Errors in community and hospital settings - Part 2

Question 1

Canadian Medication Incident Reporting and
Prevention System (CMIRPS)

Answer 1

● Health Canada - Funder
● The Canadian Institute for Health Information (CIHI) - National System for
Incident Reporting (facilities)
● The Institute for Safe Medication Practices Canada (ISMP Canada) -
healthcare practitioner / community pharmacies / consumers
● Canadian Patient Safety Institute (CPSI) - communication and coordination
Global Patient Safety Alerts

Question 2

high alert drugs

Answer 2

insulin - improper dosing, missing doses
hydromorphone - OD
morphine
acetaminophen etc

synthroid metformin

Question 3

What is Happening to Cause Harm?

Answer 3

● Health care professionals: training to do certain tasks
● Patients: complexity of their conditions, their education
● Work environment: worl=kload, time, distractions is big, changing from one activity to another
● Medications: naming of meds, tallman letting
● Tasks
● Information management systems
● Shared care of patients

lack of traiing with procedures

Question 4

Step 2 - Learn From Others

Answer 4

● ISMP Canada Safety Bulletins
● ISMP Medication Safety Alerts (US)
○ US based - some alerts are not applicable in Canada
● Provincial Regulatory Bodies
○ Patient Safety Communications
● Colleagues
○ Networks
○ Corporate pharmacy chains

Question 5

Step 3 - Implement

Answer 5

● Implement strategy based on situation
● Staged approach to effectiveness
1. Forcing / constraints (ideal)
2. Automation / computerization
3. Protocols / Standard order forms
4. Independent double checking
5. Rules / policies
6. Education / training

dec level of effectiveness

Question 6

(1) Forcing / Constraints

Answer 6

● Most effective tool as a prevention strategy
● Ideally, makes it impossible to create an error
Example: HYDROmorphone (prescribing / transcribing / dispensing /
administering)
● Most common mistake - mix up between hydromorphone and morphine
● Hydromorphone is 4X more potent than morphine (orally)
● Hydromorphone is 7X more potent than morphine (parenterally)
● Parenteral hydromorphone is 20X more potent than oral morphine

Question 7

(2) Automation / Computerization

Answer 7

● Decrease reliance on human memory / knowledge
● Less effective than “constraints” as there is an override opportunity by the
user
Example: HYDROmorphone (prescribing / transcribing)
● Computerized Physician Order Entry - integrated with drug information
database for drug interaction / dosing / “hard stop” restrictions for high alert
medications

Question 8

(3) Protocols / Standard Order Forms

Answer 8

● Removes communication and transcription errors
Example: Post op medication orders (prescribing / transcribing)
● Any patients requiring pain management post surgery have a set protocol for
nursing / pharmacy staff to follow

Question 9

(4) Independent Double Check

Answer 9

● Two people involved
● Relies on the unlikelihood of two people making the same mistake
● Still prone to human error - trying to detect errors rather than prevent error
Example: Dispensing medications in a community pharmacy

Question 10

(5) Rules and Policies

Answer 10

● Defines best practices to be followed (should create consistency)
● Can be considered a “work around” instead of actually fixing a system related
issue / concern
Example: Checklists for dispensing / counselling

Question 11

(6) Education & Training

Answer 11

● Considered the weakest tool to prevent patient safety incidents
● Relies on humans to complete / absorb / implement
● Always needed, but weakest evidence supporting effectiveness

Question 12

Scenarioscenario

● Investigation reveals T.O. received the wrong medication because of several
factors
1. Pharmacy Assistant 2 selected the wrong medication in the pharmacy dispensing system
when entering the prescription into the system
■ They used “met2.5” in their search for the drug
■ Methotrexate 2.5mg was on the prescription label that was generated
■ The pharmacy does not require staff to document the indication for the prescription in
the pharmacy dispensing system (PA2 did not ask what the medication was used for)
2. Pharmacist Assistant 2 then filled methotrexate 2.5mg tablets CORRECTLY according to the
label (bar code scanning matched drug selected and label)
3. Pharmacist C checked the prescription. The Pharmacist was the only pharmacist on shift and
it was very busy - they checked 20 prescriptions in the hour that the methotrexate prescription
was filled - they thought it was a refill prescription and not NEW for the patient. They DID NOT
review the physical prescription. No one counselled the patient on the medication.

Answer 12

1. Pharmacy information system automatically populates SIG as once a week
   when methotrexate tablets are chosen (2)
2. Pharmacy information system has a hard stop - requires indication entered
   before allowing the prescription to be filled and validated by a RPh (2)(4)
3. Implement a policy to require a TWO PERSON check at the computer entry
   stage before a prescription label is generated (4)(5)
4. Train staff on HIGH ALERT medications and risk of harm to increase their
   level of attention to this medication (6)