1201 / Reduction of medication errors by integrating a clinical pharmacist in the multidisciplinary team of an intensive care anesthesia unit

SPAIN
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Medication / IV Fluids
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Topic of the reported practice
Quality improvement project
Aim and the benefit of the Patient Safety Practice
 
It has been shown in several studies that the incidence of medication errors in intensive care units is higher than that of other services. Although rates of medication errors published by various authors are varied, the generated consequences are the same: need for greater monitoring of the patient and corrective treatment, prolonged hospital stay and sometimes, irreversible damage or death. Prevention of medication errors is a priority for the improvement of the pharmacotherapeutic process in critical patients. Due to the severity of critically ill patients, and to the complexity of the medication they require, the possibility of medication errors and drug-related problems increases considerably. Therefore, it is necessary to keep track of process and treatments, a fluid communication between the different professionals involved in the patient and form a perfectly coordinated interdisciplinary team. The measures that can be adopted and which are related to the reduction of medication errors include the following: - Voluntary declaration of errors. - Systematic review of medical records and other systems registration. - Observation. - Computerized prescription. - Use of barcode in drug administration. - Integration of a pharmacist in an interdisciplinary team Intensive care unit. In this practice we decided to integrate a pharmacist in the intensive care anesthesia unit in order to reduce medication errors in critically ill patients.
Description of the Patient Safety Practice
 
The purpose and justification of this clinical practice is to determine the incidence of medication errors in our unit. To implement improved systems to try to prevent them is a priority for the improvement of the pharmacotherapeutic process in critically ill patients. The working hypothesis was that the integration of a pharmacist in a multidisciplinary team, along with the introduction of a new reporting system for medication errors and the implementation of measures to avoid them would improve the incidence of medication errors in critically ill patients.
The objectives were: - Quantify and characterize medication errors that occur before and after the integration of a pharmacist in Anaesthesiology and Critical Care Department. - Implement a reporting system for medication errors. - Implement improved systems to reduce the incidence of these medication errors.
A prospective study of a year-long, which included all patients admitted to anesthesia intensive care unit (ICU) of the Complejo Hospitalario Universitario de Albacete (Gerencia de Atención Integrada de Albacete. Albacete, Spain). This hospital complex provides coverage to a population of approximately 285,000 inhabitants.
What was done: A clinical pharmacist was integrated on a full-time basis in the multidisciplinary team of an anesthesia intensive care unit.
Why it was done: To determine the incidence of medication errors in our environment and implement enhancement systems trying to prevent them, which is a priority for the improvement of the drug treatment process in critically ill patients.
How it was done: The project was carried out in 3 different stages: - First stage: a prospective observational study was carried out during one month, in order to detect characterize medication errors in Anesthesia ICU by the method of direct observation and to determine the baseline situation before the pharmacist´s intervention. This method consisted in observing the nursing staff when they administered drugs by independent persons (external observers, who in this case was the pharmacist) not involved in the observed action. The number of observations was a representative sample of the number of administrations of medications that are carried out in Critical Care Department in order to obtain the error rate (according to the calculation of the sample size, the minimum number of observations must be 600). The observations were made indiscriminately in shifts morning, afternoon and evening of nursing. The observations were collected on cards and compared with the original medical order detecting error if there was discrepancy. In addition to the administration of the medication, revised the original prescription, there was checked the medical original prescription, so that the complete circuit of drug use (prescription, dispensation and administration; not taking into account the stage of pharmaceutical validation because the Anaesthesiology and Critical Care Department of our center has not system of dispensation and pharmaceutical validation for the method of unitary doses, being the dispensation across semiautomatic cupboards Pyxis®) was analyzed. When the pharmacist responsible for monitoring detected an error, it was recorded and registered in the database and communicated in order to prevent it.
Errors were quantified and classified according to the following classification: a. Prescription error. b. Omission. c. Technique of Administration (wrong speed). d. Omission of the registry. e. Wrong preparation in critical care unit. f. Wrong preparation in pharmacy. g. Incorrect doses by default. h. Non-prescribed medication. i. Wrong dose excess. j. Technique of Administration (Administration wrong path). k. Drug expired / impaired. l. Incorrect monitoring.
In addition, the errors were quantified and classified into 9 categories (A to I) according to their severity, according to the classification established by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). In this stage, 36.27% errors were detected in the overall treatments, being Category C of the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) a 61.63% of them.
- Second stage (Intervention stage): During 10 months, the pharmacist reviewed the prescriptions of all patients admitted in the Anesthesia ICU unit performing the appropriate interventions over medication. Furthermore, to educate physicians and nursing staff, we organized educational meetings, and also pharmacotherapeutic protocols and guidelines of medication administration were created to standarize clinical practice. Finally, a system for reporting medication errors was introduced.
- Third stage: a prospective observational study was carried out for a month in order to detect medication errors after pharmacist’s intervention. The methodology was the same as in the first stage to compare both phases once the study is completed. In this stage, 5.9% of errors were detected in the overall treatments, 68.4% of them of Category C NCCMERP.
What was achieved: - Medication errors were reduced by more than 30%. - A pharmacist is now part of the multidisciplinary team in the ICU. - The experience has been broadcasted at the national and international level to promote the implementation of clinical pharmacist activities in our environment.
What is next: We are still working on the same areas to improve safety in drug therapy in critically ill patients. Currently, improvement measures that are being developed are: new pharmacotherapeutic protocols specifically for this unit, drugs and drug-diluent compatibility guidelines, performing new training sessions, standarize medication kits in operating rooms and implementation of the computerized prescription and a new labeling system of syringes.
Conclusion: According to our experience, this measure has shown that the contact of various professionals involved in the critical patient pharmacotherapy is the most effective measure to solve the problems derived from the medication in such a complex area.
Attachment of relevant written information and/or photos, as appropriate
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
The publications are in progress.
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Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Not known
Specification of implementation in another health care setting(s)
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Successful implementation's level  of this Patient Safety Practice across settings
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Involved health care staff
 
Physicians
Nurses
Health care assistants
Pharmacists
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
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Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
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Short description of the service users' level of involvement
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Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
No
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
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List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Staff and management recognised the need for change
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
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Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
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Contact information
 
Name: Esther Domingo Chiva
Country: SPAIN
Organisation: GAI Albacete
E-mail: estherdomingochiva@hotmail.com
Phone: 617193788
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