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Administrator
Posts: 578
Registered: ‎02-22-2010
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Medication Safety Webinar

[ Edited ]

Thanks for joining our webinar with Deb Saine, MS, RPh, as she discuss roles of the pharmacist in improving medication safety. View the on-demand webinar or download the slides.

Have a question for Deb about today's presentation? She will be monitoring this thread for a short period of time. Post your questions here and she will do her best to answer them.

Visitor
Posts: 1
Registered: ‎06-30-2010

Re: Medication Safety Webinar

GREAT PRESENTATION! Many ideas to improve med safety. 

I particularly like the "Great Catch" incentive/recognition for pharmacy staff that "catch" potential/actual med errors.

Can I ask, where did you procure the "Great Catch" baseball glove pins?

 

Thanks,

Jonathan Klemens

Director of Pharmacy

Jefferson Regional Medical Center

Pittsburgh, PA

 

JK
Trusted Contributor
Posts: 141
Registered: ‎02-19-2010
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Re: Medication Safety Webinar

Hi Deb,

 

Great presentation.  I think you have a great model for medication safety and was happy to see solutions that are making a difference to improve patient safety.

 

You talked briefly about technology and listed off a series of pharmacy technologies meant to improve safety.  I have come across various opinions as to which technologies have a larger impact on safety.  I was wondering which pharmacy technologies you believe have the biggest impact on patient safety and why.  Have you come across any that you feel has had a negative or no impact on safety?

 

Administrator
Posts: 578
Registered: ‎02-22-2010
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Re: Medication Safety Webinar

Here are some questions from our live attendees:

 

Q: When trying to introduce new practice changes done with interdisciplinary participation, what methods were successful when dealing with resistance and or slow adopters?

 

Q: Do you have a "threshold" number of events that must occur before designing and implementing an action plan?

 

Q: The changes you've mentioned making, are all of the facilities in your chain doing the same?

Occasional Advisor
Posts: 8
Registered: ‎06-29-2010
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Re: Medication Safety Webinar

I particularly like the "Great Catch" incentive/recognition for pharmacy staff that "catch" potential/actual med errors.

Can I ask, where did you procure the "Great Catch" baseball glove pins?

 

I worked with our risk manager to obtain pins -- will ask her for a resource and re-post a more specific answer when received.

-Deb

 

 

Occasional Advisor
Posts: 8
Registered: ‎06-29-2010
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Re: Medication Safety Webinar

In response to med safety Webinar discussion - here are some references to ADE costs:

 

1.  Mean cost ADE = $2262  (Classen DC et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attibutable mortality. JAMA 1997; 277:301-6)

 

2. Cost ADE = $2595, cost of preventable ADE = $4685  (Bates DW et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277:307-11)  Note that the 2007 IOM Report "Preventing Medication Errors" references this same article citing cost for preventable ADE as $5857/event. The difference is explained in the fulltext article. It should also be noted that this is 1993 cost data

 

3. Another reference that might be helpful is a literature review, with cost savings summarized in table format: De Rijdt T, Willems L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am J Health-Syst Pharm 2008; 65:1161-72.

 

Hope that gets you started!

 

-Deb

Occasional Advisor
Posts: 8
Registered: ‎06-29-2010
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Re: Medication Safety Webinar

I particularly like the "Great Catch" incentive/recognition for pharmacy staff that "catch" potential/actual med errors.

Can I ask, where did you procure the "Great Catch" baseball glove pins?

 

I worked with our risk manager to obtain pins -- will ask her for a resource and re-post a more specific answer when received.

-Deb

 

Sorry - unable to track down resource for pins. Others have reported using customized "lapel pins" through online resources.

-Deb

Occasional Advisor
Posts: 8
Registered: ‎06-29-2010
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Re: Medication Safety Webinar

Here are some questions from our live attendees:

 

Q: When trying to introduce new practice changes done with interdisciplinary participation, what methods were successful when dealing with resistance and or slow adopters?

 

A. Building good working relationships ahead of time with other disciplines contributes to success. Other strategies include:

- work with leaders from other disciplines in planning the change before implementation occurs. Create implementation plan together.

- Create educational tools with the perspective of the discipline(s) in mind. Repurposing the same poster, for example, for different disciplines, with individualized portions of information that are critical for that discipline.

- Encourage feeback from front line on how the new process is going, and include a contact person or method for providing feedback. For example, we added a "complaint" button for physicians, so they can give immediate feedback on something that's not working well with CPOE.

- Emphasize the positive when encouraging "slow adopters" - repeat the rationale for change. Share a great patient safety story to help them come on board with a change.

- If you are able to identify staff who may resist the change in mind, consider inviting that person to become a part of the planning team. This can be incredibly powerful in understanding "resistance" and may convert that resistance energy to "champion" energy.

- Try the change in a pilot area first, using an area that you know will be receptive to change.

 

Q: Do you have a "threshold" number of events that must occur before designing and implementing an action plan?

 

A. No, there is no magic number. Many factors are considered - urgency (high alert? potential for harm? likelihood of recurrence?), resources available, ease of implementation (for example, an event may be low urgency, but the change requires little resources and is easy to accomplish).

 

Q: The changes you've mentioned making, are all of the facilities in your chain doing the same?

 

A. That is our goal, if it applies to our different environments (e.g. size) and culture. Our system hospitals share information, but we do not maintain a common structure for change process. Regarding safety initiatives, we have common membership on our med safety teams to facilitate similar safety related changes. P&Ts and management are all separate. For example, all hospitals completed the ISMP ADC Self Assessment; we shared scores, but each hospital is prioritizing their own changes. We share a common Tall-man lettering list. The anticoagulation NPSG was achieved as a system initiative, however each entity had to go through their own approval process for policies, procedures, forms, etc.

Occasional Advisor
Posts: 8
Registered: ‎06-29-2010

Re: Medication Safety Webinar

Q. You talked briefly about technology and listed off a series of pharmacy technologies meant to improve safety.  I have come across various opinions as to which technologies have a larger impact on safety.  I was wondering which pharmacy technologies you believe have the biggest impact on patient safety and why.  Have you come across any that you feel has had a negative or no impact on safety?

 

A. I believe technology provides tools we can use in our workflow with potential for improving safety. How we use them in our environment (design, implementation, integration into workflow, maintenance, etc.) has a big impact on whether they will positively or negatively affect patient safety. Culture also plays a role -- for example, if management expects an unrealistic workload or speed - workarounds to the intended use of technology will emerge, rendering the use of that technology "unsafe."   That said, each organization must decide which technology will offer the most safety potential based on its culture, resources, knowledge base, and patient population. Check out the Webinar Archive for some lively discussion on BCMA vs CPOE. From my own experience, I cannot recall any technologies with negative/no impact on safety. In terms of impact, I tend towards those which can potentially protect a large number of patients, involving high alert processes or medications (for example, "smart" infusion pumps in our environment). A pharmacy information system is a top priority (most places already have that in place).

 

Deb Saine