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Hospital Harm: Medication Incidents

Medication incidents are defined as: "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communication, product labeling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use" (ISMP Canada, Definitions 2016). Medication safety is a shared responsibility among the healthcare team members, staff, and organizational leadership.

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

To prevent medication-related events involving incorrect administration or dosage of medications during a hospital stay.

Overview and Implications

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

In the Canadian Adverse Events Study, drug- and fluid-related events were the second-most common type of adverse event (Baker et al., 2004). The Institute of Medicine (IOM) Committee on Identifying and Preventing Medication Errors estimated that at least 1.5 million preventable adverse drug events (ADEs) occur each year in the United States (Aspden et al. 2006). The Institute of Medicine report, To Err is Human: Building a Safer Health System, identified medication events as the most common type of adverse event in healthcare and highlighted that in the U.S., preventable medication events resulted in up to 7,000 deaths per year in hospitals and tens of thousands more in outpatient facilities.

A study by Lucian Leape and colleagues identified the frequency of occurrence of error at each stage of the hospital medication use process: prescribing 39 per cent, order processing and transcription 12 per cent, dispensing 11 per cent and administration 38 per cent. Nearly half of the prescribing errors were intercepted by nurses and pharmacists and about one third of transcription errors were identified and corrected prior to administration. However, only two per cent of errors occurring at the administration stage were intercepted (Leape et al. 1995). Several more recent studies have assessed the prevalence of medication incidents and cost to the health care system (Bell et al. 2011; Bishop et al. 2015; Scales et al. 2016; Lee et al. 2010).

High Alert Medications

High-alert (or high-hazard) medications are medications that bear a heightened risk of causing significant patient harm when they are used in error. The Institute for Safe Medication Practices (ISMP) reports that, although mistakes may not be more common in the use of these medications, when errors do occur, the impact on the patient can be significant (ISMP 2011). Examples of high-alert medications include anticoagulants, hypoglycemic agents, opioids, concentrated electrolytes, cancer chemotherapy and paralyzing agents. For a complete list, see ISMP High-Alert Medications in Acute Care Settings. Known safe practices can reduce the potential for harm as per IHI's "Implement High Alert Medication Safety Processes" (IHI 2012).

Medication Reconciliation

Communicating effectively about medications is a critical component of delivering safe care. By identifying and resolving medication discrepancies, the likelihood of adverse events occurring within health care organizations across the continuum of care will be reduced (Accreditation Canada et al. 2012).

Medication reconciliation is a three-step process in which healthcare providers work together with patients, families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care (Safer Healthcare Now! 2017). Medication reconciliation requires a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully evaluated. It is an essential component of medication management and will inform and enable prescribers to make the most appropriate prescribing decisions for the patient. The literature regarding the potential impact of medication reconciliation continues to expand. The reconciling process has been demonstrated to be a powerful strategy to reduce ADEs as patients move from one level of care to another (Alex et al. 2016; Boockvar et al. 2011; Eggnik et al. 2010; Vira et al. 2006; Whittington, Cohen 2004; Rozich et al. 2004; Mekonned et al. 2016; Michels, Meisel 2003).

Never Events

(Canadian Patient Safety Institute, 2015)

A Never Events Report for Hospital Care in Canada includes Five Pharmaceutical Never Events that result in serious patient harm or death, and that can be prevented by using organizational checks and balances:

  • Wrong-route administration of chemotherapy agents, such as vincristine administered intrathecally (injected into the spinal canal).

  • Intravenous administration of a concentrated potassium solution.

  • Inadvertent injection of epinephrine intended for topical use.

  • Overdose of hydromorphone by administration of a higher-concentration solution than intended (e.g., 10 times the dosage by drawing from a 10 mg/mL solution instead of a 1 mg/mL solution, or not accounting for needed dilution/ dosage adjustment).

  • Neuromuscular blockade without sedation, airway control and ventilation capability.

Capturing information about the incidence of never events and sharing the learning from reviews of incidents will be key to following system safety progress over time.

Importance to Patients and Families

Patients and families can play an important role in reducing errors and harm to the patient when they understand what medications the patient is taking and why (IHI, 2012).

Patient Story

One son-in-law's pursuit to change the system.

Claire Friedman was not the typical mother-in-law of sitcoms and punchlines. She was active, vibrant and loved by friends and family. So when Bernie Weinstein walked into the hospital that day in 2002 and saw his mother-in-law restrained in a chair, he was shocked.

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of Medication Incidents, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: A10: Medication Incidents

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Concept: Medication-related events involving incorrect administration or dosage of medications identified during a hospital stay.

Notes: This clinical group does not include events caused by medications in therapeutic use.

Success Stories

Implementing MedRec at Horizon Health Network

At Horizon Health Network (Horizon), the Patient Safety Consultants: Diane Beaulieu (Saint John), John Glidden (Miramichi), Paula Pickard (Fredericton), and Melissa Stark (Moncton) are ambassadors for patient safety in their respective areas. They are passionate in assisting staff and teams with the implementation of medication reconciliation (MedRec). As a means to maintain the momentum for MedRec, they acknowledge and commend the staff for their hard work and dedication with this patient safety initiative. They recognize that quality MedRec can be unsuccessful if it is not kept at the forefront. However through persistence and use of a quality improvement framework which includes conducting small tests of change, constant monitoring, and evaluation - MedRec processes are becoming established and embedded in Horizon's organizational culture. ….. (Canadian Patient Safety Institute 2015).

Toolkit for Safe Implementation of Insulin Pens

Insulin safety is a key priority nationally for healthcare organizations, the Institute for Safe Medication Practice (ISMP) Canada and provincial governments. There is a growing interest in the adoption of insulin pens in the hospital setting as a means to improve insulin administration safety and ensure continuity of insulin product use by the patient from the community to the hospital setting and at discharge… (Health Standards Organization 2015).

References

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