UNIVERSITY OF MICHIGAN – DEPARTMENT OF PHARMACY SERVICES

 

ANNUAL REPORT FY2006

 

Pharmacy Home Page   |   ( Complete report in .PDF format - 404kb )

Welcome From the Department of Pharmacy Services   |   Inpatient Drug Distribution Services   |   Clinical Pharmacy Services
Ambulatory Pharmacy Services   |   Medication Safety   |   Drug Information and Investigation Services
Research and Education   |   HomeMed Services   |   Computerization and Automation
Continuous Quality Improvement   |   Purchasing, Inventory, Management, and Distribution   |   Business Operations

MEDICATION SAFETY

 

 

John Mitchell, Pharm.D.

Coordinator
 
The Institute of Medicine’s Report, To Err is Human, followed by the 2006 report, Preventing Medication Errors, highlights the advantages for having a dedicated individual who reviews each medication incident and helps to maintain the integrity of the database that is used to analyze and focus attention on important areas for improvement.  The Medication Safety Coordinator for the department focuses his attention on a variety of activities.  Working in close collaboration with the Risk Management Department, the coordinator reviewed nearly 2,400 reported medication incidents in the past fiscal year.  Though most reports originate from the hospitals, medication incidents are reported from throughout medical system, including offsite locations such as our Brighton and East Ann Arbor locations.  Pharmacy-related errors (approximately 15% of the total reports) precipitate a more exhaustive review.  Whenever possible, the coordinator notifies those staff members involved with the incident and seeks their input as to system and personal changes that can be made to minimize the potential of a similar event in the future.  This type of collaborative, non-punitive interchange of ideas has stimulated many changes, some of which include:

 

·         Implementation of PCA “smart pump” technology

·         Revision and revision, as needed, of the hospital’s intrathecal policy

·         Numerous additions to our computerized dose-checking program

·         Inclusion of standard indications for use on the MAR for those drugs which have a single use indication

 

Throughout the year, the Medication Safety Committee has worked closely with the hospital’s computer team, which is charged with implementing computerized prescriber (CPOE) order entry before the end of 2006.  Literature suggesting that CPOE potentially could inject new errors into the healthcare process made this collaborative effort a high priority to reduce that potential. 

 

 

Medication Safety Committee (MedSafe)

 

The Medication Safety Committee is a multi-disciplinary group of clinicians who are dedicated toward improving the safe use of medications throughout our healthcare environment. The committee is represented by medical, pharmacy, and nursing staffs as well as members from Risk Management, Quality Improvement, and HomeMed (see membership list below).  The committee, which meets monthly, is advisory in nature and reports directly to the hospital’s Pharmacy and Therapeutics Committee.  MedSafe engaged in a wide range of activities during the past fiscal year.  Some of these include:

 

·         Selectively reviewed a number of the 2391 medication safety incident reports submitted in the past 12 months.

 

·         In compliance with JCAHO revisions, UMHS changed its list of unapproved abbreviations eliminating AU, AS, and AD.

·         Conducted a thorough analysis of Ultravist contrast media reactions; advised P&T to allow continued use of Ultravist when it appeared that the number of serious adverse reactions trended downward with less Emergency Department visit requirements.

·         Text Box: Primary Goals of the Medication Safety Committee 1. Reduce error rates for error-prone processes 2. Review and Analyze Adverse Drug Reactions 3. Review and Analyze Medication Errors 4. Conduct External Data Reviews 5. Promote and Conduct Staff Education 6. Enhance Medication Error Reporting 7. Cultivate a Non-punitive Environment Added a key member of the UM CareLink team to the committee to help coordinate medication safety efforts with those being considered for computerized order entry.

·         Supported efforts during Pain Awareness Month by providing pens to staff imprinted with the statement “Medication Safety:  1 mg Dilaudid = 10 mg morphine”.

·         Proposed several changes to the Patient Care Orders Policy as a result of an event that may have been precipitated by the use of homeopathic medication.

·         Approved a list of standard PRN medications with single indications and requested Pharmacy to add those indications to the instruction line of the MAR.

·         In response to a JCAHO sentinel event review, changed the process for dispensing vincristine from a syringe to a 25-mL IVPB (except in pediatric patients with fragile veins or who cannot cooperate during the slow IVPB infusion).

 

 

Interdepartmental Activities

 

Medication Safety belongs to every member of the healthcare team who comes into contact with our patients.  Risk Management plays a large role in providing a content-rich database for all reported patient safety incidents, including medication safety reports.  The medication safety coordinator meets with members of the risk management team and nursing on a regular basis to discuss both individual significant events and cumulative data that suggest trends requiring the attention of MedSafe.  

Patient Safety Rounds are conducted bi-weekly and headed by the Office of Clinical Affairs (OCA).  These rounds provide an avenue for staff members to voice issues and concerns regarding systems that may subject a patient to errors.  The medication safety coordinator is a permanent member of this rounding team. 

 

Serious adverse events and sentinel events result in the activation of multi-disciplinary teams that investigate the facts surrounding the event, determine the root cause(s) of the event, and develop an action plan to minimize the likelihood of the event reoccurring.  This team is launched after a review by OCA and usually includes physicians, pharmacists, nursing, risk management, and quality improvement.  Other disciplines may be included as the event warrants.

 

Quarterly reports are developed for the Continuous Quality Improvement Program Lead Team in consultation with quality improvement, risk management, pharmacy, and nursing.