An Integrated Approach / Multi-Faceted approach to High Alert Medication Safety: Detecting Errors and Lessons Learned Bac ground:

!here are "any no#n factors that contri$ute to the co"ple%ity of the "edication

"anage"ent& 'hen a "edication error happens( it is often "ultifaceted and can in)ol)e a co"$ination of hu"an factors and syste"s issues& Heparin and *otassiu" +hloride considered as High Alert Medications are co""only "ishandled and are causes of inad)ertent errors& In SM+H( the organi,ation adapted and deployed inter)entions to reduce and pre)ent recurrence of errors& !hese approaches are specifically designed in i"pro)ing patient safety $y facilitating correct "edication "anage"ent& -ey approaches .as per the ISMP) included #ere: Fail Safe and Forcing Functions .usage of Infusion *u"ps/( +onstraints .0nit Dose Syste"( Standari,e Ad"i%tures( *har"acy *reparation( 1ero stoc of -cl in clinical areas(etc&/(+entrali,e Error *rone *rocess .-cl in phar"acy and special designated areas only( Heparin Infusion preparation in phar"acy/(Access to Infor"ation .a)aila$ility of for"ulary/(Standardi,e and Si"plify .**2 for"s( eli"ination of a$$re)iations( standardi,ation of dosing guidelines/protocols/(Differentiate/0se 'arnings and 3e"inders . High Alert Stic ers( La$elling(etc&/( and 3edundancies/Dou$le +hec s& 2$4ecti)e: !he goal of this study #as to descri$e and e)aluate the High Alert Medication Manage"ent in SM+H& Ad)erse Drug E)ent and 5ear Misses #ere re)ie#ed to deter"ine factors associated to the e)ent& Further"ore( to deter"ine if the integrated approaches in "anaging High Alert Medications reduce nu"$er of HAM related "edication errors& Methods: A concurrent study of patients ad"itted to "edical #ard and I+0-++0 recei)ing High Alert Medications specifically( *otassiu" +hloride and Heparin Infusion& +hart re)ie#s #ere perfor"ed $y the *har"acy and !herapeutic +o""ittee to identify possi$le errors "ade during prescri$ing( possi$le near "isses and unreported ad)erse effects& Additionally( co"pliance to the i"ple"ented standardi,ed approaches and progra"s #ere e)aluated and ho# it significantly reduced the nu"$er of errors and pre)enting one to occur& Analyses #ere also "ade to identify $arriers in the successful i"ple"entation of the integrated "ethods& 3esults: !he preli"inary phase in)ol)ed the concurrent "onitoring process to "easure co"pliance #ith the i"ple"entation of the High Alert Medication safety syste"s& !he *har"acy and !herapeutic +o""ittee #ith the HAM *atient Safety !ea" de)eloped "onitoring tools to perfor" clinical audit& For the first t#o "onths of i"ple"entation #ith the pilot clinical areas .Medical 'ard and I+0-++0/ and Inpatient *har"acy( 678 and 978 o)erall co"pliance #ere recorded& I""ediate actions #ere done follo#ing the clinical audits and #ith the direct in)ol)e"ent of front line staff in i"ple"enting the strategies( the organi,ation reached 9:8 o)erall co"pliance at the end of the year& !o deter"ine #hether the progra"s effecti)ely reducing HAM errors( data fro" SM+H incident reporting data $ase #ere co"pared and re)ie#ed concurrently& An increased )oluntarily reporting #ere noted upon the co""ence"ent of the progra"& !o note( 5ear Misses identified $y the In-patient *har"acy through the use of pre-printed for" re)ie# and "edication usage re)ie# increased fro" ; incidents to <= incidents& Independent Dou$le +hec ing in the clinical areas contri$uted to > reported near "iss incidents& A nota$le indicator of i"pro)e"ent is the a$sence of sentinel e)ent related to the

usage of HAM& 3oot +ause Analysis #ere "ade to all identified near "iss and actual incidents to directly identify causes and contri$utory factors leading to the e)ent& +onclusion: Medication errors related to High Alert Medications are pre)enta$le #ith the use of a "ultifaceted approach yet( sustaina$ility of such progra"s are undenia$ly the challenge& Factors identified during the study as $arriers lead to the i"ple"entation of the further in)ol)e"ent of the *har"acy Depart"ent #hich includes =;/> access to phar"acy assistance( standardi,ation of a)aila$le stoc s to reduce )ariation and co"ple%ity&