CAH Medication Safety Assessment 2009 - 2010



CAH Medication Safety Assessment CAH facility name: CAH facility location: Site visit date:Site visit participants:Demographics:Hospital ownership:TJC accredited (Y/N/planning): Last TJC survey: Last survey findings (medication-related): Number beds (inpatient/swing/ICU): Number onsite pharmacist FTE: Pharmacist onsite hours:Number onsite pharmacy technician FTE:Surgeries performed: Pharmacy information system: ADC (vendor/locations):Lab system: Remote med review company: Interfaces available:Clinical decision support software:IV pumps: MAR: ER documentation/ordering system: ER volumes (visits/year): Electronic drug information reference (vendor/locations): IV chemotherapy preparation: CPOE: Pediatrics: Payer mix: Methods:The following standards and self-assessment tools were utilized to prepare the safety assessment:2004 ISMP Medication Safety Self Assessment2005 ISMP Medication Safety Self Assessment for Antithrombotic Therapy2009 ISMP Medication Safety Self Assessment for Automated Dispensing Cabinets2009 The Joint Commission National Patient Safety Goals2009 The Joint Commission Medication Management Standards2010 The Joint Commission National Patient Safety Goals for CAHIHI High-alert medication campaignVarious medication safety initiativesTreatment guidelinesPrior CAH site visit reportsSCORING KEY:A = There has been no activity or has been formally discussed and considered, but it has not been implemented.B = This item has been partially implemented in some or all areas of the organization.C = This item is fully implemented throughout the organization.N/A = Not applicable or not able to assess during site visitINDICATOR ASSESSMENT KEY:C = Chart reviewV = Visual observationI = InterviewP = Policy or other documentCLINICAL INFORMATION AVAILABILITYABCN/AIThe organization has the following information accessible to onsite pharmacist: age, sex, diagnoses, allergies, sensitivities, current medications, height and weight, pregnancy and lactation information, laboratory resultsIThe organization has the following information accessible to offsite pharmacist: age, sex, diagnoses, allergies, sensitivities, current medications, height and weight, pregnancy and lactation information, laboratory resultsIThe organization has the following information accessible to onsite prescriber: age, sex, diagnoses, allergies, sensitivities, current medications, height and weight, pregnancy and lactation information, laboratory resultsIThe organization has the following information accessible to offsite prescriber: age, sex, diagnoses, allergies, sensitivities, current medications, height and weight, pregnancy and lactation information, laboratory resultsIThe organization has the following information accessible to nursing staff: age, sex, diagnoses, allergies, sensitivities, current medications, height and weight, pregnancy and lactation information, laboratory resultsPCritical lab values are communicated in a way that allows immediate follow-up. All critical labs are included and have appropriate thresholds.ALLERGY INFORMATIONABCN/AIA nurse, pharmacist, or prescriber verifies that any patient allergy information collected is clinically accurateVPatient allergy information entered into the computer system is spelled correctly and properly coded to allow for pharmacy computer screening.CAllergy symptoms are documented in the patient medical record.VOrders cannot be entered into the pharmacy computer system until the patient’s allergies have been properly entered and coded (patient allergies is a required field).VThe pharmacy computer system automatically screens drugs to which patients may be allergic and provides a clear warning during order entry. IThe hospital has a written process to remove inaccurate allergy information from the patient medical record.CAllergies are listed and clearly visible on all pages (or screens) of medication administration records (MARs).CAllergy information is consistent across all documents in medical chartDRUG INFORMATIONABCN/AVCurrent drug information references are available in the pharmacy, nursing unit and emergency department. Outdated drug information references are not available.IDrug information updates for medication order entry are loaded at least quarterly. MEDICATION ORDERSABCN/ACIInclude the mg/kg dose for pediatric patients (under 40 kg) AND patient-specific dose for drugs with published pediatric mg/kg dosing guideline.CMedication-related documents do NOT contain any of the following: U, IU, qd, qod, trailing zero, lack of leading zero, MS, MSO4, MgSO4 CPhysicians write complete orders for all drug therapy that include dose, route, and frequency.COrders to “resume the same medications” or to “take medications from home” are not accepted.CAll PRN medication orders contain an indication for use.CPRN medication orders with duplicate indications are avoided OR administration instructions are clearly defined.P IVerbal or telephone orders are never accepted for oral chemotherapy.CINurse or pharmacist receiving a verbal order immediately writes it down and reads it back to the prescriber for verification.MEDICATION ORDER REVIEWABCN/AIBefore dispensing a pharmacist reviews all medication orders unless a licensed independent practitioner controls ordering, preparation, and administration or when a delay would harm the patient in an urgent situation.ITurn-around-times expectations for pharmacist review of medication order entry is established and monitored.IWhen pharmacy services are not available 24 hours a day, 7 days a week, a retrospective review of all medication orders during this period is conducted within a maximum of 24 hours. IThe pharmacist directly reports medication errors directly to the prescriber (not nurse) in a defined timeframe with recommendations for correction. CLINICAL DECISION SUPPORTABCN/AIThe pharmacy computer system performs clinical checks that include dose range, allergies, drug-drug interactions and contraindications. IThe decision support program is periodically reviewed for clinically insignificant and false positive alerts, and action is taken to minimize the appearance of these alerts.MEDICATION DISPENSINGABCN/AVCommercially prepared parenteral medications are dispensed whenever available. Includes heparin, antibiotics, maintenance IV infusions, TPN, potassium boluses, saline and heparin flushes, LMWH.VSpecially designed oral syringes, which cannot be connected to IV tubing, are used for oral liquid solutions not available in unit of use dosing cups.VMedications are dispensed in the most ready-to-administer forms available, and, if feasible, in unit dose. This includes less or more than a full tablet & warfarin doses.IV COMPOUNDINGABCN/AVLaminar airflow hood inspections are current. LAFH is cleaned appropriately prior to use.IA pharmacist, or pharmacy staff under the supervision of a pharmacist, compounds or admixes all sterile preparations except in urgent situations or when the product’s stability is short. MEDICATION LABELINGABCN/AVAuxiliary warnings or other label enhancements are used for sound-alike or high-alert drugs.VThe expiration date is present on opened injectable multidose vials.VMedication containers are labeled whenever medications are prepared but not immediately administered.VLabels are clear and distinctive free of error-prone abbreviations and nonessential information (e.g., computer MNEMONICS and other pharmacy codes).MEDICATION ADMINISTRATIONABCN/AVBar coding that utilizes at least two identifiers of the patient is used to verify patient identity during drug administration.VNurses (including nurse anesthetists) and physicians (including anesthesiologists) prepare and/or select one patient’s medications at a time, immediately before administering the medication.IStandard times for scheduled drug administration have been established and are consistently used on each unit throughout the organization.VUNIT-DOSE oral medications remain in the packaging up to the point of actual drug administration at the bedside.VBefore administration, the individual administering the medication: Verifies that the medication matches the medication order and product label.VBefore administration, the individual administering the medication: Verifies the medication has not expired.VBefore administration, the individual administering the medication: Verifies no contraindications exist.VBefore administration, the individual administering the medication: Verifies the proper administration time, the prescribed dose, and the correct route.VTwo patient identifiers are used when administering medications. The patient’s room number or physical location is not used as an identifier.VMARs are taken to the patient’s bedside for reference during drug administration.PThe hospital establishes a nursing double-check policy for high-alert medication administration that includes a check of the original order, the quantity of medication to be administered and setting of any infusion pump that may be required.PIf self-administration of medications is allowed, written processes that address training, supervision, and documentation are established. ISmart pumps with defined dose ranges are used for all infusions.MEDICATION ADMINISTRATION RECORD (MAR)ABCN/AVThe MAR drug names match the drug names on medication labels to avoid confusion with brand/generic names or therapeutic substitutions.VComputer-generated or electronic MARs that share a common database with the pharmacy system are used to guide and document medication administration. CLINICAL PHARMACY SERVICESABCN/AIPharmacists are involved in the dosing and monitoring of anticoagulants.IPharmacists are involved in the dosing and monitoring of aminoglycoside therapy.IPharmacists are involved in the dosing and monitoring of vancomycin therapy.TARGET MEDICATION CLASS - ANTICOAGULANTSABCN/ACA standardized weight-based protocol is required when intravenous heparin is prescribed.VTables that list doses and corresponding infusion rates for standard concentrations of heparin are readily available in patient care units.VA protocol is available to guide the reversal of supra-therapeutic INR values.VThe formulary limits the variety of heparin concentrations and vial sizes. Heparin 10,000 unit/mL vials are not available in the hospital.CWarfarin administration is scheduled for the same time each day, after INR results are available (e.g., afternoon, early evening).CINR values are well-titrated and kept in range.CPTT targets are achieved within 24 hours and kept in range thereafter.CVTE risk is appropriately assessed and selected prophylaxis adequate.TARGET MEDICATION CLASS - INSULINABCN/ACA standardized subcutaneous insulin protocol is required when subcutaneous insulin is prescribed. CSliding scale dosing of insulin is avoided and basal/bolus approaches preferred.VInsulin vials / pens are diverse to prevent look-alike/sound-alike errors.VInsulin vials are NOT placed back in original boxes for storage after opening.CA standardized IV insulin protocol is required when IV insulin is prescribed.CGlucose control outcomes meet current standards.TARGET MEDICATION CLASS - ANTIBIOTICSABCN/ACAntibiotics are prescribed consistent with published guidelines.IThe hospital publishes an antibiogram at least ulture and sensitivity results are used to streamline antibiotic therapy.TARGET MEDICATION CLASS – PAIN MEDSABCN/AITransdermal fentanyl therapy is NOT initiated on inpatients.ITransdermal fentanyl therapy is NOT used for acute pain.IMeperidine is NOT listed in the hospital Formulary and cannot be ordered as a non-formulary medication.IDarvocet is NOT listed in the hospital Formulary and cannot be ordered as a non-formulary medication.CPain is consistently assessed and documented.CPain management is adequate and adjusted to pain scores as needed.TARGET MEDICATION CLASS – DOSE ADJUSTMENTSABCN/ACDoses are adjusted for medications that may be toxic in patients with renal or liver impairment.CThere is adequate therapeutic drug monitoring in narrow therapeutic drugs.PRE-PRINTED ORDERSABCN/AIThe hospital reviews and updates preprinted order sheets annually or sooner if necessary, based on current evidence and practice.IA pharmacist reviews and approves all medications listed on pre-printed physician orders prior to implementation.CIStandardized pre-printed physician orders are required for the treatment of chest pain/acute myocardial infarction. CIStandardized pre-printed physician orders are required for the treatment of heart failure. CIStandardized pre-printed physician orders are required for the treatment of pneumonia. CStandardized pre-printed physician orders are required for VTE prophylaxis. CRASH CARTSABCN/AVMedications in crash cart are NOT expired.VMedications in crash carts are organized in a safe manner and standardized among all carts in the hospital.VCrash carts are in constant surveillance by approved hospital personnel.VCurrent pediatric emergency drug references are available. Outdated pediatric emergency drug references are not available.VConcentrations of injectable medications in the emergency medication tray match the concentrations on the pediatric emergency drug reference.VWhenever possible, emergency medications are available in unit-dose, age-specific, and ready-to-administer forms.MEDICATION STORAGE AND SECURITY (INSIDE PHARMACY)ABCN/AVCardboard shipping boxes are NOT present in the hospital pharmacy.VMedication refrigerators are organized in a manner to prevent product selection errors. VRefrigerator temperature logs are complete (daily / twice daily for vaccines). Actions to temperature deviations are recorded.VThe pharmacy is organized in a manner, which reduces the potential for retrieval errors (separate bins; high-alert drugs flagged; appropriate labels).VProducts with look-alike drug names or packaging are stored separately and not alphabetically.VAll controlled (scheduled) medications are locked.IOnly a licensed pharmacist is allowed to enter the pharmacy unescorted.IWhen non-pharmacist health care professionals obtain medications after-hours secondary verification is required of retrieved medications is required. IThe hospital has a functional procedure to retrieve and handle medications that are recalled or discontinued for safety reasons.VVials of concentrated forms of electrolytes (potassium chloride, potassium phosphate, and sodium chloride greater than 0.9%) are NOT stocked in the hospital.VPromethazine 50 mg/mL vials are NOT stocked in the hospital.VNeuromuscular blocking agents are sequestered from other medications and labeled with auxiliary warnings.DRUG STORAGE OUTSIDE PHARMACYABCN/AVAll medications stored outside of the pharmacy are in automated dispensing cabinet. No medication carts are used.VADCs are placed in areas that have minimal distractions.VSufficient space is available to place the MAR so that it may be read while at the ADC.IAll ADCs have profile capabilities and profiling is enforced.VIIndependent double-checks are employed and documented by staff when removing all high-alert medications from non-profiled ADCs or on override?. VPatient allergies appear on the ADC screen.VA warning is presented to the user if a medication is requested to which a patient is allergic.VTall man lettering is used on ADC screen displays to help differentiate look- and sound-alike medications.VAbbreviated or truncated drug names are not used in ADC screen displays.VThe time the last dose was removed from the ADC is displayed on the screen.VEach individual medication and strength is stored in a separate storage location in the ADC that limits access only to the correct medication. VIf matrix drawers are used, they do not contain high-alert medications such as narcotics, neuromuscular blocking agents, vasopressors, insulin, or anticoagulants.IADC restocking using appropriate safeguards including barcoding, limited designated personnel, double-check of high-alert medications, and segregation of each drug/dose/dosage from send to ADC.PA policy with criteria for the use of ADC overrides is approved by the P&T or similar drug use committee in the organization. POverride criteria are adequate.IDocumented rationale is required for each medication removed from ADCs via the override function.IOverride reports are routinely reviewed to identify and address the reasons for overrides.VThe drug and dose removed on override are checked against essential patient information, (e.g., allergies and weight). VAll medications returned to ADCs are placed in a secure, one-way return bin that is maintained by the pharmacy.VNeuromuscular blocking agents are not available as floor stock and/or in automated dispensing cabinets (except in operating room/anesthesia stock). VMedication refrigerators are organized in a manner to prevent product selection errors. VRefrigerator temperature logs are complete (daily / twice daily for vaccines). Actions to temperature deviations are recorded.VDrug cabinets or other storage areas outside of pharmacy and ADCs are organized in a manner, which reduces the potential for retrieval errors (separate bins; high-alert drugs flagged; appropriate labels).MEDICATION FORMULARYABCN/APThe hospital Formulary contains minimal duplication of therapeutically equivalent products.VThe Formulary is readily available to those involved in medication management.IPhysicians prescribe consistent with the hospital Formulary.IThe hospital has an automatic interchange program.INon-formulary products are used only when therapeutically necessary and appropriate. IPatient-owned medications are only used when not on formulary.IPatient-owned medications are not administered until an authorized prescriber has approved their use and a pharmacist has inspected the medications.IPPatients are NOT allowed to use their own supply of controlled substances, injectables, or liquid medications.IPharmaceutical vendors and prescribers are prohibited from distributing drug samples in inpatient areas and the use of samples is prohibited for inpatients.MEDICATION SAFETY COMMITTEE AND CULTUREABCN/APThe ISMP Medication Safety Alert!? and Joint Commission Sentinel Alerts are regularly reviewed and action is taken to prevent errors.IError volume is not used in hospital employee performance evaluations. No disciplinary action is taken against practitioners who make an error in the post-event process unless malicious or illegal behavior occurred.PThe hospital has an adequate number and variety of error reports with good description of etiology and causes.IPractitioners and other staff report and openly discuss errors without undo embarrassment or fear of reprisal from the hospital/organization. IAll medication errors that reach the patient, regardless of the level of harm that results, are honestly disclosed to patients/families in a timely manner.IHospital administration/management provide positive incentives for individuals to report errors and are otherwise engaged in medication-related quality improvement.IAll hospital staff can describe how error reports are used and why they are important.IEvery serious error or near-miss is followed with a root cause analysis. PRCA documentation reflects a comprehensive analysis with good system orientation and adequate action steps.IPrescribing errors that are detected by pharmacists and nurses are recorded, analyzed, and used in conjunction with medical staff quality improvement activities, including presentation at medical staff meetings.PThe hospital establishes a multidisciplinary Medication Safety Committee, which includes risk management/quality improvement professionals, pharmacists, nurses, physicians, clinical information technology staff, and hospital leadership. The committee meets monthly to review medication error reports and other relevant data. IThe committee performs ongoing review of compliance with established clinical protocols and facilitates action to reduce noncompliance.IThe committee retrospectively reviews outcome data reflective of protocol effectiveness and safety and makes organization-wide process recommendations. MEDICATION RECONCILIATIONABCN/ACAt the time the patient enters the hospital or is admitted, a complete list of the medications the patient is taking at home (including dose, route, and frequency) is created. The patient, and family as needed, are involved in creating this list. CIThe medications ordered for the patient while under the care of the hospital are compared to those on the list created at the time of entry to the hospital or admission.CIAny discrepancies (that is, omissions, duplications, adjustments, deletions, additions) are reconciled and documented while the patient is under the care of the hospital.CIWhen the patient leaves the hospital’s care, the current list of reconciled medications is provided and explained to the patient, and their family as needed. This interaction is documented. ................
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