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Medication Error Reduction Plan Program
Loriann De Martini, Pharm.D.Chief Pharmaceutical Consultant
Michael Alexander, M.Sc.Pharmaceutical Consultant II
Presentation Goals
• Provide an update on MERP program• Provide information which may help you to
decrease medication errors • Relate some important findings during MERP
surveys• Provide overview of Med-SET project• Provide CDPH with recommendations for
medication safety focus areas for next triennial survey cycle starting January 2012
MERP Survey Summary January 2009 – December 2011
• 374 – Hospitals to be surveyed• 368 – Exited surveys (98 %)• 346 – Survey data received (94 %) • 323 – Noted deficiencies (93 %) • 23 – In compliance ( 7 %)
Data as of 01/23/2012
Common Deficiencies
• 68 % - Develop and implement P&Ps for safe and effective use of medications [CCR 70263(c)(1)]
• 63 % - Conduct an annual review to assess effectiveness of the implementation of MERP [HSC 1339.63 (e)(2)]
• 46 % - Identify weakness or deficiencies that could contribute to errors [HSC 1339.63 (e)(1)]
• 45 % - Include a multidisciplinary process to regularly analyze all errors [HSC 1339.63 (e)(6)]
Issues:
• Automated Dispensing Cabinets Discrepancies, overrides, profiling (e.g., Radiology,
PACU, ED)
• Emergency medications (MH, carts, boxes) Sealed, list of meds, exp. date
• Refrigerators (storage); warmers in OR
Issues:
• Lack of policies and procedures
• Policies and procedures not followed
• Recent medication deaths: heparin, morphine, warfarin, fentanyl
Issues:
• Limit access to medications
• Drawing up emergency medications correctly
• Preprinted orders – include parameters for dose changes (e.g., norepinephrine, nitroprusside)
Expired Drugs
• Operating room areas • Transport boxes, kits• Emergency department (succinylcholine?)• Clinics• Unit inspections
Malignant Hyperthermia
• Do nurses, pharmacists, physicians know how to treat MH?
• Do nurses, pharmacists, physicians know where to get drugs to treat MH?
• Do you have all of the MHAUS recommended drugs in your cart?
IV preparation in the ED
• Are nurses compounding/mixing activase and tenecteplase?
• Has pharmacy conducted in-service programs and developed quality control procedures for compounding IVs?
MERP Activities
• NICU• Radiology• Nuclear Medicine• Conduct med pass observations• Anywhere meds are stored/used
Department of Health and Human Services
OFFICE OF INSPECTOR GENERAL
ADVERSE EVENTS IN HOSPITALS:
NATIONAL INCIDENCE AMONG MEDICARE
BENEFICIARIES 11/2010
Department of Health and Human Services
OFFICE OF INSPECTOR GENERAL
HOSPTIAL INCIDENT REPORTING
SYSTEMS DO NOT CAPTURE
MOST PATIENT HARM
January 2012
Office of Inspector General Report
• 14% of events are reported Reason – don’t see the outcome as an error
• 11% of events that led to death reported• Medication = 38% of adverse events 13% reported Changes in mental status (delirium); excessive
bleeding, hypoglycemic event
CDPH Administrative Penalties
• AP amounts: $50,000 - $100,000• Issuance of an AP is accompanied with a press
release and posting on CDPH internet• Events generating administrative penalties: Medication or pharmacy related errors: 30% Patient care issues: 20% Retention of foreign object: 22%
Best Practices
“The department may work with the facility's health care community to present an annual symposium to recognize the best practices for each of the procedures and systems.”
[HSC 1339.63 (g)]
Med SET
• Objectives: Collect, quantify, and analyze medication safety data
reported from deficiencies written by Pharmaceutical Consultants
Categorize types of medication–related events associated with Federal/State deficient practices .
• Goals: Identify medication safety system vulnerabilities and
their trends Use Med SET data to inform and educate internal and
external providers on medication safety issues
Med SET
• Data extracted from Statement of Deficiencies• All facility types: SNF, GACH, Clinics, ESRD, etc.• Used MERP defined systems or procedures and
expanded• 12 categories with 85 sub-categories• Compare different facility types• Present level of harm
1. Prescribing2. Prescription order
communication3. Product labeling4. Packaging and
nomenclature5. Compounding6. Dispensing7. Distribution8. Administration9. Education10.Monitoring 11.Use
1. Prescribing2. Prescription order communication3. Product labeling, packaging and
nomenclature4. Compounding5. Dispensing6. Distribution7. Administration8. Monitoring 9. Competency10.Use11.Technology12.Transitions in care
MERP Med SET
28
Med SETMedication System Event Tracker
Error Categories - 20XX15
1
6
1 2 3 2 31 2 1
02468
101214161820
Presc
ribing
Rx Ord
er Comm
Produc
t Lab
el, P
ack..
.Compou
nding
Dispen
sing
Distrib
ution
Administrat
ionMon
itorin
gCompete
ncy UseTec
hnolog
y
Error Category
Num
ber o
f AP
Occ
urre
nces
Med SETMedication System Event Tracker
Prescribing
12
1
3 32 2
1 1
34
8
4
7
1
0123456789
10
Failure
to O
rder
Unauthoriz
ed Pres
cr...
Wrong Patien
t
Contra
indicate
d Med
...
Wrong Dosag
e Form
Wrong Dose
Wrong Freque
ncyWrong Rou
te
Wrong Duratio
n
Wrong Rate of In
fusion
Wrong Indica
tion
Unclea
r Orders
Informed
Consent
Unnec
essa
ry Med
Order S
ets
Error Subcategories
No.
of O
ccur
renc
es
MERP Program
• 2002 2005 2007 2008 2009• Stakeholder input meetings : 6 and 72 Notification AFL Simulation surveys: Survey Process AFL Surveys pre-announced
• 2010 – Program enhancement Survey Evaluation Survey Process – Document request Survey Questionnaire
• Medication Safety Symposium – 4 - 5