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Applications of Resilience Engineering: Prevention of Medication Error Traps

Posted by Wrae Hill on Tuesday April 12th, 2016

Applications of Resilience Engineering

Interagency coordination to anticipate and prevent Medication Error Traps 

From loading dock to loading dose: While clinician vigilance is crucial, but it cannot be our only defense. 

This case study reviews the supply chain coordination of communication with clinicians about drug format changes and patient safety

Principles: 

Restorative Just Culture / Organizational learning

1)     Build/ rebuild trust and forward looking accountability by including all affected persons from the drug purchasers (regional level) to the anesthesia care team

2)     Commit to fixing what we can within the operational constraints

3)     Commit to documenting what cannot be immediately fixed and trying to influence system change

Resilience Principles: Anesthesia care team & Pharmacy / Supply chain perspectives 

Anticipation

Monitoring

Response

Learning

ANESTHESIA

 

What do you expect to see?

How could you prepare?

Is the system visible to you?

 

 

What is current state of drug supply chain?

How do you assess the evolving situation?

How do you monitor what is occurring outside?

How do you respond?

 

How do could you respond?

What can you do now?

 

How can we improve communication to anesthesia care providers?

PHARMACY /SUPPLY CHAIN

 

What do you expect to see?

How do you prepare?

How do you assess risk?

 

What is current state of drug supply chain?

How do you assess the evolving situation?

How do you monitor what is occurring outside?

How could you respond?

 

How do could you respond?

 

How best to communicate with the Anesthesia care teams?

What can you do now?

 

How can we improve communication to anesthesia care providers?

Context: Contributing Factors 

Brittle Supply Chain: The Canadian drug supply chain is brittle, and there are hundreds of drug substitutions and backorders each year, representing a new norm. In BC, currently there are over 300 drug shortages, 30 of these are critical. These changes, over 350 /year, must be communicated to the correct affected users at the correct time. A daunting challenge for all involved, especially when attempting to use email.

Example:

Backordered Drug: Cisatracurium 2 mg/ml 10 mL, BX/10 $ 83.20 (Manufacturer X) / DIN _____

Auto sub replacement: Cisatracurium 2 mg/ml 10 mL, BX/10 $ 175.00 (Manufacturer Y) / DIN _____ 

Email communication: The communication system used before this event was email broadcasts, (without photos) to those who order these drugs (buyer’s perspective). The notification system was not risk specific, and was not directed to the clinician’s frame of reference. Further, most anesthetists do not use the health authority’s email system. We therefore had to rely upon intermediaries. This constant flux and ineffective communication created error traps for clinicians and patients.

Perioperative medication errors – Much more common than we think

A recent prospective study showed that the risk of perioperative medication errors are much higher than previously thought (Anesthesiology 2016)Setting: 1,046-bed tertiary care academic medical center  

Observations: 277 operations were observed over 8 months with 3,671 medication administrations (avg. 13.5/case). This prospective observational study found that approximately 1 in 20 (5.3%) perioperative medication administrations, (which average 13.5 medications /case) and every second operation resulted in a medication error and/or an adverse drug event. More than one third of these errors led to observe patient harm, and the remaining two thirds had the potential for patient harm.  

Evaluation of Perioperative Medication Errors and Adverse Drug Events Karen C. Nanji, et al   Anesthesiology 2016; 124:25-34

Local site changes resulting from this case:

  • Pharmacy technicians now stock anesthesia trays, which now include Rocuronium and Succinylcholine eliminating the need for physicians to bring their own supply of these agents in to the OR.
  • In the next 3-5 years barcoding will be available (Omnicell) across the Health Authority however it will not completely solve these problems.

Interagency / Regional communication changes resulting from this case; 

1)     Provincial Supply Chain (Buyers) handles routine notifications via broadcast email. These now include color photos of the pre/post change & packaging in both the body of the email and as an attached .pdf. This new process was tested and refined.

2) Screening by Regional Pharmacy (Formulary); this discretionary process supports timely and focused communication to local (site based) Pharmacy Professional Practice Leaders including a follow up request to clinicians.

Example: Ketamine Packaging Change:

Color photos of the pre/post change & packaging are included in both the body of the email and as an attached .pdf “Please communicate this change to drug prescribers / affected clinicians including this colour notice. Specifically ask clinicians to inform you of any potential look-a-like drugs or packaging”. Please communicate this to the regional formulary manager within one week.”

 

 

 

Figure

 

 

 

 

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Wrae works in the Interior of British Columbia as the Manager of Human Factors and System Safety in a large health region (18,000 staff/ 2,000 Physicians). As a Respiratory Therapist (Toronto 1988), Wrae spent many years caring for patients, and leading others in neonatal, pediatric and adult critical care units in Vancouver, Riyadh, Toronto and Edmonton. 

In 2005 Wrae moved into the growing quality improvement field and was trained as a Canadian Patient Safety Officer and faculty trainer in investigations and disclosure. His graduate work (2008-2010) in Human Factors and System Safety was at the University of Lund , School of Aviation (Sweden).  Wrae co-developed a Patient Safety Investigation (PSI) curriculum and has experience in major system safety work including cognitive task analyses in medical device patient safety. Wrae’s keen interest and research is in Interactive Handover for all healthcare providers. This research combines high reliability/resilience science and direct observation of the nature of clinical expertise. This has led to the development of a simple handover mnemonic and quality score (HQS) to measure improved communication in healthcare. Wrae also serves as an adjunct Professor of Nursing at UBC-Okanagan.

Wrae works in the Interior of British Columbia as the Manager - Human Factors and System Safety in a large health region (18,000 staff/ 2,000 Physicians).
As a Respiratory Therapist,(Toronto 1988), Wrae spent many years caring for patients, and leading others in ; neonatal, pediatric and adult critical care units in; Vancouver, Riyadh, Toronto and Edmonton. 

In 2005 Wrae moved into the growing quality improvement field and was trained as a Canadian Patient Safety Officer and faculty trainer in investigations and disclosure. His graduate work (2008-2010) in Human Factors and System Safety was at the University of Lund , School of Aviation (Sweden).  Wrae co-developed a Patient Safety Investigation (PSI) curriculum and has experience in major system safety work including cognitive task analyses in medical device patient safety. Wrae’s keen interest and research is in Interactive Handover for all healthcare providers. This research combines high reliability / resilience science and direct observation of the nature of clinical expertise. This has led to the development of a simple handover mnemonic and quality score (HQS) to measure improved communication in healthcare. Wrae also serves as an adjunct Professor of Nursing at UBC-Okanagan.

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