qu- ct 9

New KSA University Hospital

Original Date: November 17, 2017

Effective Date: January 01, 2018

ADMINISTRATIVE POLICY AND PROCEDURE (APP)

TITLE: MEDICATION ERROR REPORTING

1. Statement of Purpose

To provide patient safety standards by ensuring proper reporting of medication errors, improving awareness of medication error reporting, guiding employees of using safety reporting system (SRS) and applying just/accountability culture in KSA University Hospital.

2. Authority

Medication errors reporting policy is authorized by Saudi medication safety chairman, executive director of operation, chief operation officer, chief medical officer and chief executive officer.

3. Scope

3.1 The policy applies to all relevant departments and healthcare providers including medical involved in the medication process and non-medical staff working at the New KSA University Hospital and affiliated facilities.

3.2 Related references:

3.2.1 Administration of medications

3.2.2 Chemotherapy drugs

3.2.3 Computerized Provider Order Entry (CPOE) system

3.2.4 Informed consent

3.2.5 Joint Commission International “do not use” list of abbreviations

3.2.6 Just/ accountability culture

3.2.7 Medical code of ethics

3.2.8 Medication errors

3.2.9 Nursing code of ethics

3.2.10 Prescribing and dispensing of medications

3.2.11 Patient rights

3.2.12 Safety Reporting System (SRS)

4. Responsibility

4.1 It is the responsibility of pharmaceutical, nursing and medical services and other relevant departments to ensure implementation of this APP.

4.2 Internal audit, quality services, patient safety and medication safety committee will monitor the implementation of the provisions within this APP.

4.3 Quality services, patient safety and medication safety committees will ensure staff compliance to New KSA University Hospital standards and guidelines.

4.4 Quality services, patient safety and medication safety committees will provide necessary education and guidance about medication errors reporting to all staff within New KSA University Hospital.

5. Definitions

5.1 Safety Reporting System (SRS) is an electronic reporting system utilized for safety incident reporting, collection of information and feedback (Elliott, Martin & Neville, 2014).

5.2 Computerized Provider Order Entry (CPOE) system is a computer-aided system that offers healthcare providers a platform for entering electronic orders such as medication prescriptions, diagnostic tests and laboratory tests for patients. (Atique, Lee, Shabbir, Hsu & Rau, 2016).

5.3 Medication Process it is the process of prescription, transcription, dispensing, administration and discharge summaries. (Lisby, Nielsen & Mainz, 2005).

5.4 Medication order appropriateness is the process of

5.5 Medication Error is a preventable event that can cause or lead to inappropriate medication use which will result in patient harm or death while the medication is in the control of the healthcare provider or patient. (Makary & Daniel, 2016)

5.6 Informed consent is a legal required process whereby physicians provide information, alternatives, risks and benefits to the patients or legal guardians about any intervention. The process involves understanding, authorization and decision of patients to consenting physicians. (American Academy of Pain Management, 2017; Faden, Beauchamp & Kass, 2014).

5.7 Just/ accountability culture is a balanced culture of accountability, learning and trust in which it doesn’t blame individuals for errors but seek to know reasons behind committing errors (Duffy, 2017).

5.8 Five Rights of medication administration are right patient, right medication, right dose, right route and right time. (Alabdulhafith & Sampalli, 2017).

5.9 Near Miss is any process variation that is identified before it reaches to the patient and cause affect or harm. (Crane et al., 2015).

5.10 Root Cause Analysis is a process to identify the main contributory factors that lead to medication errors (Teixeira & Cassiani, 2010).

POLICY

I. Policy Statement

The policy provides guidelines of medical error identification, monitoring and reporting in New KSA University Hospital. It prevents and controls potential medical errors from occurring in order to enhance patient care, improve patient safety and decrease length of stay and hospital cost. (Pham, Girard & Pronovost, 2013).

II. Policy

A. Medication Order Process

a. Medication order process is based on New KSA University Hospital policies and procedures.

b. Medication administration is covered by general informed consent.

B. Medication Error Identification

a. Any violation or variation of medication order process will result in medication error.

b. Any identification of medication errors before it reaches to the patients is a near miss which is a type of medication errors.

c. Identification of medication error by healthcare providers require reporting (Shamsaei, Hejazizade & Arefi, 2016)

d. Types of medication errors are listed in (appendix A) (Teixeira & Cassiani, 2010).

C. Medication Error Reporting

a. Medication error reporting is anonymous, non-punitive and strongly encouraged process.

b. Adherence to hospital policies by concerned individuals will avoid and/or minimize medication errors.

c. Medications errors, near misses and hazardous situations shall be documented in SRS system (Kachalia & Bates, 2014).

d. Just/ accountability culture will be exercised to deal with medication errors (Shamsaei, Hejazizade & Arefi, 2016).

D. Education and Training of Medication Error Prevention

a. All healthcare providers within New KSA University Hospital should be medication safety certified.

b. All heath care providers should receive comprehensive CPOE training and should be CPOE certified.

c. Nurses should pass all required competencies of medication administration including medication calculation exam (Tshiamo et al., 2015).

d. Pharmacists should pass all required competencies of medication preparation, reviewing and dispensing (Pedersen, Schneider & Scheckelhoff, 2015; Wertheimer, 2014).

Procedure

I. Medication Order Process

a. Medication orders are prescribed by qualified physicians and healthcare providers in CPOE system (Radley et al., 2013).

b. Any variation of medication ordering in terms of medication type, dosage, route, interaction with other medications or allergy status it will result in system alert to notify the prescriber about it (Radley et al., 2013).

c. Overriding the system alert is allowed in case of justification.

d. Medication order in CPOE is electronically transferred to qualified pharmacist for reviewing, approval and preparation (Pedersen, Schneider & Scheckelhoff, 2015).

e. Pharmacist needs to complete medication order appropriateness to sign and approve the medication order (Radley et al., 2013).

f. Pharmacy runner will dispense the medication to the nursing unit where the patient is admitted.

g. Registered nurse will check, accept and receive the medication.

h. Five rights of medication administration will be checked at bedside and medication will be signed electronically.

i. Medication will be administered at bedside according to the hospital medication administration policy with consideration of independent double check of high alert medications (Lisby, Nielsen & Mainz, 2005).

II. Process of Medication Error Reporting

a. Observation and identification of medication by healthcare providers.

b. Stop medication and address patient’s needs.

c. Report to most responsible physician.

d. Report to departmental manger.

e. Complete SRS incident report.

f. SRS incident report is assessed by manger.

g. SRS incident report is reviewed by medication safety committee.

h. Medication safety committee and Total Quality Management must identify a root cause analysis (RCA) of medication error (Stewart et al, 2016).

i. Analysis, recommendation and feedback to be presented to healthcare leaders and executives for analysis and improvement plans as required to prevent future medication errors (Shamsaei, Hejazizade & Arefi, 2016).

III. Guidelines of Medication Error Prevention

a. New KSA University Hospital encourage all healthcare providers to report medication error in SRS system.

b. Just/ accountability culture to be practiced when dealing with medications.

c. Healthcare providers to be instructed not to use the list of unapproved abbreviations (Samaranayake et al., 2014).

d. Patient and family education is key control of medication error.

e. Physicians to be encouraged to prescribe medications using generic names.

f. Clinical pharmacists should make a daily round to check medications orders in each assigned nursing unit.

g. Use of Tall man lettering is effective way of medication error prevention.

h. Electronic technology such as the use of electronic scanner devises to scan bar coded medications for right patient can help in prevention of medication errors (Wertheimer, 2014).

IV. Discipline

A. The hospital is aware of the adverse consequences that come with medication errors, especially on the patient and family. High levels of discipline must be embraced at all time when a medication error arises to include:

a. Information about medication error should only be informed to the relevant bodies which include a professional consulted, line manager, director and the patient or family.

b. Only confirmed action should be taken and patient or the family should be informed before the remedy is taken (Stump, 2000).

c. Decision making should be given to patient and family whether to accept the offered remedy or seek assistance elsewhere.

d. Ethical and professional language should be used all through to make the patient and the family feels that the error was not the intention and the cause of the error explained to them.

e. Evaluation of medication error incident based on just culture algorithm (appendix B) to identify if it is reckless action, at risk behavior or human error (Marx, 2008).

f. Necessary actions to be taken post just culture evaluation of medication error (Marx, 2008).

g. Effective communication about prevention of medication errors are needed for healthcare organization success (Stump, 2000).

Appendix A

Figure 1. Categorization and definitions of medication errors were adapted from Root cause analysis: evaluation of medication errors at a university hospital by Teixeira, T. C. A., & Cassiani, S. H. D. B, 2010. Revista da Escola de Enfermagem da USP, 44(1), 139-146.

Appendix B

Figure 2: Just Culture Algorithm adopted from Marx, D. (2008). The Just Culture Algorithm. Outcome Engineering. Retrieved from: https://www.outcome-eng.com/the-just-culture-algorithm/

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