Pharmacy & Therapeutics - December 2008 - (Page 732)

MEETING HIGHLIGHTS: Onmark Forum continued from page 723 MEDICATION ERRORS continued from page 686 Changes in Information Gathering By soliciting a show of hands in the audience regarding the use of online Web sites, Dr. Blayney showed that although most of the attendees in the room regularly made on-line travel arrangements, few had made use of modern computer technology for accessing patient records. The disadvantages of relying on digitized records include losses on the “social side” (reduced personal interactions, reduced information from voice cues), the learning curves associated with adjusting to and integrating new technology, and the threat of “being turned into data entry clerks.” While acknowledging the validity of such reservations, he commented, “The patients and our younger physician colleagues are ready for this. We need to do our work in standard ways.” As an illustration of the power of standardized procedures, Dr. Blayney referred to the well-known published articles by Atul Gawande, MD, from Brigham and Women’s Hospital, on the enormous benefits to medicine demonstrated by the use of checklists, originally developed in aviation. In a New Yorker article and in a New York Times op-ed piece, Dr. Gawande described how a simple five-step checklist for catheter insertion, created by Peter Pronovost, MD, of Johns Hopkins University, made a vast difference clinically. The checklist cut the hospital’s catheter bloodstream infection rate in 15 months from 4% of cases to zero, saving 1,500 lives and nearly $200 million. The list consisted of items that included washing the hands with soap; cleaning the patient’s skin with chlorhexidine antiseptic; putting sterile drapes over the entire patient; wearing a sterile mask, hat, gown, and gloves; and putting a sterile dressing over the catheter site after the line is inserted. The study of 100 Michigan hospitals using the checklist found that 30% of the time, surgical teams skipped one of the five steps. Still, the worst Michigan hospital’s infection rate was better than that of the average hospital in the U.S. The message,” Dr. Blayney said, “is do it right every time.” Checklist strategies for guiding other processes (e.g., ordering chemotherapy) entail making processes uniform, a step that helps to reduce waste and minimize duplication of efforts. Other efforts toward monitoring internal quality improvement and creating greater efficiency in Michigan hospitals have led to reductions in the average time patients wait for infusions from 41 minutes to 20 minutes and reductions in the frequency of chemotherapy given in the last two weeks of life. Discussing practice quality assessment tools, including ASCO’s Quality Oncology Practice Initiative (QOPI), Dr. Blayney noted that benefits emerging simply from having an institution’s or practice’s patterns observed (i.e., Hawthorne effects) come powerfully into play. The idea, he underscored, is not to pit one group against another but to allow groups to see where they stand in relation to norms. At the beginning of the presentation, speaking about declining cancer death rates, Dr. Blayney had said, “We have a good story to tell.” At the conclusion, he said, “To continue the good news story, we need to figure out how to do our work with less expensive and potentially less well trained people.” He added that oncologists can borrow data and qualityimprovement tools from other industries to help themselves better perform their jobs. I differentiate them from medications or other solutions and to eliminate the risk of accidental injection. 4. All medications and labels should be confirmed. a. The scrub person and the circulating nurse should be required to verify all medications or solutions visually and verbally by reading the product name, strength, and dosage from the labels. b. If there is no scrub person, the circulating nurse should verify the medication or solution with the licensed professional who will be performing the procedure. c. When the person passes the medication to the licensed professional who will be performing the procedure, he or she should visually and verbally verify the medication, its strength, and the dose by reading the medication label aloud. d. All original containers of medications and solutions should be kept in the room for reference until surgery is completed. 5. Unlabeled medications should be discarded. a. Staff members should not assume that they know what is contained in an unlabeled syringe, cup, or basin. b. All unlabeled solutions or medications found in the perioperative area (including the sterile field) should be discarded. c. If an unlabeled product is found, this event should be reported as a hazardous condition. d. No unlabeled drugs or solutions should leave anyone’s hands. 6. Walk-arounds should be conducted. Staff members should conduct regular safety rounds in perioperative areas so that they can observe labeling procedures, promote consistency, and ask about any barriers to implementing this important safety practice. 7. More pharmacy personnel should be present in the operating room. Although operating rooms are sometimes considered off limits for pharmacists, establishing close ties between pharmacists and the operating team (via satellite or by inperson visits) may help spur necessary practice changes to improve labeling on the sterile field. 8. Perioperative staff members should be apprised of errors involving unlabeled products. a. To encourage practice changes and to enhance awareness, staff members should inform perioperative personnel about tragic mix-ups that have occurred in other facilities when medications and solutions were unlabeled on the sterile field. b. A multidisciplinary perioperative safety team that includes nurses, technicians, pharmacists, and physicians from various sites where invasive procedures are performed might also help to improve consistent labeling as well as enhance interdisciplinary relationships. REFERENCE 1. Association of periOperative Registered Nurses (AORN). Guidance Statement: Safe Medication Practices in the Perioperative Practice Settings. Elsevier: May 1, 2002. The reports described in this column were received through the USP– ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the ISMP Web site (www.ismp.org) or the USP (www.usp.org) Web site or communicated directly to ISMP by calling 1-800-FAILSAFE or via e-mail at ismpinfo@ismp.org. I 732 P&T® • December 2008 • Vol. 33 No. 12 http://www.ismp.org http://www.usp.org

Table of Contents Feed for the Digital Edition of Pharmacy & Therapeutics - December 2008

Pharmacy & Therapeutics - December 2008 Contents Editorial Medication Errors Prescription: Washington New Drugs/Drug News/ New Medical Devices Drug Forecast Interpreting Estimates of Treatment Effects Chemotherapy Foundation Symposium XXVI: Innovative Cancer Therapy for Tomorrow Third Annual Onmark National Payor/Provider Forum Fourth Annual Ophthalmic Drug Development and Delivery Summit Classification and Pharmacological Management Of Obesity CE Test and Forms Season’s Greetings: Thanks to Our Readers and Reviewers

Pharmacy & Therapeutics - December 2008

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