Embed Size (px)
Citation preview
Daniel S Sarasin DDS
MEDICATION SAFETY FOR DENTAL ANESTHESIA
GOAL
OPTIMAL ANESTHESIA OUTCOME
▸Alleviate patient’s anxiety and discomfort during surgery
▸Allow for the dentist to properly treat the patient
▸Deliver safe anesthesia and pain control
MEDICATION SAFETY =REDUCING/PREVENTING
MEDICATION ERRORS AND ADVERSE DRUG EVENTS
DEFINITION
ADVERSE DRUG EVENTAn injury due to medication use
▸Unpredictable event: idiosyncratic or allergic response▸Predictable and potentially avoidable
event: medication errors and side effects or toxic reactions of the drug
DEFINITION
MEDICATION ERRORFailure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
▸An error in prescribing, dispensing, administration, and monitoring
WHAT DO WE KNOW ABOUT MEDICATION SAFETY?
“Hum…Didn’t see dat in dental school!”
HEALTH CARE
MEDICATION ERRORS AND ADVERSE DRUG EVENTS IN MEDICINE
▸Key global public heath concern
▸Seen in a variety of health care settings
▸Dramatic growth in studies over the past 30 years
HEALTH CARE- HOSPITAL
PREVALENCE OF ADVERSE DRUG EVENTS AND THE COST
▸Colorado Utah Study- 2.9% of hospitalizations
▸6.6% led to death
▸New York Study- 3.7% of hospitalizations
▸13.6% led to death
▸Over half resulted from medication errors
HEALTH CARE- HOSPITAL 1997
WHAT DOES EXTRAPOLATING THIS INFORMATION TO OVER 33.6 MILLION
ADMISSIONS MEAN?▸Colorado Utah Study-
▸44,000 deaths each year due to ME
▸New York Study-
▸98,000 deaths each year due to ME
▸Total national costs of preventable adverse events are estimated to be between $17 billion and $29 billion
▸Over half represent health care costs
HEALTH CARE- HOSPITAL 2005
“A HOSPITAL PATIENT IS SUBJECT TO AT LEAST ONE MEDICATION ERROR PER
DAY”
▸MEs are commonly seen in all steps of the medication process
▸Most frequently occur at prescribing and administration stages
HEALTH CARE- OTHER CARE FACILITIES 2005
“OVER 1.3 MILLION PREVENTABLE ADVERSE DRUG EVENTS OCCUR IN OTHER HEALTH
SETTINGS IN THE U.S.”
▸Long-term care- at least 800,000
▸Ambulatory care- among outpatient Medicare patients alone- at least 530,000
▸Above data exclude errors of omission medication
INCIDENCE
DETERMINING THE INCIDENCE OF MEDICATION ERRORS AND ADVERSE DRUG EVENTS
▸Variety of methods are used to identify these problems
▸Self-reporting
▸Chart review
▸Direct observation
▸The accuracy of these assessment tools vary greatly
FLYNN EA, ET AL. AM J HEALTH SYST PHARM 2002, 59:436-46
COMPARISON OF METHODS FOR DETECTING MEDICATION ERRORS IN 36 HOSPITALS AND
SKILLED-NURSING FACILITIES
▸2,557 doses of medication were administered
▸Direct observation- 456 MEs were detected
▸Chart review- 34 MEs were detected
▸Self-reporting- 1 ME was detected
HOW DID MEDICINE REDUCE THE PROBLEM?
HEALTH CARE- HOSPITALS AND CLINICS
INITIATIVES TO REDUCE MEDICATION ERRORS AND ADVERSE DRUG
▸Develop a “medication safety” culture
▸Education
▸Improved error reporting
▸Learn from errors & near misses
▸Closely follow the incidence of MEs and ADEs and causes
HEALTH CARE- HOSPITALS AND CLINICS
INITIATIVES TO REDUCE MEDICATION ERRORS AND ADVERSE DRUG
▸Develop, implement, and monitor safety strategies
▸Drug administration following multiple checks
▸Utilization of technology safety advances
▸Formulation of clinical practice agreements
MEDICAL ANESTHESIA
MEDICATION ERRORS AND ADVERSE DRUG EVENTS IN ANESTHESIA
▸Anesthesia is not immune to these issues
▸Majority of studies are chart review or self-reporting
▸Anesthesia in ORs is one of the only health care settings that had not undergone vigorous assessment until recently
▸Few of the hospital safety measures were used
NANJI KC, ET AL. ANESTHESIOLOGY 2016; 124: 25-34
EVALUATION OF PREOPERATIVE MEDICATION ERRORS AND ADVERSE DRUG EVENTS
▸Prospective observational clinical trial using anesthesia trained study staff and chart review at Mass General
▸Approximately 1 in 20 medication administrations and every other surgery resulted in an ME and/or ADE
▸More than one third of the MEs caused patient harm
ANESTHESIA
STEPS INVOLVED IN PREOPERATIVE MEDICATION ADMINISTRATION
▸Ordering/obtaining/storage
▸Dispensing
▸Preparing
▸Administering
▸Documenting
▸Monitoring
ANESTHESIA
TYPES MEDICATION ERRORS
Labeling error Omitted/extra dose
Incorrect dose Inadvertent bolus
Wrong drug Wrong route
Wrong timing Improper drug management
ANESTHESIA
LABELING ERRORS▸No label
▸Incorrect label
▸Incomplete label
▸Wrong drug
▸Wrong concentration
▸Missing time of preparation
▸Missing time of expiration
ANESTHESIA
INCORRECT DOSAGE
▸More than one concentration of drug available
▸Switched concentration of drug- different vender
▸Inadequate understanding of pharmacokinetics/ pharmacodynamics of drug
▸Calculation error
AVIDAN A, ET AL. J CLIN ANES 2014; 26:276-80
ANESTHESIOLOGISTS’ ABILITY IN CALCULATING WEIGHT-BASED CONCENTRATIONS FOR PEDIATRIC
DRUG INFUSION
▸Faculty and residents were asked to calculate amount of drug and amount in ml to be drawn up from a standard vial to be added to a 50ml syringe to reach a specific infusion rate
▸Only 15% were correct
▸61% had significant calculation errors
▸12% miscalculated the amount of drug to be drawn up
▸Drug concentration ranged from 50X to low- 56X to high
ANESTHESIA
IMPROPER DRUG MANAGEMENT
▸Use of a multi-dose vial on more than one patient
▸Improper storage
▸Improper disposal
▸Leaving a controlled substance unintended
ANESTHESIA
INITIATIVES TO REDUCE THE INCIDENCE OF PERIOPERATIVE MEDICATION ERRORS AND
ADVERSE DRUG EVENTS
▸Improve medication safety education
▸Implement safety strategies▸Technology-based interventions
▸Process-based interventions
ANESTHESIA
ME AND ADE CONTRIBUTING FACTORS
▸Distraction
▸Haste/stress/outside pressure
▸Fatigue/long surgery
▸Inadequate knowledge, communication, patient information
ANESTHESIA
ME AND ADE CONTRIBUTING FACTORS
▸Look alike/sound alike drugs
▸Misread vial or label on syringe
▸Unexpected/unfamiliar drug
▸Severity of patient comorbidity/ high # of drugs administered
ANESTHESIA
INITIATIVES TO REDUCE THE INCIDENCE OF PERIOPERATIVE MEDICATION ERRORS AND
ADVERSE DRUG EVENTS
▸Technology-based interventions
▸Point of care bar code-assisted anesthesia document systems
▸Specific drug assisted support
▸“Smart” infusion devices with drug libraries
ANESTHESIA
INITIATIVES TO REDUCE THE INCIDENCE OF PERIOPERATIVE MEDICATION ERRORS AND
ADVERSE DRUG EVENTS
▸Process-based interventions
▸Change the timing of drug documentation
▸Connect infusions to the most proximal intravenous port
▸Use prefilled/premixed syringes and infusions prepared by pharmacy
ANESTHESIA
APSF INITIATIVE TO IMPROVE MEDICATION IN THE OR (STPC PARADIGM)
▸Standardization
▸Technology
▸Pharmacy/Prefilled/Premixed▸Culture
ANESTHESIA
INITIATIVES TO REDUCE THE INCIDENCE OF PERIOPERATIVE MEDICATION ERRORS AND
ADVERSE DRUG EVENTS
▸Safety strategies must be realistic, practical, and effective
▸Implementing technologic-based initiatives are costly
ANESTHESIA
INITIATIVES TO REDUCE THE INCIDENCE OF PERIOPERATIVE MEDICATION ERRORS AND
ADVERSE DRUG EVENTS
▸Some safety measures have minimal costs▸Minimize distractions and interruptions▸Use of closed loop communication▸Use of drug calculator aids▸Nomograph for calculating max dosage▸Pediatric emergency drug calculator
IT SEEMS SO SIMPLE
WHAT DO WE KNOW ABOUT MEDICATION SAFETY?
NOT AS MUCH AS WE SHOULD
DENTAL ANESTHESIA
MEDICATION ERRORS AND ADVERSE DRUG EVENTS IN DENTAL ANESTHESIA
▸There is a paucity of literature on these issues
▸The incidence of MEs and ADEs is unknown
▸Dental anesthesia studies like Nanji did, would be great
▸They won’t happen
DENTAL ANESTHESIA
MEDICATION ERRORS AND ADVERSE DRUG EVENTS IN DENTAL ANESTHESIA
Is this the best way to learn about MEs and ADEs?
DENTAL ANESTHESIA
▸Medication safety lags far behind most health care settings including ORs
▸We can only assume the types of MEs and actual or potential ADEs are occurring are similar to those occurring in the hospital ORs
MEDICATION ERRORS AND ADVERSE DRUG EVENTS IN DENTAL ANESTHESIA
ANESTHESIA
TYPES MEDICATION ERRORS
Labeling error Omitted/extra dose
Incorrect dose Inadvertent bolus
Wrong drug Wrong route
Wrong timing Improper drug management
DENTAL ANESTHESIA
REDUCING MEDICATION ERRORS AND ADVERSE DRUG EVENTS IN DENTAL ANESTHESIA
▸We can’t duplicate all safety initiatives our medical anesthesia colleges have or will implement
▸Technologic differences
▸Lack of pharmacy support
▸Exorbitant costs
DENTAL ANESTHESIA
REDUCING MEDICATION ERRORS AND ADVERSE DRUG EVENTS IN DENTAL ANESTHESIA
▸There are many safety initiatives that can be incorporated in our offices
▸There will be costs
Patient safety is worth it!
DENTAL ANESTHESIA
DENTAL ANESTHESIA MEDICATION SAFETY PARADIGM (DAMSP)
▸Improve medication safety awareness/education▸Know the patient▸Know the drugs▸Proper management of anesthesia and
emergency medications
DENTAL ANESTHESIA
DAMSP: IMPROVE MEDICATION SAFETY AWARENESS / EDUCATION
▸Drug safety education for all▸Heighten awareness of medication safety▸Reducing MEs and ADEs is everyones job▸Careful assessment of what we are and aren’t
doing▸Learn from our errors and near misses
DENTAL ANESTHESIA
DAMSP: KNOW THE PATIENT▸Comprehensive workup is necessary▸Review of all medications/supplements
patient is using and allergies▸Review potential drug interactions:
patient’s medication and proposed anesthetic agents
▸Develop an individualized anesthetic plan
DENTAL ANESTHESIA
DAMSP: KNOW THE PATIENT▸Develop an individualized anesthetic plan▸Including alteration of the patient’s
medication/supplement regimen*▸Day of anesthesia/sedation ▸Assessment preoperatively- update health history,
reconciliation of patient’s medications, and compliance with recommendations▸Review anesthesia plan*
DENTAL ANESTHESIA
DAMSP: KNOW THE DRUGS
▸Understand and review all the anesthetic drugs in the office▸Educate everyone in the safe use of a
drug prior to adding a new medication▸Pharmacokinetics and
pharmacodynamics vary between age groups
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF ANESTHESIA AND EMERGENCY
AGENTS▸Medication management begins with
ordering drugs from vendors and ends with discarding unused/expired drugs▸Errors can occur at any step in the
process
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF ANESTHESIA AND EMERGENCY MEDS-
OBTAINING DRUGS▸Limit vendors/pharmacies you work with▸Order correct medication and concentration▸Avoid more than one concentration of a
drug▸Inspect the drugs received before using▸Appropriate logging and drug storage
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF ANESTHESIA MEDS- PREPARING DRUGS
▸Filling syringes
▸Tasks done in a clean, quite place
▸Done with two people*▸Check the drug/concentration
▸Utilize strict sterile technique▸Combined medication syringes*
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF ANESTHESIA AND EMERGENCY MEDS-
PREPARING DRUGS▸Labeling syringes▸Place labels on syringes immediately after
they are filled▸Label should have drug/concentration/time
of preparation and expiration
▸Color coding for look alike/sound alike drugs
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF ANESTHESIA AND EMERGENCY MEDS- ADMINISTRATION,
DOCUMENTATION AND MONITORING ▸Should occur simultaneously▸Concerted effort by everyone is required▸Focus is on one thing- Patient▸Closed loop communication▸Critical language protocol- “Stop phrase”▸Reduce outside distractions/interuptions
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF ANESTHESIA AND EMERGENCY MEDS-
DISCARDING DRUGS ▸Proper disposal of unused/expired
medications ▸Immediately after anesthesia▸Witnessed▸Avoid the sink
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF EMERGENCY MEDICATIONS
▸Understanding and periodic review by everyone ▸Recall of vital drug information during an
emergency is problematic▸Use small note cards next to the drug▸Use emergency flow charts/algorithms▸Practice “preparation for the worst case”
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF EMERGENCY MEDICATION- PEDIATRICS
▸Preprinted emergency drug sheet▸Use of a pediatric emergency drug
calculator (e.g. Rollert pediatric calculator- adsahome.org)
▸Broselow strip
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF EMERGENCY MEDICATION- ALL
PATIENTS▸“Ten minutes saves a life” app▸Download from adsahome.org▸Emergency algorithms and drug calculator▸Designed for three levels of anesthesia
providers
DENTAL ANESTHESIA
DAMSP: PROPER MANAGEMENT OF EMERGENCY MEDICATION- DRUG KITS
▸Use of pharmacy prepared emergency drug kits▸Reduce medication delivery time and
medication preparation errors▸Are they available? Are they practical?
DENTAL ANESTHESIA
IMPLEMENTING A DENTAL ANESTHESIA MEDICATION SAFETY PLAN IN AN OFFICE
▸Making changes to reduce MEs and ADEs can be a daunting costly task▸Resistance to change▸“If it ain’t broke… why fix it?”
DENTAL ANESTHESIA
“IF IT AIN’T BROKE… WHY FIX IT?”
▸It all comes down to how we look at medication errors and adverse drug▸Retrospective- easy and comfortable (Oster
study)▸Prospective- difficult and uncomfortable
(Nanji study)
Type to enter a caption.
OSTER BA, ET AL. CAN J ANAETH 2001; 48:139-46
MEDICATION ERRORS IN ANESTHESIA PRACTICE: A SURVEY OF 687 PRACTITIONERS
▸Survey study reported than 85% of anesthesiologist reported at least one drug error or near miss during their careers
NANJI KC, ET AL. ANESTHESIOLOGY 2016; 124: 25-34
EVALUATION OF PREOPERATIVE MEDICATION ERRORS AND ADVERSE DRUG EVENTS
▸Prospective observational clinical trial using anesthesia trained study staff and chart review at Mass General
▸Approximately 1 in 20 medication administrations and every other surgery resulted in an ME and/or ADE
▸More than one third of the MEs caused patient harm
DENTAL ANESTHESIA
IMPLEMENTING A DENTAL ANESTHESIA MEDICATION SAFETY PLAN IN AN OFFICE
▸Institute safety strategies in all of the DAMSP areas
▸Awareness/Education is essential for compliance
▸Introduce multiple changes and revisit/modify existing protocols over time “baby steps”
▸Evaluate how they are working and the burden created with incorporating the strategies
DENTAL ANESTHESIA
IMPLEMENTING A DENTAL ANESTHESIA MEDICATION SAFETY PLAN IN AN OFFICE
▸If safety initiatives are perceived as “to much of a burden” compliance will be low
▸The benefits seen by implementing a medication safety plan to reduce MEs are unknown… it just makes sense. It’s like getting life insurance for ourselves
“KNOWING IS NOT ENOUGH; WE MUST APPLY.WILLING IS NOT ENOUGH; WE MUST DO.”
Goethe
QUESTIONS?
THANK YOU
