Improving medication safety is at the forefront of most hospital pharmacists’ minds. This complex issue has numerous facets and nuances, and nearly endless opportunities for pharmacists to jump in and make interventions that change hospital policy resulting in better, safer care.
At the 2015 American Society of Health-System Pharmacists Summer Meetings, pharmacists from three health systems shared their success stories for improving medication safety with insulin U-500 administration, patient-controlled analgesic (PCA), and implementing a process for weighing all patients using metric units instead of pounds.
Insulin resistance problems continue to escalate as Americans’ weight continues to climb and higher doses of insulin are needed to meet glycemic goals. Insulin dose requirements exceeding 200 units per day has led physicians to increase the use of insulin U-500. According to a 2013 safety alert from the Institute for Safe Medication Practices (ISMP), “along with the increased use of U-500 insulin, we have been receiving a growing number of U-500 insulin-related medication error reports and/or complaints from health professionals.”
Elizabeth Wade, PharmD, BCPS, Medication Safety Officer at Concord Hospital in Concord, NH, participated in her hospital’s efforts to evaluate and improve the use of insulin U-500.
She pointed out several advantages and disadvantages to the higher dose. “With insulin U-500, [one of] the advantages [is that] large doses of insulin can be administered with fewer injections,” she said. “[There is a] cost savings per unit when the dose of insulin is greater than 100 units.” She noted that disadvantages include confusion between insulin U-500 and U-100 volumes when preparing doses, which “may result in a fivefold overdose.” The reason for the confusion, noted Wade, is that no U-500 calibrated syringe exists. “U-500 insulin is not interchangeable on a unit-to-unit ratio with U-100 insulin due to pharmacokinetic differences,” she said.
Wade and her team assessed whether insulin U-500 should be on the hospital’s formulary. “We had a lot of discussion. The visceral response was ‘well, let’s just get rid of the U-500, no one should be on it.’ It should not be on the formulary,” she said.
The advantage of taking insulin U-500 off a hospital’s formulary is that fewer safeguards are needed, but “you still have to manage patients [who are on it],” said Wade. For example, what if a patient comes into the hospital with his or her own supply? You still need a medication process to manage it, she noted.
The team then looked at the idea of formulary restriction. This approach gives hospital staff the ability to keep a reduction strategy in place, while still being able to control the use of insulin U-500. “Insulin U-500 absolutely is a very scary drug,” concluded Wade. “We wanted to implement as many risk reduction strategies as possible throughout the medication use process to decrease the likelihood of an error.” She noted that a formulary restriction policy can help reduce clinical use while still allowing for safeguards in the process.
Sondra May, PharmD, Medication Safety Coordinator at the University of Colorado Hospital, gave a presentation about strategies to improve the safety of PCA. In 2012, May and her group looked at PCA error data over an 18-month period. “We saw a concerning trend of a large number of errors related to PCA therapy,” she said. The team found 70 reported PCA medication-related errors. “Around half of the errors involved the wrong dose or the wrong rate of administration, and around 13% of errors involved the wrong concentration,” said May.
According to May, smart pump technologies aid in delivering safer patient care, but it is not enough to purchase these pumps and hope that their safety features alone will improve patient outcomes. Protocols still need to be in place to ensure medication safety.
The group conducted a risk analysis to more fully understand the problem and identify solutions. May and her team “spent a lot of time talking to staff” and developed a timeline to address all of the issues that affected PCA therapy based on staff feedback and data.
The timeline had two phases. Phase one included several process improvement initiatives, such as optimizing the electronic health record (EHR) and the medication administration record and standardizing an independent double-check process. May noted that establishing minimum standards for completing an independent double check reduces variation and improves outcomes.
After implementing these process improvement initiatives, May and the team saw a 47% reduction in the number of errors that reached the patients.
Phase two focused on standardizing medication concentrations. To do this, May and the team reduced the number of available medication concentrations, increased the storage capacity of the automated dispensing cabinets, establishes a new workflow, and implemented more training for the nurses.
This phase also included the development of order sets and a drug library to enhance patient safety that resulted in a 55% reduction in canceled infusions.
“We continue to see a decline in medication errors associated with PCA,” said May. “We’ve seen a 67% reduction in the number of patient occurrences and a 70% reduction in errors requiring treatment or intervention.”
May noted that safe use of PCA depends on a comprehensive program that employs key safety principles throughout each step of the medication use process. “Our interprofessional team utilized an innovative multiphase strategy to design an approach to care that ultimately reduced medication errors and patient harm related to PCA,” she said.
Rebecca Prevost, PharmD, Medication Safety Officer at the Florida Hospital HealthCare System, presented a third strategy to improve medication safety. She explained that one of ISMP’s targeted medication safety best practices for hospitals is to measure and express patient weights in metric units only, and that scales used for weighing patients should be set to measure only in metric units.
Prevost and her team thought this would be an easy thing to do when they implemented their EMR system in 2007 because the EMR automatically converts weight in pounds to kilograms. “But that didn’t solve our problem,” said Prevost.
She highlighted several true-life patient examples in which the wrong patient weight was used. She noted that one patient’s weight was 60 kg, but it was entered into the computer as 135 kg, so the heparin rate was running twice as fast as it should be. In another example, Prevost explained that the patient weight was estimated at 54.4 kg, but actual weight of the patient was 38 kg. As a result, the patient received an overdose of vancomycin and tobramycin. Prevost recalled one instance where a provider entered a daptomycin dose of 1,530 mg, which the pharmacist thought was unusually high. After further investigation, it turns out that patient weighed 255 lbs, not 255 kg.
Prevost put together a multidisciplinary team to help fix the problem. The team started with nurses, pharmacists, and patient safety personnel, but Prevost soon realized she needed to broaden the team’s scope to include facilities management, biomedical engineering, purchasing, and information technology (IT). Prevost told meeting attendees that the clinicians didn’t need a lot of convincing to move to the metric system, but there were numerous areas that wanted to be excluded. “Some people are hesitant to make the conversion because they think it doesn’t apply to them,” said Prevost.
For example, noted Prevost, in the state of Florida, pounds are required for a newborn’s birth certificate. In the emergency department, a patient may not be able to stand, so staff often ask the patient for their weight, and the answer is almost always in pounds.
Prevost and the multidisciplinary team implemented several initiatives. The first was to standardize the scales, giving clinicians the ability to weigh only in kilograms. The scales were labeled with big bright stickers that said the weight was in kilograms.
“The team worked with IT to make changes to the electronic patient intake form,” said Prevost. “Now there is only one choice,” where clinicians must enter the patient’s weight in kilograms. She added that there is also a big yellow box on the screen that says patients must have an actual weight in kilograms recorded. She noted that if you take away the option to put in kilograms or pounds, then you “make it easy to do the right thing. That’s what we’re trying to enforce—the ability to do the right thing,” she said.
The team also revised hospital policy to reflect that patients should be weighed in kilograms for medication dosing.
Prevost noted that the keys to successfully making the change from pounds to kilograms included obtaining executive and medical staff support by stressing the safety benefits for patients. She noted that it is helpful to highlight real examples of miscalculations from your institution and to set a realistic timeline with assignments and accountability.