Unsafe Use of Drugs:Death and Harm: Unsafe Use of Drugs: Death and Harm Presented by John M. Kessler, Pharm. D., B.C.P.S. Assistant Director of Pharmacy Duke University Medical Center


Safe Medication Use: Safe Medication Use What does it mean to be “unsafe”? Accidents, slips, mistakes? Failure to act? Unforeseen adverse reactions? Unforeseen adverse interactions? Poor judgment?


Safe Medication Use: Safe Medication Use Which are medication errors? 2.2 kg = 1 pound Aspirin EC 325mg now heart attack Insulin 20 U SQ now and repeat daily LDL-chol of 180 mg% (untreated) after stroke Salmeterol 2 puffs now for breathing


Safe Medication Use: Safe Medication Use Which are medication errors? Treating an infant’s fever with aspirin Hypotension after vancomycin inj. Prescribing warfarin and aspirin together Dispensing prescriptions for prenatal vitamins and captopril


Safe Medication Use: Safe Medication Use Safety is CREATED when there is good planning AND good execution


Safe Medication Use: Safe Medication Use Harm is CREATED when there is an active error (mistake) AND injury to a patient (or lack of the desired effect)


Safe Medication Use: Safe Medication Use Harm is REDUCED when an active error (mistake) AND injury to a patient are detected at the earliest possible time


Safe Medication Use: Safe Medication Use REDUCING HARM is a PRIMARY GOAL of our Medication Safety Program


Safe medication use: reducing harm: Safe medication use: reducing harm Making Health Care Safer: A critical analysis of patient safety practices Agency for Healthcare Research and Quality (AHRQ) July 18, 2001 www.ahqr.gov


Safe medication use: reducing harm: Safe medication use: reducing harm Very High Evidence of Effectiveness Appropriate pre-operative antibiotics Patient self-monitoring of warfarin Perioperative beta-blocker use in non-cardiac surgery


Safe medication use: reducing harm: Safe medication use: reducing harm High Evidence of Effectiveness Monitoring high alert drugs (e.g. KCl, heparin, antibiotics, morphine) Decreasing drug-induced delirium Improving pain control with non-drug therapies


Safe medication use: reducing harm: Safe medication use: reducing harm High Evidence of Effectiveness Information sharing between outpatient and inpatient pharmacies Supplemental O2 decreases surgical site infections Gut decontamination reduces rate of ventilator-associate pneumonias


Safe medication use: reducing harm: Safe medication use: reducing harm Moderate Evidence of Effectiveness Computerized doctor order entry Clinical pharmacist consultations Perioperative glucose control Anticoagulation services/clinics Pneumococcal/influenza vaccines


Safe medication use: reducing harm: Safe medication use: reducing harm Moderate Evidence of Effectiveness Prevention of GI stress ulcers/bleed Multidisciplinary pain consult team Antibiotic guidelines resistance Protocols for high alert drugs (e.g. heparin)


Safe medication use: reducing harm: Safe medication use: reducing harm Moderate Evidence of Effectiveness Computerized doctor order entry Clinical pharmacist consultations Perioperative glucose control Anticoagulation services/clinics Pneumococcal/influenza vaccines


Safe medication use: reducing harm: Safe medication use: reducing harm Lower Evidence of Effectiveness Heparin flush central line infection Automated drug dispensing devices Bar coding for patient identification Unit dose drug distribution Sucralfate vent. pneumonia


Dangerous Medications: Dangerous Medications Concentrated drugs and large volume containers can kill Potassium (KCl, KPO4, K- acetate) Epinephrine 1 ml and 30 ml vials Bulk chemotherapy vials Vasopressor - mcg/min, mcg/kg or mcg/kg/min?


Unsafe Medication Practices: Unsafe Medication Practices “Line switches” can be deadly high risk - drugs administered by continuous infusion IV pumps must trace lines from IV to patient use “change of shift” line checks environmental control - (e.g. good lighting, minimize distractions)


“Line switches” can be deadly: “Line switches” can be deadly Intensively monitor these IV’s- difficult to detect adverse events Insulin (before and after infusion) Heparin (before and after infusion) Electrolytes (K, Mg, Ca) Thrombolytics (tPA)


“Line switches” can be deadly: “Line switches” can be deadly Intensively monitor these IV’s- easier to detect adverse events Morphine/opiate analgesics Dopamine, norepi, epi, isoproterenol Midazolam


Safe Medication Use: Safe Medication Use Monitoring for safety and efficacy Sedation (fentanyl and midazolam) Oxygen saturation Pain assessment and vital signs Level of consciousness Recovery to baseline after sedation


Safe Medication Use: Safe Medication Use Monitoring for safety and efficacy Antibiotic therapy Duration of use (minimize days of tx) Bacterial sensitivities (microbiology) Renal and liver function changes Drug levels (for selected drugs) Missed doses


Safe Medication Use: Safe Medication Use Monitoring for safety and efficacy Heparin Rate of administration Dose or rate change (high risk action) Write target aPTT or ACT Standardize concentration in IV bag.


Safe Medication Use: Safe Medication Use Monitoring for safety and efficacy Insulin infusions Standardize concentration in IV bag Monitor glucose Sliding scales can be dangerous Standardized order sets Dose adjustment plan (e.g. meals)


Safe Medication Use: Safe Medication Use Rules for safety and efficacy Verbal orders Not allowed for chemotherapy, investigational drugs, insulin, t’lytics Culture that allows and rules that require “checks” for accuracy Write orders immediately


Safe Medication Use: Safe Medication Use Rules for safety and efficacy Unsafe abbreviations for drug names (MS04, 5 FU, rPA, VCR) Standardized concentrations Pre-printed medication orders Standardized administration times


Institute for Safe Medication Practices: Institute for Safe Medication Practices ISMP (www.ismp.org) Michael Cohen, FASHP Awareness of cause of errors Self-assessment survey Non-punitive culture for reporting Use “forcing functions” to do right


Institute for Safe Medication Practices: Institute for Safe Medication Practices 2 Major Goals after the I.O.M. report Eliminate handwritten scripts within 3 years White paper on errors and technology (see website) Benchmarking survey of hospital practices Self-assessment with comparative reports to be available (1,435 usable responses) 194 questions 20 core distinguishing characteristics of a safe med system 5 degrees of implementation (not discussed……fully implemented)


ISMP’s 10 elements for self assessment: ISMP’s 10 elements for self assessment Patient information Drug information Communication of drug/patient information Package labeling, packaging, nomenclature Drug standardization, storage, distribution Delivery device acquisition, use, monitoring Environmental Staff education/competency Patient education Quality improvement and risk management processes


Education and Credentialling: Education and Credentialling In the United States, my automobile mechanic receives more training on his diagnostic machines, than most practitioners receive about new drugs!


Education and Credentialling: Education and Credentialling At Duke, all new Formulary items include a drug data sheet that lists unbiased comparative information and key criteria for monitoring safe and effective drug use. All new drugs have an educational plan when they are approved.


Education and Credentialling: Education and Credentialling 3 Levels of Education I - general announcements/news II - targeted group education III - individual credentialling (dofetilide, thalidomide, sedation, chemotherapy, epoprostenol)


Summary: Summary Creating safety means…. Identifying high alert medications Identifying high risk practices Developing effective drug monitoring Developing “safe” reporting systems Planning, monitoring, improving


Perguntas e Debates: Perguntas e Debates Obrigando a todos pela atenção e estou pronto para perguntas e debates