Improving the Quality of Care: Infrastructure

Quality of Care• Designate a patient-safety officer and form a multidisciplinary patient-safety team.

Although it is important to stress that medication safety is the responsibility of all individuals involved in the medication-use process, supervision of the process should be delegated to a patient-safety officer. This individual should be charged with ensuring that medication-safety efforts are coordinated throughout the organization, across departments and committees. A multidisci-plinary team, reporting to the P&T committee (the team could be the P&T committee itself, in smaller facilities), should exist to promote medication-safety issues. Such a team must include front-line staff, management, and medical staff. A physician champion should be identified, as he/she is critical to gaining buy-in from medical staff.

• Use clinical pharmacists in high-risk patient care areas. Numerous studies have shown that incorporating a pharmacist into the patient-care team can positively affect patient safety. Priority should be given to the high-risk areas of the organization (e.g., oncology, critical care, transplant services), where drugs with a lower margin of safety are commonly used. The challenge in today’s environment is convincing hospital administration of the economic necessity of providing such services. Also, given the present shortage of pharmacists in many areas of the country, pharmacy directors must be creative in allocating the necessary time for pharmacists.
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• Establish area-specific guidelines for drug stock. Organizations must take a critical look at the medications that are stocked outside of the pharmacy on patient-care units. Medications must be assessed from a safety perspective to determine their appropriateness for a given unit. The skill level of the caregivers on the unit, as well as their ability to monitor response to the medications and respond to problems, must be considered. The physical setup of the drug stock (even within an automated dispensing unit) should separate look-alike or sound-alike drugs from one other, so as to minimize the chance of confusing the drugs. Drugs should be in a form that requires minimal manipulation by caregivers prior to administering them to patients. Ideally, automated dispensing units would interface with the pharmacy profile so that, with the few exceptions allowed by JCAHO, medications cannot be removed unless they have been reviewed and approved by a pharmacist.

• Establish protocols for obtaining and communicating essential patient information.

The safe use of medications requires that appropriate patient information (e.g., allergies, height, weight, and laboratory values) be available to the caregiver at the time of medication ordering/processing/administration. Information systems and order forms should be designed to capture the information deemed necessary by the organization and regulatory bodies. Information systems that are integrated across departments can ensure that such information is available. For example, an interface that uses the patient’s serum creatinine, height, and weight can calculate an estimated creatinine clearance; this information can then be presented to the user at the time of order entry/processing for medications requiring adjustment for renal function. Procedures for ensuring the proper identification of inpatients and outpatients prior to medication administration should also be included in this action goal. canada viagra online

Clinical Practice

• Eliminate dangerous abbreviations and dose designations. Traditionally, organizations have published lists of approved abbreviations that may be used in the medication-ordering process. However, despite these lists, other abbreviations continue to be used, many of which cause confusion and resultant medication errors. The P&T committee should consider developing a list of dangerous drug abbreviations and dosage conventions (e.g., simply writing ‘u” for units, failing to use a leading zero). This list must be promulgated to the medical, nursing, and pharmacy staffs during orientation and on an ongoing basis. Computer systems, pre-printed order sets, protocols, and clinical pathways should be assessed for the presence of these abbreviations. The organization might consider providing constructive feedback to practitioners who continue to use inappropriate order conventions.

• Implement strategies for high-alert drugs.

JCAHO requires organizations to identify high-alert medications used within their facilities. This should be a function of the P&T committee, and a plan of action should be developed to minimize the risk of errors with these drugs. For example, the committee might limit the number of locations in which a given medication may be stored, restrict who may administer the medication, or require a documented doublecheck of the medication by two caregivers prior to drug administration. A process to formalize the potential actions to be taken to minimize the potential for error with high-alert drugs will likely show that an organization already carries out a number of proactive steps without a formalized process in place.

•  Implement safety checklists for infusion pumps.

Despite advances in infusion-pump technology, errors continue to occur with these devices, and because the more dangerous drugs are often administered via a pump, the potential effects of an error can be serious. The P&T committee, or the committee that deals with biomedical safety equipment, should ensure that personnel who use infusion pumps have documented training in their use; the safety checklists for the use of the pump are available to staff (ideally, the checklist should be attached to the pump); and that the biomedical department assesses infusion-pump safety and performance.

•  Develop limitations and safeguards for verbal orders.

Verbal orders are another source of potential errors because orders can be misinterpreted when given by a physician to another care provider. Institutional policy should limit those circumstances in which a verbal order may be taken, and should outline the procedure to be followed by the individuals giving and receiving the orders. In view of the widespread availability of fax machines, the transmission of a written copy of an order or outpatient prescription is preferable to verbal transmission.

•  Perform failure mode and effects analysis as part of drug and equipment procurement.

Failure mode and effects analysis (FMEA) is a proactive root-cause analysis (i.e., an effort to predict what errors could occur, and building safeguards into the system to prevent or minimize the effects of such errors). P&T committees should conduct an FMEA on each medication being considered for addition to the formulary. The analysis should examine each point in the medication process (ordering, storing, dispensing, administering, and monitoring) to determine potential ‘failure modes.” Involvement of front-line staff is critical to ensuring the validity of the analysis. The results of the FMEA can be used to determine whether a drug is to be considered high-alert. FMEA can also be applied to the purchase of equipment or when a new brand/manufacturer of a formulary product is being considered.
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•  Implement triggers and markers to indicate potential adverse medication events.

The P&T committee should work to develop a list of triggers that can be used to identify actual or potential medication errors, adverse drug reactions, or problems with medication use. For example, an increase in the use of Vitamin K injection (the trigger) could signal a problem with the prescribing of warfarin, or a laboratory problem with measuring the international normalizing ratio (INR). As another example, an information system could be used to alert a physician when a patient is receiving a potentially nephrotoxic drug, and a significant increase in serum creatinine has occurred. Depending on the capabilities of the information system used, an organization can effectively use triggers to improve the care of its patients.

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Tags: Infrastructure, PROGRAM CONTENT

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