showed the exact time the warning appeared and yet the pharmacist denied ever seeing it. When shown the evidence the answer was “there are so many warnings, who has the time to read each and every one? If I read every one I’d never get my work done!”

If that refrain sounds familiar to anyone, it’s because it is something that everyone who has ever worked in the trenches knows all too well. Hurry up and follow all procedures but if you make a mistake you should have slowed down. It seems that the plethora of information appearing on the screen at times only manages to overwhelm the users and negates our ability to absorb and respond to the information. This is the eternal dilemma we pharmacists have all faced at one time or another.

This is just one case of course and proves that that pharmacist involved was lulled into a false sense of complacency and assumed that “….this warning was like the other three I just read. Besides I am late and have to get this done. If the warning was really important the nurse or someone else would catch it.” In theory that is absolutely correct, in practice however, not so much.

How many of us have been put into that same situation? We are trying to get the work done, there is a deadline and the screen keeps showing us information. So, we prioritize. Unfortunately not all decisions always translate to good patient care. Warnings are there for a reason. We need to make professional judgments as to what is critically important and must be acted upon versus what is useful informational but not critically important.

The dilemma of alert fatigue becomes intensified when a prescriber is reviewing clinical alerts. This is because prescribers, with much less time to spend on order entry, will more easily be conditioned to press override if inundated with many  warnings with low clinical significance.  What we need to do is try to make the pop-ups that appear have meaning. Then we need to differentiate between simply informational warnings and the life threatening warnings! We need a way to turn off the superfluous and accentuate the serious. How do we make sure the warnings are actually understood and acted upon in the appropriate manner?

Pharmacists also need to have their alerts tuned, since they are often the final defense in order scrutiny for clinical problems. I believe they should see a fuller complement of warning messages than prescribers. The point to take away here is that managing your alerts and making sure the most important alerts take the user out of their comfort zone making them think before overriding the really important pop-ups and warnings.

As members of the health care Team it is all our responsibility to ensure patient safety. We don’t sacrifice judgment for speed. Instead we use all the features our closed loop medication systems offer. Systems must be fine-tuned so that prescribers see the most clinically significant alerts and pharmacists review a broader range of flags.

When possible we customize alerts and explain why some warnings are more important than others. If possible we design those critical warnings that force the user stop and actually think before automatically checking a box to override a critical alert. It is not just the system but how we respond to its warnings that keep us focused on our job. Have a great and safe summer!


Keeping an Open Mind about Health Homes

By Penny Casebolt RN, MSN, MHA

Last month, I had the opportunity to attend the OPEN MINDS Planning and Innovation Institute in New Orleans. OPEN MINDS provides resources, education, and support to those in the field of providing health and human services to individuals with chronic conditions and complex needs. The focus of the Institute was Behavioral Healthcare and the changes in the service delivery model with a gentle warning of innovate, adapt, or be left behind thrown in for good measure. The program delivered detailed sessions on new and aggressive movements in the behavioral healthcare field.  Telehealth, integrated care, and health homes were care delivery models stressed as essential to meet new regulatory and consumer demands for behavioral healthcare.

With a background in primary care nursing and involvement in the development of Medical Homes, I was intrigued with the discussion on Health Homes. Health Homes were created under the Patient Protection and Affordable Care Act as a state Medicaid option for individuals with chronic conditions and/or severe behavioral health diagnosis. The purpose of the program is to improve patient outcomes and quality of care through the facilitation of access and coordination to health care services with a strong focus on behavioral healthcare and long-term community based services and support. With enrollment beginning only as recently as January 1, 2011 the concept is new but is showing strong results from the few states with implemented programs.

One of the impetuses behind the program is the high rate of co-morbidities of patients with mental health issues. I was amazed to hear the statistics of patients on anti-psychotic medications who develop obesity, hyperlipidemia, hypertension and diabetes. There is also a high percentage of tobacco use with behavioral health patients. It makes sense that an integration of care between behavioral health specialist, primary care providers, and community-based services would enhance patient care and improve long-term outcomes.   As such, many programs are embedding a primary care provider within the behavioral health facility or developing a strong collaboration in the community.

As a clinician intricately involved in the use of electronic health records I was interested in the role of the EHR in the creation and sustainability of health homes. Presenters from existing Health Home providers shared insight on the role of the EHR for success and sustainability of a health home. The adoption of electronic health records in behavioral health has been slower than seen in acute care and medical practices. It was abundantly clear from the presentations that adoption of an EHR will be not only necessary but extremely beneficial in the management and integration of the patient’s care.   An EHR can provide decision support, treatment guidelines, preventive health alerts, medication interactions and alerts, as well as track and flow key indicators.   Quality indicators can be tracked and reported as can business data on services provided and costs associated.

It is the ability to share relevant clinical data with all the collaborators in the patient’s care team I find most exciting. Although I realize the sensitive nature of treatment notes for behavioral health patients there is benefit of being able to provide “whole person” care in a collaborative manner.   Primary care providers are in a position to refer patients with needs to behavioral health specialist and assist in monitoring complex conditions related to treatment.   A formal addition to the behavioral health care team with sharing of information and outcomes will certainly enhance patient care and ultimately improve outcomes.

Remembering Allergies within your EHR

By Ted Stucka, PhD

“What were your symptoms?” I asked casually.

“Vomiting and feeling weird.” was the response.

Such was the discussion this past Memorial Day when my neighbors and I began chatting about the myriad allergies that each of us suffered from. And out of the 10 people who claimed an allergy to this or that only 1 may have been an actual allergy. I tried to tell these people that most were actually experiencing side effects and not a true allergy. As a pharmacist I tried to explain to the folks with “drug allergies” that the next time they see their physicians they should review these allergies and see if their doctor believes they are really allergies and NOT simply side effects.

“Well, I don’t want to use it again, I hate that feeling. Who needs that drug anyway? They can give me something else.”….and that became the general consensus. “What’s the difference?”

What people just don’t seem to understand is the danger they can put themselves in when their allergy history is wrong. We have all seen septic patient with second and third line drugs being used because they we “allergic” to the drug of choice. How many complications arose because the drug of choice was never given? How many times did that third drug of choice not work as well? Too many, is the answer and we all know it. A true allergy history can be lifesaving or live endangering if not accurate. What we as pharmacists need is a robust system that allows room for all of this information.

We need a good way to:

  • Document the reaction in the allergy system with details in order to ascertain if it is indeed and allergy and not a side effect- Need enough room to explain the reaction as opposed to the “in 25 characters or less describe the reaction”
  • Archive changes in the allergy fields to either add or delete with explanations to allow future decisions based on good information
  • A way to let others know the issue may be not the drug but the delivery system of the manufacturer (Certain manufactures adhesives on patches cannot be tolerated but the drug itself is not the issue)
  • When the allergy is detected a warning appears not just with the drug and allergy but with enough information available to allow a rational decision to be made regarding its use.
  • To make sure this information is available for all subsequent admissions.
  • Lastly, and perhaps most importantly, if the patient cannot or is unable to give an allergy history we can use the one we already have. While it may not be complete, it is a start and can literally save a life.

In the end, what good is recording allergies if they are lost upon discharge or if the system does not allow specific information to address the issues so a different prescriber cannot get a complete and accurate allergy history? Allergies (real or imagined) are vitally important to the patient care. Don’t you want a system that helps you make the best clinical decisions and provides you and your staff with all the information needed. I know I do.

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