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Ade part4 for pdf

THUS FAR IN THE GUIDE, YOU HAVE LEARNED:
The Model for Improvement, which can be applied toany area you want to improve. A step-by-step guide to using that model to work onreducing adverse drug events, with each of the basicsteps — setting aims, forming the team, establishingmeasures, and developing and testing changes —illustrated with examples. A group of change concepts that can be applied in different ways throughout the medication system toreduce adverse drug events. Achieving Breakthrough Improvement in Reducing Adverse Drug Events
This section provides a comprehensive guide to reducing adverse drug events by showing how organizations in the Collaborative applied the change concepts introduced in Part 3, to different parts of the medication system. Part 4 THE BASICS
THE MEDICATION SYSTEM (FLOWCHART)
Changes to Improve the Ordering Process
Changes to Improve the Dispensing Process
Changes to Improve the Administration Process
80 Breakthrough Series Guide: Reducing Adverse Drug Events The Basics The first steps for error
Enforce standardized prescribing
Many errors result from sloppy or hurried prescribing practices — abbreviating, using code symbols,or leaving out elements of the order. Well-publicized and firmlyenforced prescribing rules will Basic rules for standardized
prescribing:
• Use the word “unit,” not “u” • Do not use the letter “Q” or “q” dose, strength, units (metric), route, frequency, and rate.
• Use full names (preferably generic).
• Use only authorized abbreviations.
• Use metric system only.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
prevention in every hospital
Simplify
Standardize multiple processes
the greater the likelihood of error.
ardization is a form of simplification.
more likely to discover errors madeby others.
Changes to simplify the process:
Candidates for standardization
include:

potentially lethal drugs: potassiuminjection, insulin, lidocaine, sodiumchloride injection, calcium injection,magnesium injection, chemother-apeutic agents, heparin, dextroseinjection, narcotics, adrenergic ago-nists, theophylline 82 Breakthrough Series Guide: Reducing Adverse Drug Events Use unit dosing
Use pharmacy-based admixture of
IV medications

istration that could have far morecostly results.
Eliminate too-long or double shifts
Use computerized drug profiling
in the pharmacy

check system should identify thera-peutic duplication, contradictoryorders, and potentially harmful drug-drug interactions.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Use error-preventive packaging
Make allergy information available
easily tell drugs apart. “Look-alike” Institute 24-hour pharmacy service
Have an effective system to monitor
and report adverse drug events

understand the nature and extentof their ADEs, which is the first steptoward redesigning systems to reduce errors.
84 Breakthrough Series Guide: Reducing Adverse Drug Events The Medication System
Unfortunately, those participating in thissystem tend to focus on their own part of the process and overlook the extent towhich parts of the process are interrelated and the extent to which errors early inthe process may cause later errors.
medication system, from orderingthrough dispensing and administration.
Each step is annotated with some of thefactors that affect the accuracy and effi- ciency with which the step is completed.
points, that is, steps where preventingerrors is crucial because unchecked errors can lead to multiple errors lateron. Actually, almost every stage in the medication system is a critical controlpoint —but some are more critical than others. While no two hospitals have pre-cisely the same system, all share some essential elements and their accompany-ing hazards.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Ordering
1

Prescriber conceives order
Prescriber writes order
Order legible?
Clarify with
prescriber or nurse
Prescriber conceives order
Prescriber writes order
Order legible?
Here the issue is communication.
Prescribers often write orders thatare hard to read, nonstandardin form, and use unauthorizedabbreviations. The goal is toensure unambiguous, error-freecommunication.
86 Breakthrough Series Guide: Reducing Adverse Drug Events Ordering (continued)
4

Order transcribed to MAR
Nurse reviews order
Order OK?
Clarify with
prescriber
Order transcribed to MAR
Nurse reviews order
Order OK?
new order? How does the systemensure that the MAR and theappropriate drug and patientinformation are available? Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Order transmitted
Pharmacist reviews order
Order OK?
to pharmacy
Clarify with
prescriber
Order transmitted to pharmacy
Pharmacist reviews order
Order OK?
patient receiving another med-ication with similar effect? 88 Breakthrough Series Guide: Reducing Adverse Drug Events Dispensing
10

Drug prepared and
Drug delivered to unit
dispensed
Drug prepared and dispensed
Drug delivered to unit
Before an order arrives, two issues must be resolved: • Drug purchasing: Are drugs provided in appropriate forms and packages and with labeling that minimizes errors? • Drug storage: Are “look-alike” or “sound-alike” drugs stored separately so that they cannot easily be confused? The following factors relate specifically to the dispensing function.
Here, careful reading, accuracy, and vigilance are important.
To ensure accuracy, the system must address the following: • Is it the right drug (no mistakes due to look-alikes or sound-alikes)? • Is the drug appropriate for the patient? • Did the pharmacist screen for drug-drug interaction, therapeutic duplication, appropriate dosing (age and weight check or body • Are the dose and amount calculated correctly? • Is the dose prepared correctly?• Is the packaging unique and not easily confused with another drug?• Is the labeling clear, including drug identity, dose, and patient identity? Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Administration
12

RN matches
RN prepares to
RN takes drug to patient
drug to MAR:
administer dose
Clarify with
prescriber
RN matches drug to MAR
RN prepares to administer dose
RN takes drug to patient
properly? Does it increase ordecrease errors? • Is unit dosing used?• If unit dosing is not used, then how are calculation, counting,and measuring accuracy ensured? 90 Breakthrough Series Guide: Reducing Adverse Drug Events Correct patient?
Drug administered
Medications charted
Clarify with
prescriber or nurse
Correct patient?
Drug administered
Medications charted
to errors and confusion? Aremedications charted correctly? Self-administration has someadvantages, but may pose addi-tional problems.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Patient response monitored
Patient response monitored
IMPROVING THE MEDICATION SYSTEM
Each major process in the medication system— ordering, dispensing, and administration — has its own unique oppor- tunities for error. However, a few key change concepts have been found to be particularly useful in redesigning all three processes to improve patient safety.
For each major process in the medication system, the chartson pages 92–118 indicate the following: • Change concepts that are useful in redesigning the process
• Problems in applying each change concept
• Useful process changes
• Examples of process changes tested by organizations either
before or during the Collaborative
Resources
This symbol indicates that a resource developed by an organization in the Collaborative is included at the endof Part 4.
92 Breakthrough Series Guide: Reducing Adverse Drug Events Changes to Improve the Ordering Process
Change Concept
Reduce Reliance on Memory
Ordering
• There are too many drugs and too many facts to be remembered.
Problems
• When prescribers rely on memory, they forget important details about Useful Process
Use computerized prescriber order entry.
Use preprinted orders.
Use guided dose algorithms.
Check dose ranges.
Use protocols for hazardous drugs (chemotherapy, insulin, anticoagulants, etc.).
Make accurate allergy information available to the physician, the pharmacist,
and the nurse.
Use an automatic dose reduction plan.
Examples of
Use preprinted orders.
Tested and implemented by:
Process Changes
Antibiotic Order Form
Use an automatic dose reduction plan.
Tested and implemented by:
Elderly patients and patients with renal failure need to receive Creatinine Clearance
substantially lower doses of many medications than those Protocol (p. 121)
generally prescribed for adults. Physicians frequently forget to prescribe lower doses for these patients. One hospital institut- ed a program in which the pharmacist automatically reduces doses as needed for elderly patients and those with renal fail-ure, thus virtually eliminating overdosing in these patients.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Simplify
Ordering
• The large number of drugs increases the likelihood of error.
Problems
• The need for transcribing orders introduces an additional opportunity for error.
Useful Process
Limit the number of drugs in the formulary.
Limit the number of dose options.
Use protocols for hazardous drugs.
Eliminate transcription.
Examples of
Limit the number of drugs in the formulary.
Tested and implemented by:
Process Changes
Many highly toxic drugs or drugs likely to be used incorrectly have little therapeutic advantage over other less hazardous drugs designed to treat the same disorders. One hospital removed these hazardous drugs from the formulary, thus elimi- nating hundreds of potential adverse drug events per year.
94 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Standardize
Ordering
• Stylistic practices, such as individual differences in the use of terminology, use Problems
of improper abbreviations, and failure to follow rules continue to be tolerated.
• Physicians use multiple “sliding scales” for insulin.
Useful Process
Use standard usage rules (for example, “unit” not “u”; leading not trailing zeroes).
Use abbreviations sparingly; use standard abbreviations only.
Use standard measures (metric).
Use preprinted orders.
Reject illegible orders.
Examples of
Reject nonstandard orders.
Tested and implemented by:
Process Changes
Adult Medication Order
Guidelines (pp. 122–123)
after three weeks, physicians stillusing nonstandard notation receivedin the mail their nonstandard ordersaccompanied by a “pink slip.” Thisprocess proved very effective, and thepercentage of nonstandard or illegibleorders received in the pharmacydropped by 60%.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Use Constraints and Forcing Functions
Ordering
• Excessively hazardous drugs are ordered when safer substitutes are available.
Problems
• Many ordering processes permit ordering of toxic or lethal doses.
Useful Process
Use computerized order entry.
Make high-hazard drugs and doses unavailable for use.
Allow certain drugs to be used only by protocol.
Examples of
Use computerized order entry.
Tested and implemented by:
Process Changes
Most computerized order entry systems are programmed so that medications have dose range checks based on the age, height, and weight of patients, as well as screens for allergies.
The prescriber cannot specify a dose that is improper for the patient. A more sophisticated system can calculate dosages for the prescriber, given the medication, its indication, andthe height, weight, and age of the patient. Of course, mostof these systems allow the user to override the computer, butto do so requires some effort—which often allows the pre-scriber time to reflect on the correct dose.
96 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Use Protocols and Checklists Wisely
Ordering
• Complicated medication routines, such as those used for anticoagulation and Problems
for chemotherapy, frequently lead to errors.
Useful Process
Use protocols for hazardous drugs.
Use preprinted orders.
Use protocols for hazardous drugs.
Tested and implemented by:
Examples of
Process Changes

such items as patient identifiers; double- Orders for Chemotherapy
fully before beginning the infusion.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Improve Access to Information
Ordering
• Medical records and nursing charts do not make information easily available. Problems
• Drug information is not easily available at the time it is needed.
• Communication among multiple caregivers is often incomplete.
Useful Process
Use a computerized medical record.
Use computerized order entry.
Have a pharmacist make rounds with doctors and nurses.
Have a pharmacist available on the unit rather than in the pharmacy.
Make protocols available at order entry.
Provide for effective recovery and display of allergy information.
Provide for effective feedback of lab findings.
Examples of
Have a pharmacist make rounds with doctors and nurses.
Tested and implemented by:
Process Changes
Several organizations have begun to include a clinical phar- macist on the nursing units. Having pharmacists available when physicians are writing orders (during rounds) allows for a dialogue between physicians and pharmacists concern- ing specific medications and makes it easier to get the order right the first time. This also prevents the delay in ordering that occurs when an incorrect order goes to the pharmacy before the error is identified and corrected, usually requiring an additional call to the physician.
Figure 4.1 shows the increase in the number of days between medication interventions that occurred at one hospital when a pharmacist began participating in ICU rounds in October1996. When this pilot test stopped in November, the inter-ventions again became more frequent.
Increase in Days Between
Medication Interventions
(Longer Is Better)
Number of Days Since Last Intervention
Consecutive Intervention Number
98 Breakthrough Series Guide: Reducing Adverse Drug Events Changes to Improve the Dispensing Process
Change Concept
Reduce Reliance on Memory
Dispensing
• Drug and patient information is too extensive and complicated to remember.
Problems
• Look-alike and sound-alike drugs are difficult to distinguish.
Useful Process
Use computerized order entry.
Use computer profiling of patient data.
Use computerized drug information.
Use computerized alerts.
Use preprinted orders.
Use robotic dispensing.
Bar-code drugs.
Label boldly and clearly.
• Print recommended rate of administration on label.

Examples of
Use computer profiling of patient data.
Tested and implemented by:
Process Changes
profile patients’ medications and moni- Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Simplify
Dispensing
• Multiple dosage forms increase the opportunity for error.
Problems
• Multiple steps in the dispensing process increase the likelihood of error.
Useful Process
Limit the choice of drugs.
Limit the doses for each drug.
Limit the number of administration times.
Institute a pharmacy IV admixture program.
Repackage drugs to eliminate look-alikes.
Allow automatic drug dispensing on the nursing unit.
Examples of
Limit the doses for each drug.
Tested and implemented by:
Process Changes
Several organizations have limited the concentrations of heparin solutions available on the nursing units to one.
Nurses report fewer near misses — times when they almost Most hospital pharmacies are able to identify the two or three IV solutions that are used most often and how much of these solutions is used each day. In several organizations, the pharmacy mixed a stock of these solutions in a batch each day so that during the press of a busy day only a few had to be mixed to order. There was occasional waste whensolutions expired, but teams believed that the errors pre-vented by doing the admixture on the slower-paced nightshift more than compensated for this cost.
100 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Standardize
Dispensing
• Manufacturers do not provide standardized products or packaging.
Problems
• Pharmacists sometimes have idiosyncratic practices.
Useful Process
Standardize the following: doses, dosing times, storage locations, concentrations,
packaging, labels, delivery times.
Institute an IV admixture program.
Use protocols for hazardous drugs.
Conduct a systematic review of every order.
Examples of
Standardize doses.
Tested and implemented by:
Process Changes
Standardize packaging and labels.
Tested and implemented by:
identical cartridges. In order to prevent ups in administering the morphineand averted cases of overdose.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Use Constraints and Forcing Functions
Dispensing
• Stylistic practices exist in the pharmacy; different pharmacists dispense and Problems
• Medication orders can be processed without the pharmacy knowing a patient’s clinical conditions (for example, allergies or renal failure).
• Toxic drugs can be ordered in excessive doses.
Useful Process
Program the computer not to process an order unless key information
has been entered.
Dispense epidural medications only in unique spinal syringes.
Remove hazardous drugs of limited value from the formulary.
Use automatic dose reduction for the elderly and patients with renal failure.
Examples of
Program the computer not to process an order unless key
Tested and implemented by:
Process Changes
information has been entered.
An effective way to eliminate errors is to program the pharmacy computer to require entry of certain critical information (such as drug allergies, height, weight, date of birth) before an order for medication can be processed. The responsibility for obtaining these data still rests withthe nurse, but this change ensures a fail-safe check before any medication is dispensed.
102 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Use Protocols and Checklists Wisely
Dispensing
• Complicated processes are difficult to remember.
Problems
• Variation in the use of hazardous drugs increases the likelihood of error.
Useful Process
Use protocols for hazardous drugs.
Require double check by a second person for hazardous drugs.
Examples of
Require second checks for
Tested and implemented by:
Process Changes
hazardous drugs.
(TPN) solutions are double checked bya second pharmacist before dispensing.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Improve Access to Information
Dispensing
• Important patient information (for example, presence of allergies and Problems
laboratory data) is not always sent to the pharmacy.
Useful Process
Use computerized order entry.
Use computer profiling of patient data.
Use computerized drug information.
Make the formulary available on-line.
Use computerized alerts.
Use preprinted orders.
Print IV administration guidelines and compatibility charts.
Use on-line laboratory data.
Include critical information on drug labels.
Examples of
Use computerized alerts.
Tested and implemented by:
Process Changes
Program pharmacy computers to deliver a warning when an abnormal laboratory finding (such as a very high PT or PTT) is obtained, as well as when the patient is taking another med- ication that is incompatible with a new drug being ordered.
104 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Decrease Reliance on Vigilance
Dispensing
• Look-alike and sound-alike drugs increase the chance of errors.
Problems
• Pharmacists may fail to intercept out-of-range doses.
• Errors will occur when only one person is responsible for preventing them.
Useful Process
Institute automatic, daily monitoring of doses of toxic drugs
(for example, chemotherapy).
Eliminate look-alike drugs. Repackage as needed.
Store look-alike drugs separately.
Develop a system to differentiate sound-alike drugs.
Enlist the patient and family in vigilance tasks.
Examples of
Institute automatic, daily monitoring of doses of toxic drugs
Tested and implemented by:
Process Changes
(for example, chemotherapy).
Have another observer monitor the use of toxic drugs.
One hospital used a clinical pharmacist to monitor daily the use of high-hazard substances on specific units. Heparin, aminoglycosides, chemotherapeutics, and experimentaldrugs are examples of the types of medications that requireincreased attention.
Eliminate look-alike drugs. Repackage as needed.
Tested and implemented by:
One organization stocked two concentrations of morphine sulfate in identical cartridges. To reduce wrong-dose errors, the pharmacy labeled the higher concentration cartridge with bright orange tape. (See “Standardize packaging and Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Reduce Handoffs
Dispensing
• Multiple participants —pharmacists, technicians, clerks, and others —increase Problems
Useful Process
Use computerized order entry.
Use computerized order transfer.
Use a satellite pharmacy.
Use a computerized medication administration record (MAR).
Use robotic dispensing.
Use unit dosing.
Use automatic dispensing.
Examples of
Use a satellite pharmacy.
Tested and implemented by:
Process Changes
Decentralization of pharmacy functions increases the ease of communication and reduces the number of people involved in each drug handoff. In addition, the principle of “going where the action is” not only makes the pharmacist more accessible,but enhances the job satisfaction of some pharmacists bymaking them more personally involved in the patient careprocess.
106 Breakthrough Series Guide: Reducing Adverse Drug Events Changes to Improve the Administration
Change Concept
Reduce Reliance on Memory
Administration
• There are too many drugs and too many facts to remember. Nurses may Problems
• On-time administration of medications depends on the nurse’s memory.
Useful Process
Make allergy information readily available.
Use patient allergy color-coded wristbands.
Partner with the patient.
Make drug information readily available.
Bar code drugs.
Use timers or reminder systems.
Use IV guidelines.
Use protocols for hazardous drugs.
Use protocols for epidural medications.
Use guidelines for the use of infusion pumps.
Reduce variation in equipment and supplies.
Examples of
Partner with the patient.
Tested and implemented by:
Process Changes
Enlist the assistance of conscious and cooperative patients by asking them to double check what medications they are getting and when. In one organization, the patients received a list of their medications daily. When the nurse came to administermedications, the nurse reviewed the list with the patients. Thisoffered both a double check and an opportunity to educate thepatient. Using this method prevented many errors, and thepatients liked being involved in their care as well.
Use timers or reminder systems.
Tested and implemented by:
In one organization, the IV antibiotics often “ran out” and were not switched back to the main IV bag because the nurse, busy with other patients, forgot to change the bag.
The solution: Nurses hung small digital timers on the doors of patients’ rooms to remind them when to change specific IV piggyback medications. If the patient’s nurse was notnearby, someone else would hear the alarm and notifythe nurse, who could then make the appropriate change.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Examples of
Use IV guidelines.
Tested and implemented by:
Process Changes
One organization wanted to ensure the accuracy of cardio- Tested (continued)
vascular drip rates for NICU patients, concerned that the process of calculating drips under urgent conditions was prone to error. To prevent miscalculations, the team in the Cardiac Drip Worksheet
NICU developed a guideline for mixing the solutions and setting the drip rate to maintain the proper dose and fluid 108 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Simplify
Administration
• The need for the nurse to mix medications provides an opportunity for error.
Problems
• Some hospitals use multiple types of infusion pumps.
• Multiple participants, multiple drugs, and multiple dose strengths make administration complex and susceptible to error.
Useful Process
Limit the following: choice of drugs, access to the medication room, doses for
each drug, number of administration times.
Institute a pharmacy IV admixture program.
Institute automatic drug dispensing on the nursing unit.
Reduce the number of protocols for hazardous drugs (for example, KCl, insulin,
anticoagulants, chemotherapy).
Use unit dosing.
Have a single record for entry of medications.
Use standard equipment with simple instructions and a convenient user interface.
Examples of
Limit the number of administration times.
Tested and implemented by:
Process Changes
Institute a pharmacy IV admixture program.
Tested and implemented by:
In most organizations, the pharmacy places additives in IV solutions. Removing the task of calculating and mixing additives such as KCl from nursing staff simplifies the administration process for the nurses. The pharmacy is better organized to carry out this process, providing the requiredaccuracy and a distraction-free environment. The properlymixed solution comes from pharmacy when needed, and thenurse need only verify correctness and calculate the flowrate (perhaps using an IV drip rate “cheat sheet”). Purchasingpremixed solutions from the manufacturer reduces the risk of errors even further.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Examples of
Reduce the number of protocols for hazardous drugs (for example,
Tested and implemented by:
Process Changes
potassium chloride, insulin, anticoagulants, chemotherapy).
Tested (continued)
Many organizations have simplified their work by restricting the number of protocols for the same medication. When nurses have three or four heparin protocols, it is easier for them to confuse which protocol is being used. Using only one protocol for deep vein thrombosis prophylaxis and one for treatment of embolism helps staff remember what is required.
Use unit dosing.
Tested and implemented by:
In most organizations, medications arrive at the floor ready to be packaged and administered specifically to each patient.
The pharmacy fills a drawer for each patient with single-dose packages of the medications ordered for the patient for the day and brings the drawer to the unit. The nurse need not preparethe medications from a vast floor stock, a task that requiresmaking calculations and drawing up or mixing the medica-tions. The task is simplified: the nurse finds the medicationordered in the drawer, verifies the correctness (right dose, drug,time, patient, and route), and administers it to the patient.
Use equipment with simple instructions and a convenient
user interface.

Hospitals frequently use infusion pumps to regulate the flowof IV fluids. Nursing staff rely on the accuracy and goodworking order of these pumps. Pumps that frequently deliverfalse alarms are annoying, and the nursing staff may respondby ignoring the alarms or turning them off. Select pumpsthat give information about the cause for the alarm, havemoderate sensitivity, and prevent free flow when the unit isturned off. Also, stock only one or two types of pumps pernursing unit.
110 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Standardize
Administration
• For certain drugs, ordered doses vary widely.
Problems
• Administration times for ordered drugs vary widely.
• Physicians use multiple dosing scales for insulin, heparin, and other medications.
• Complex drug regimens are difficult to follow.
Useful Process
Standardize the following: doses, administration times, delivery times,
storage locations, concentrations, infusion pumps
Institute an IV admixture program.
Use preprinted orders.
Use protocols for hazardous drugs.
Use protocols for epidural infusion.
Examples of
Standardize administration times.
Tested and implemented by:
Process Changes
that the first dose be given in the hold- How to Stagger Anti-
biotics to Get Them on
Standard Times (p. 128)
reduction of 66% from previous levels.
Standardize storage locations.
Tested and implemented by:
Every medication room in a hospital is laid out in the same way and medications are stored in the same place. One organization decided to store the two concentrations of IV heparin on separate shelves in the medication room. Storing look-alike bags side-by-side had been a case of wrong-dose errors waiting to happen. After changing the location of the higher-dose bag and notifying nurses of the change, the number of near misses (taking the wrong concentration offthe shelf) decreased.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Examples of
Use protocols for hazardous drugs.
Tested and implemented by:
Process Changes
Tested (continued)
Sliding-Scale Insulin
Protocol for Adults
with the prescriber about lab resultsand dosing.
112 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Use Constraints and Forcing Functions
Administration
• Availability of concentrated potassium chloride permits accidental fatal injection.
Problems
• Similar fittings permit accidental IV injection of gastrostomy feeding solution.
• Certain drugs (for example, KCl, insulin) can easily be fatal if the wrong dose is Useful Process
Remove hazardous drugs from the nursing unit (for example, concentrated KCl).
Use special fittings to prevent the mismatch of enteral and parenteral medications
to the wrong route.
Limit access to the medication room.
Examples of
Remove hazardous drugs from the nursing
Tested and implemented by:
Process Changes
unit (for example, concentrated KCl).
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Use Protocols and Checklists Wisely
Administration
• Multiple dosing schedules for hazardous drugs increase the potential for error.
Problems
• On-time administration of medications (for example, preoperative antibiotics) • Complex processes are difficult to remember accurately.
• Some regimens (for example, chemotherapy) must be carried out precisely.
Useful Process
Use protocols for hazardous drugs.
Use protocols for epidural drugs.
Use protocols for preoperative antibiotics.
Coordinate insulin dosing with labs and meals.
Use double check systems for blood products and high-hazard substances.
Examples of
Use protocols for hazardous drugs.
Tested and implemented by:
Process Changes
By establishing one weight-based heparin protocol for pro- phylaxis, organizations eliminated the constant phoning and dosage adjustment that occurs in the absence of the pro- tocol. The nursing staff learn just one protocol and become Heparin Protocol Dosing
familiar with it, which, in turn, allows them to speed up Order Sheet (p. 130)
the steps required to respond to lab results. As a result of one organization’s work, the average time required to reach a therapeutic level dropped from more than 24 hours to less than 8 hours, and the number of dosage adjustmentsdecreased as well.
114 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Improve Access to Information
Administration
• Medical records and nursing charts are not organized to make information Problems
• Drug and patient information is not readily available when and where nurses • There are too many drugs and too many facts for nurses to remember.
Useful Process
Make allergy information prominently available on the medication administration
record (MAR).
Provide a pharmacist on the unit.
Make computerized drug information easily accessible.
Make patient clinical and lab information available on-line.
Display protocols in the medication room.
Have patients wear color-coded allergy wristbands.
Partner with patients about drug names, doses, and times.
Locate the MAR at the bedside.
Place commonly used information where it is needed.
Post generic/trade name “translation” charts.
Examples of
Have patients wear color-coded allergy wristbands.
Tested and implemented by:
Process Changes
One organization instituted a red identification wristband for patients with drug allergies. The red color prompted the nursing staff to recheck allergies prior to giving any medications, thus preventing the patient from receiving thewrong medication.
Locate the medication administration record (MAR) at the bedside.
Tested and implemented by:
One organization moved the medications and the medication administration record to the bedside. With this information available at the point of administration, it was much easier to see what the patient needed, and omissions, wrong doses, and wrong-drug errors were prevented. This system required extrasteps to update medication administration records when orderschanged, but the errors averted by having information availableat the bedside more than compensated for the extra work.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Examples of
Place commonly used information where it is needed.
Tested and implemented by:
Process Changes
Nursing staff cannot reliably recall all the necessary informa- Tested (continued)
tion concerning protocols, drug interactions, trade and generic names, and other facts. To address this problem, many orga- nizations placed easy-to-read laminated information sheets Medication Administration
or cards where they are needed. Dosing protocols are printed Times for Food/Drug
on laminated cards that clinicians can keep in their lab coat Interactions (pp. 131–132)
pockets. A listing of times that medications need to be given in order to avoid negative interactions with food is posted on the medication cart. IV drip rate calculation sheets are hung on IV pumps. Such “cheat sheets” serve to make information Post generic/trade name “translation” charts.
Tested and implemented by:
One hospital was concerned about sound-alike and look- alike narcotics in the narcotics cabinet, as well as confusion of trade and generic names. The team put together a generic/trade name chart and attached it to the narcotics box.
As a result, nurses could correctly identify the right medica- tion, regardless of whether the ordering physician used a trade or generic name, and wrong-drug errors decreased.
116 Breakthrough Series Guide: Reducing Adverse Drug Events Change Concept
Decrease Reliance on Vigilance
Administration
• Fatigue, overwork, complexity of tasks, and responsibility for multiple patients Problems
make it difficult for nurses to maintain vigilance.
Useful Process
Remove high-hazard medications from the nursing unit.
Use automatic drug dose checking.
Use checklists.
Use premixed IV bags.
Use a double check system for hazardous drugs.
Eliminate look-alike drugs.
Use distinctive, clear labels.
Use targeted monitoring for hazardous drugs.
Examples of
Use a double check system for hazardous drugs.
Tested and implemented by:
Process Changes
Many organizations use a double check system for adminis- tering blood products and insulin. The nurse administering the medication shows another nurse the order and the dose and explains how it was calculated. This procedure, while cumbersome, can be extended to apply to other high-hazard drugs such as narcotics, chemotherapy, and heparin. While the risk is that the double checks will be cursory, if done Use targeted monitoring for hazardous drugs.
Tested and implemented by:
Narcotic Flowsheet
Monitors that track the therapeutic effects and side effects of specific drugs reduce reliance on vigilance. One organiza- tion noticed excessive narcotics doses and instituted routine monitoring of respiration rate every hour for patients onnarcotics. The use of antidotes for narcotic overdose decreasedto near zero. Monitoring the electrocardiogram for any patient oncardiac active drugs and monitoring blood pressure electron-ically for patients on vasopressors are other examples oftargeted monitoring. Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
Change Concept
Reduce Handoffs
Administration
• Late delivery of medications from the pharmacy can result in omissions Problems
• Multiple staff working with medications increase handoffs on the nursing unit.
Useful Process
Use unit dosing.
Use automatic drug-dispensing machines.
Use patient self-administration of drugs.
Use patient partnering.
Examples of
Use automatic drug-dispensing machines.
Tested and implemented by:
Process Changes
Automatic drug-dispensing machines stock up to 70% of the most commonly used medications on each nursing unit. A copy of the physician’s order is sent to the pharmacy for review. If the order is appropriate, the pharmacist enters the order into the pharmacy system. Through an interface, the order is shared with the automatic drug-dispensing machine, and the nurse may access the medication directly from the machine. These systems help to prevent the administration of a medication to a patient with a known allergy and minimize confusion over brand and generic names. However, the systemshave their own potential for errors—they must be filled cor-rectly, and the nurse must still select the correct medication.
Use patient self-administration of drugs.
Tested and implemented by:
In some hospitals, capable patients are allowed or even encouraged to administer their own medications. Particularly for pain control or medications taken over a long period oftime (such as insulin or cardiac medications), patients canassume continuing self-care. This reduces the need for bothpharmacy and nursing to be involved in the administrationprocess and allows patients some control over their med-ication regimen. It also eliminates another opportunity forerror — handoffs from pharmacy to nursing to patient.
118 Breakthrough Series Guide: Reducing Adverse Drug Events Resources
The Medication System

Antibiotic Order Form
Creatinine Clearance Protocol
Adult Medication Order Guidelines
Orders for Chemotherapy
Cardiac Drip Worksheet
Lucile Salter Packard Children’s Hospital at Stanford How to Stagger Antibiotics to Get Them on Standard Times
Sliding-Scale Insulin Protocol for Adults
Heparin Protocol Dosing Order Sheet
Medication Administration Times for Food/Drug Interactions
Methodist Hospital/HealthSystem Minnesota Narcotic Flowsheet
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
CHILDREN’S HOSPITAL, BOSTON
Antibiotic Order Form
Use this form to document all new antibiotic orders. A new form must be used for changes or additions.
Rewrites every 7 days.
Routine Surgical Prophylaxis: Single dose recommended to be administered at time of incision.
30 mg/kg per Dose
Routine Antibiotic Orders: Circle choice, fill in dose, duration and circle interval, route.
Daily Dose Range (divided by admin- Circle Restricted Antibiotic Orders: Describe intended use and provide required information.
Preapproved indications: (Refer to directions on form back.) Important: Automatic stop order at 72 hours.
Some restricted antibiotics may be used for up to 72 hours while cultures are pending. Look up the codefor preapproved indications from table on reverse side of this form. Place the code after the drug name inthe order box. Example: cefotaxime (2B) All other use of restricted antimicrobials: (Requires ID approval.) Indication:
Fill in name of ID physician approving use: 120 Breakthrough Series Guide: Reducing Adverse Drug Events CHILDREN’S HOSPITAL, BOSTON
Antibiotic Order Form (continued)
The restricted antibiotics may be used for listed indications without prior infectious disease approval. Only drugs and indications listed below are preapproved. All other use of restricted antibiotics, antifungals,and antivirals must be explicitly approved by infectious diseases prior to use.
(Copy number/letter code to front page) No preapproved indications: Call infectious Diseases.
q6h or 1A: Substitute for other beta-lactam antibiotics to provide gram- negative coverage if patient allergic to penicillin/cephalosporin.
1B: Substitute for aminoglycosides for gram-negative coverage in patients with or at high risk for renal insufficiency or hearing loss.
1C: Cystic fibrosis only if piperacillin or ceftazidime not appropriate.
q6h or 2A: R/O sepsis in newly admitted patient (not nosocomial r/o sepsis).
2B: Meningitis, probable bacterial (with vancomycin if gram-positive).
2C: R/O sepsis if penicillin-resistant pneumococcus is likely (or vancomycin).
3A: Cystic fibrosis only when piperacillin not appropriate (allergy, resistance).
3B: Empiric treatment for fever and neutropenia when piperacillin + gentamicin not appropriate due to allergy.
4A: One dose for early discharge from hospital.
One dose IM for temporary IV access problem.
5A: Cystic fibrosis only if piperacillin or ceftazidime not appropriate.
6A: Cystic fibrosis only if piperacillin or ceftazidime not appropriate.
7A: Appendicitis — Note: q8h interval (preapproved for full 7-day course).
7B: Cystic fibrosis if pseudomonas and staph coverage needed (add addi- tional piperacillin to reach total piperacillin dose of 300–500 mg/kg/day).
7C: Fever and neutropenia per Clinical Practice Guideline (duration to 7 days).
Vancomycin is not restricted. Guidelines for empiric use: Do not use van- comycin for empiric therapy of suspected CVL infection, post op wound infection, C. difficile diarrhea, or fever and neutropenia unless patient iscritically ill. Use alternative abx until cultures confirm need for vanco.
8A: Per approved protocol. Oral acyclovir is not restricted. Switch to Antibiotic Unit Doses Available from the Pharmacy
Available Doses (All orders should be in these increments) 50, 100, 150, 200, 250, 300, 400, 500, 750 mg: 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 3.5, 4 gm etc.
1– 6 mg by 0.25 mg increments; 7, 8, 9, 10, 12, 14, 16, 18, 20, 25,30, 35, 40, 45, 50, 60, 70, 80, 90, 100 mg etc.
10 –100 mg by 10 mg increments; 125 –250 by 25 mg increments; 250 –800 mg by 50 increments; 900, 1000 mg General Dosing Rule: If the calculated dose (mg/kg/dose) is in the lower third of the increment, round down.
If the calculated dose is in the upper two-thirds of the increment, round up.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
FAIRVIEW HEALTH SYSTEM
Creatinine Clearance Protocol
Usual Dosage
Comments
mL/min mL/min mL/min
Reprinted by permission of Fairview Health System.
122 Breakthrough Series Guide: Reducing Adverse Drug Events DARTMOUTH-HITCHCOCK MEDICAL CENTER
Adult Medication Order Guidelines
1. All medication orders must be complete. A complete medication order includes: 2. If the medication order is time sensitive (STAT, ASAP), the time the order is written must be
included. Use “STAT” or “ASAP” when an order is time sensitive. Do not use “now.”
3. Generic names are preferable, but the use of trade (brand) names is acceptable in (a) Combination products containing two or more drugs within one formulation (b) Extended or sustained release formulations must be indicated with the name of the medication (e.g., Procan SR 500 mg OR Cardizem CD 120 mg).
4. Do not abbreviate medication names.
5. An order cannot be changed once it has been transcribed. It must be rewritten.
Legibility and Completeness of Medication Orders:
Medication orders that are illegible, unclear, or incompletely written will not be carried out untilrewritten or clarified in writing. The individual who wrote the original order will be contacted. If thatperson is unavailable, the covering provider will be contacted.
Do (acceptable)
Don’t (not acceptable)
Use a leading “0” (for example: 0.2 mg) Don’t use trailing “0” (for example: 2.0 mg) * “µg” “u” “U” as abbreviations have led to dosing errors; these are no longer acceptable. Other metric units may be abbreviated.
Some common reasons why medication orders are unclear or incomplete:
1. Injectable formulation of medication must be ordered by dosage, not volume, for example: potassium phosphate 15 mmol (not 15 mL vial).
2. The use of “prn” must be accompanied by a frequency and/or indication, for example: q 6h prn; and prn loose stool max 8 tablets/24 hr (not just prn).
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
DARTMOUTH-HITCHCOCK MEDICAL CENTER
Adult Medication Order Guidelines (continued)
Verbal Orders:
Anyone taking a verbal order will write the order in the same manner as described above andbe held responsible for rewriting or clarifying the order as needed. The individual taking a verbalorder must write and read back the order as written to the prescriber. The verbal order mustbe co-signed by a physician.
Reference Sources:
The following reference sources are available to clinicians: American Hospitals Formulary Services: Drug Information In addition, pharmacists are available for consultation. Please contact the Pharmacy at ext. XXXX.
Reprinted by permission of Dartmouth-Hitchcock Medical Center 124 Breakthrough Series Guide: Reducing Adverse Drug Events FAIRVIEW HEALTH SYSTEM
Orders for Chemotherapy
Call for lab results before initiating chemotherapy.
Proceed with chemotherapy if lab values are Frequency
Special Instructions
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
FAIRVIEW HEALTH SYSTEM
Orders for Chemotherapy (continued)
Frequency
Special Instructions
Antiemetics (prophylactics):
granisetron 0.01 mg/kg IV (not to exceed 1 mg) Antiemetics (rescue):
Follow paclitaxel or cisplatin routines (see separate page). Check here to omit Give test dose prior to bleomycin or asparaginase. Check here to omit Reprinted by permission of Fairview Health System.
126 Breakthrough Series Guide: Reducing Adverse Drug Events Cardiac Drip Worksheet
Medication
Amount to Add
Med. Vol.
Total Vol.
Concentration
*Nitroprusside: Dissolve 50 mg vial in 5 mL D5W; then dilute as above.
Drips will be made in 60 mL syringes.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
LUCILE SALTER PACKARD CHILDREN’S HOSPITAL AT STANFORD
Final Dose Equivalence
Dose Range
Final Drip
Concentration

Reprinted by permission of Lucile Salter Packard Children’ 128 Breakthrough Series Guide: Reducing Adverse Drug Events ST. MARYS HOSPITAL MEDICAL CENTER
How to Stagger Antibiotics to Get Them
on Standard Times

Time Next Dose(s) Due per Antibiotic Interval
Time 1st IV
Dose Hung
• Hang first dose of antibiotic ASAP — don’t wait to get on schedule. (You can potentially shorten the patient’s length of stay depending on how quickly you hang the first dose.) • Antibiotics ordered by pharmacokinetics (for example: gentamicin, vancomycin, etc.) are an exception to the above schedule. Pharmacy will inform you regarding the schedulingof these drugs.
• If a staggered time extends into the next day’s MAR, make sure to indicate on the next day’s MAR when the next dose is due.
• If you must deviate from the standard times, make sure to communicate this to Pharmacy, but BEWARE — any doses already dispensed by Pharmacy need to be corrected on thenext day’s MAR by the nurse doing that evening’s MAR check.
Reprinted by permission of St. Marys Hospital Medical Center Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
GARDEN CITY HOSPITAL
Sliding-Scale Insulin Protocol for Adults
1. Check blood glucose with glucometer before meals and at bedtime if patient is eating or every 6 hours if the patient is not eating.
2. Administer regular human insulin subcutaneously according to the following dosage schedule: Glucose Result
Coverage
<60 * STAT random blood sugar by lab draw. Call House Officer and notify of lab results.
> 400 STAT random blood sugar by lab draw.
Give insulin; call House Officer with results. Recheck One Touch in 2 hours.
3. This protocol is optional for prescribers.
4. This protocol is not recommended for patients in ketoacidosis.
5. Patients with a hematocrit < 25% or > 60% or dialysis patients require a lab draw for glucose due to limitations of the One Touch. (Refer to Nursing Policy and Procedure Manual,Metabolic/Endocrine Section, page 1, number 4.) See Nursing Policy and Procedure Manual, Metabolic/Endocrine Section, page 8,Hypoglycemia Treatment.
NOT A PERMANENT PART OF THE PATIENT’S CHART
Reprinted by permission of Garden City Hospital.
130 Breakthrough Series Guide: Reducing Adverse Drug Events LATROBE AREA HOSPITAL
Heparin Protocol Dosing Order Sheet
(Protocol is recommended for the treatment of patients with DVT, PE, A. Fib., Unstable Angina,and Acute MI who have not received thrombolytics during this admission.) 1. Weigh patient and record:
(Weights expressed in pounds must be converted to kilograms for subsequent calculations.) 2. Initial Therapy:
Round dose to nearest 500 units. Do not exceed 10,000 units bolus.
Infusion:
Round dose to the nearest 50 units. Standard concentration is 25,000 units/500mL D5W (50 units/mL).
3. Laboratory Procedure:
A. Draw baseline aPTT and CBC now, if not already done within the past 24 hours.
B. Initiate therapy and draw first aPTT in 6 hours.
C. CBC with platelets every 3 days.
D. Urinalysis and stool guaiac on initiation or within 24 hours.
E. aPTT 6 hours after any dosage change, adjustment as per below sliding scale.
*When 2 consecutive 6 hour aPTTs are therapeutic, order aPTT every AM while on heparin.
4. Adjust heparin infusion according to sliding-scale below:
Adjust Rate Adjust Rate Adjust Rate Adjust Rate aPTT Test ** Valid infusion rate adjustments for standard dilution only (50 units/mL) 5. Inspect for abnormal bleeding or bruising, changes in mental status or level of conscious-
ness, black tarry tools, hematuria, hemoptysis, or back pain every shift. If any of these occur,contact the physician immediately.
Reprinted by permission of Latrobe Area Hospital.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
METHODIST HOSPITAL/HEALTH SYSTEM MINNESOTA
Medication Administration Times
for Food/Drug Interactions

Trade Name
Generic Name
Special Instructions
Comments
Food helps to decreaseGI irritation.
tion by 30–40% time asis tid or q8hr. 7–20 for BID schedule.
8:30—12:30— Food helps reduce 17:30—21 Food decreases GI upset and helps increasecompliance.
8:30—12:30— Food helps reduce 17:30—21 132 Breakthrough Series Guide: Reducing Adverse Drug Events METHODIST HOSPITAL/HEALTH SYSTEM MINNESOTA
Medication Administration Times for Food/Drug
Interactions (continued)

Trade Name
Generic Name
Special Instructions
Comments
8:30—12:30— Med works by binding17:30 phosphorous in food so itis not absorbed.
Food decreases GIupset and helps increasecompliance. 8:15–9:45acceptable.
Food decreases absorp-tion. Give at 17:30 if BID.
patient has symptomsduring the day).
Any HS dose on this list can be given earlier if the patient goes to bed early. Empty stomach is 2 hours after ameal and 1/2–1 hour before a meal. Meals on 5W are 8:15—12:15—17:30.
Reprinted by permission of Methodist Hospital/HealthSystem Minnesota.
Part 4 Achieving Breakthrough Improvement in Reducing Adverse Drug Events
KAWEAH DELTA HEALTH CARE DISTRICT
Narcotic Flowsheet
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Document the following information every 4 hours and as needed
*Sedation Scale
** Pain Intensity
Reprinted by permission of Kaweah Delta Health Care District.

Source: http://www.improvementskills.org/remotes/ADE_Guide_Part4.pdf

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