Monthly Archives: December 2014

Root Cause

Program Reduces Use of Antipsychotics & Improves Resident’s Quality of Life

By ThinkReliability Staff

Although the use of antipsychotic drugs for nursing home residents suffering from dementia can increase their risk of death and falls, they are still prescribed for nearly 300,000 nursing home residents across the U.S. The “Nursing Home Patients Bill of Rights” allows their use only under specific conditions: “psychoactive drugs (including antipsychotics as well as drugs for depression and anxiety) may be administered only on the orders of a physician and only as part of a written plan designed to eliminate or modify the symptoms for which the drugs are prescribed. Such drugs may be given only if, at least annually, an independent, external consultant reviews the appropriateness of the drug plan of each resident receiving such drugs.”

Despite the risk of these drugs, and the requirement that their use be continually reviewed, some nursing home residents are given antipsychotic prescriptions and are never taken off them. In 2009, the staff of a small nursing home decided to embark on a program to reduce the use of antipsychotics. It was so successful that they extended the program to all the nursing homes owned by the nonprofit Ecumen. After the first year, antipsychotic use was reduced 97%. At the original facility, 5-7% of residents receive antipsychotics, compared to the national average of 19%.

The change in the residents’ quality of life was dramatic after the program was instituted. Because the residents “came alive and awakened”, they called the program Awakenings. To understand how the program works, it’s helpful to imagine the program being the solution to the problem of overuse of antipsychotics in nursing homes.

First, viewing the problem with respect to the organization’s goals can help determine what the real issue to be addressed is. In this case, resident safety and resident quality of life are two important goals of a nursing home. Resident safety is impacted by the use of antipsychotics because it increases the risk of death and the risk of falls. Resident quality of life is impacted because the use of antipsychotics was not being effectively re-evaluated as required.

The risk of increased death and falls are both related to the use of antipsychotics, which have been found to increase death in those with dementia and also increase the risk of falls. Generally the residents at the nursing home were found to have been prescribed antipsychotics as an intervention to some type of behavior resulting from the dementia (wandering, aggression, resisting care) and the resident’s need for antipsychotics was not effectively re-evaluated, so residents remained on the drugs.

A program to reduce their use had to address both of these causes. The nursing home team consulted with experts to begin weaning patients off the antipsychotics. The Awakenings process then addressed the behaviors being treated with the medication. For each resident, both the medical and personal history is taken into account while developing a care strategy. The care strategy is distributed to the entire care team, including housekeepers and cooks. The care strategy uses as many non-medication-based interventions as possible – and addresses all of the resident’s five senses. Some of the strategies include balloon volleyball, massage, aromatherapy and white noise. For those familiar with the Plan-Do-Check(Study)-Act, this is the “Plan” step.

The care plan is implemented by all staff (Do) and all staff participate in observation and assessment to monitor problem behaviors or other issues (Check/ Study). When issues do arise, the care plan is adjusted – whenever possible, without use of additional medication (Act). The process is described by the Awakenings program like this: “Long-term antipsychotic use masks behavioral symptoms rather than addressing them.   Awakenings discovers unmet needs that often trigger behavioral symptoms and addresses the triggers with non-pharmacological care techniques.  This is done in collaboration with a physician to reach the optimum balance and benefit of non-pharmacological and biomedical approaches.” Although the initial setup is expensive; as Dr. Mark Lachs, chief of geriatrics at Weill Cornell Medical College says, “Behavioral interventions are far more time-consuming than giving a pill”, the staff is pleased with the results and optimistic for the future. Laurel Baxter, the Awakenings project manager says, “I believe we may learn that spending a little time now with a resident, preventing the use of psychiatric medications and their side effects, you’ll save time and money in the long run. I’m optimistic.”

To see the root cause analysis of antipsychotic overuse in a Cause Map (or visual diagram of cause-and-effect relationships) and the Awakenings process, please click on “Download PDF”.

Root Cause

Hospital Admits Fault, Implements Improvements after Death due to Medication Error

By ThinkReliability Staff

A hospital in Oregon administered the wrong medication to a patient who stopped breathing. Because of a fire alarm that happened shortly afterwards, the patient was not monitored for about twenty minutes. After that time the patient had experienced irreversible brain damage and was taken off life support on December 3, 2014.

In a surprising move, the hospital has taken responsibility for the error. Dr. Michel Boileau, the chief clinical officer, has stated, “We do know there was a medication error. We acknowledge that. It’s our mistake.” While an Oregon law, which took place in July, encourages transparency with patients and loved ones and reporting in the case of medical errors, the hospital says communication in the case of errors has been its practice for years and that it’s the right thing to do.

Supporting the transparency, the victim’s son says, “We want the community to know what happened. Precautions need to be taken. The only message we really have is that life is short and you never know when something like this could happen.”

Detailed information regarding the case has been released in the media. Using that information, it is possible to put together a Cause Map showing the cause-and-effect relationships that led to the death, and show how the hospital’s planned improvements address the causes.

In this case, administration of the paralyzing agent Rocuronium instead of the prescribed anti-seizure medication fosphenytoin caused the patient to stop breathing, leading to cardiac arrest and irreversible brain damage. Monitoring of the patient may have caught the lack of oxygen prior to irreversible damage, but in this case the patient was not monitored. Shortly after the administration of the IV, the hospital experienced a fire alarm (“code red”), at which point staff left the patient’s room and closed her door. Staff estimates she was unmonitored for about twenty minutes.

Medication errors that happen within hospital facilities almost always involve an error in the medication process. As part of the investigation, Dr. Boileau states, “We’re looking for any gaps or weaknesses in the process, or to see if there has been any human error involved.” So far the hospital has determined that the IV bag given to the patient was filled with the wrong medication at the in-patient pharmacy but then coded for the correct drug. It’s unclear exactly what happened at the pharmacy, but there was either no check of the medication filling or the check was ineffective, as it allowed the wrong drug to be delivered to the patient for administration.

According to the hospital’s chief nursing officer, Karen Reed, “We are all committed to honoring Ms. Macpherson’s name by learning everything there is to learn here and making sure no other patient has to go through this again.” While the investigation into the details continues, the hospital has already planned some improvements to work towards that goal.

To reduce the risk of medication errors, the hospital is designating a safe zone to be used for medication verification. (Distraction has been shown to be a primary driver of medication mix-ups.) They’re also reviewing and updating their medication protocols and ensuring that a detailed checking process is implemented. Because of the particular danger associated with mistakes involving paralyzing agents (like Rocuronium), alert stickers have been added to these types of drugs. Because of the issues with patient monitoring, procedures that ensure patient monitoring after IV administration (presumably even in the case of an unusual event or emergency) will be implemented.

What does this mean for you? Medication errors are considered rare, but even one is one too many. Medication administration processes at healthcare facilities must be designed to minimize the risk of error by reducing interruptions and ensure double checks. Other guides, such as alert stickers, can be used to emphasize particular risks (not limited to medication errors). In healthcare facilities (or any other facilities where operations can’t safely be put “on hold”), there needs to be a plan for ensuring that necessary tasks are performed, even with emergency or unusual situations.

Read more about this incident.

Learn more about medication errors.

Root Cause

Causes for Medication Errors Identified in Cumulative Cause Map

By ThinkReliability Staff

Despite continuing efforts to reduce patient safety impacts from medical errors, more work is needed to make patients safer. One of the areas which has been identified as a key safety issue is that of medication errors within healthcare facilities. A Cumulative Cause Map is a tool that can identify causes proactively (before incidents occur) based on industry experience, including past errors. As a Cause Map is a visual form of root cause analysis, a Cumulative Cause Map can be considered a visual form of Failure Modes and Effects Analysis (FMEA). It captures potential causes (causes that COULD result in an impact to patient safety) in order to develop and implement solutions that will reduce the risk of the impacts.

In this case, the term “medication error” is used to refer collectively to errors that result in patients receiving the wrong medication, patients receiving medication prescribed for another patient, patients receiving the wrong dose of the correct medication or having the correct medication delivered by the wrong route, and patients receiving medication to which they have a known allergy or has a negative interaction with another medication the patient is known to be taking. An adverse drug event (or ADE) results when the medication error causes patient harm. Our analysis will focus on preventable issues. (Patients may experience an ADE even when a medication is administered correctly.) About half of ADEs are considered preventable, i.e. they result from a medication error.

In this case, our Cumulative Cause Map will identify errors that occur at all steps of the medication delivery process. This process begins when a need for medication is identified and ends when the medication has been administered to the patient. At a very high level, there are four steps to this process: prescribing, transcribing, dispensing, and administration. The process typically begins with a physician, who prescribes the medication, moves to a clerk who transcribes the prescription (if necessary), then to a pharmacist who dispenses the medication, and then typically to a nurse, who administers the medication.

Based on information from studies, industry guides, and case studies of actual medication errors, common issues can be identified at each step of the process. In the prescribing stage, a medication can be prescribed for the wrong patient if there has been insufficient verification of the patient’s identity (and a matching of the patient to their medical records). Additionally, an inappropriate medication, dose or route may be prescribed if the physician is unaware of a patient’s allergies or other medications which could interact with those being prescribed. Miscalculating a dose is another potential error at the prescribing stage. Distraction and/or similar-sounding drug names are other causes for prescription errors.

In the transcribing stage, errors typically result from legibility issues on handwritten prescriptions. However, distraction and/or similar sounding drug names can result in the wrong medication/ dose and/or route of administration being transcribed. Distraction and/or similar sounding drug names is an issue during the prescribing step, as is miscalculating a dose. When medications have to be substituted (for availability or cost concerns), there’s also the potential to choose an inappropriate medication if a patient’s allergies or current medications are unknown.

At the administration step, medication can be administered to the wrong patient due to insufficient identity verification. Or, the wrong medication, dose or route can be administered due to similar sounding names and/or distraction. According to the Institute for Safe Medication Practices, every interruption increases the risk of medication error 12.7%, and medical staff can be interrupted as often as every two minutes while working on the medication delivery process. For this reason many hospitals are trying to reduce interruptions of medical staff during this process by various means.

By looking at the causes that come up again and again in the proactive analysis, steps for improvement at each level of the process can be identified. Ensuring that the right patient is matched to the medical record/ care instructions at every step of the process can reduce medication being administered to the wrong patient. The use of non-handwritten prescriptions and including both the drug’s brand name, generic name and purpose can also reduce the risk of the wrong drug being administered. Ensuring that drug allergies are clearly captured within a patient’s records (and potentially on the patients themselves, in the form of a wristband) and that a current medication list is up to date can reduce the risk of drug reactions. An organization’s experience with these different types of errors will allow it to determine what level of control over each cause is necessary to reduce the risk to an acceptable level.

To view the one-page PDF with a proactive analysis of medication errors in healthcare facilities, please click “Download PDF” above. To learn more about Medication Errors, please join our FREE Webinar on December 18th.

Root Cause

Anesthesia Without Electricity or Oxygen Tanks

By Kim Smiley

Almost 32 million surgeries are performed globally each year without a proper supply of oxygen and anesthesia, predominantly in developing nations.  Many more surgeries are canceled or delayed because anesthesia isn’t available.  One of the issues that plague hospitals in low income countries is that traditional anesthesia machines need electricity and oxygen tanks to function, both of which can be in short supply. A new design, called the Universal Anesthesia Machine (UAM), can operate without electricity or oxygen if necessary and is proving to be a practical solution to this difficult problem.

The UAM was invented by a doctor, Dr. Paul Fenton, who worked as an anesthesiologist at Queen Elizabeth Central Hospital in Blantyre, Malawi where he saw the problems with providing adequate anesthesia first-hand.  He designed his machine to use electricity when it is available, but to continue to function if power is lost by using a hand-powered pump on top. A digital display of oxygen levels switches to a 10 hour battery when power is lost so that the patient can continue to be monitored.  It also uses a compressor and air from the room so oxygen tanks aren’t required.

In an effort to make the UAM as practical to use as possible, it doesn’t use specialized parts.  Parts needed to maintain the machine should be available through a typical auto supply shop.  It’s also a flexible design that is compatible with all standard adult and pediatric breathing systems.

Honestly, this invention sounds too good to be true, but the UAM seems to be functioning as promised.   The number of UAMs in use is still relatively small (100 have been distributed to 18 countries), but they have already provided oxygen for over 30,000 surgeries.  Inadequate anesthesia is a huge issue, but this new machine may very well prove to be an important step in working towards a solution.

Click on “Download PDF” above to see a Cause Map of the problem of inadequate anesthesia.  You can also learn more about how the Universal Anesthesia Machine works by clicking here.