10-12 JULY 2019

INTERNATIONAL CONVENTION CENTRE

NUSA DUA –BALI,INDONESIA

WORKSHOP 7,13.30-15.15 : 7,12 ,JULY 2019

MEDICATION SAFETY IN EMERGENCY

DEPARTMENT

Yahaya Hassan, Pharm.D,

Professor,Department of Clinical Pharmacy ,
School of Pharmacy, Management & Science University ,University Drive,
Off Persiaran Olahraga, Section 13,40100, Shah Alam, Selangor Darul Ehsan, Malaysia,
profyahaya@gmail.com
 MEDICATION SAFETY
One of the important missions of the
healthcare providers is to ensure
patient safety.
Unfortunately medication errors do
occur and often go undetected.
Some medication errors may result in
serious patient morbidity and
mortality
 Why Medication Safety is Important
ADEs are a serious public health problem.
more than 1 million emergency department
visits.
280,000 hospitalizations each year.
$3.5 billion is spent on medical costs of ADEs
annually.
more than 40% of costs related to ambulatory
ADEs are preventable
 MEDICATION SAFETY
Enhanced awareness on medication
safety:
New and potent medicine
More drugs available

Ensuring patient safety at all levels and

various systems and processes
involved in the entire medicines
management cycle.
 MEDICATION SAFETY
The proposed mechanism is a ‘Medication Error
Reporting System’ through which medication errors will
be monitored and preventive measures can be defined.
This system requires a collective effort from various
parties and a change in the way we manage medication
errors.
We need to be able to discuss errors openly, encourage
reporting of errors and maintain a culture that is non-
punitive and blamelessness.
With this, healthcare providers will be able to learn
from the errors.
EMERGENCY PHARMACY
DEPARTMENT
MEDICATION SAFETY IN
THE ED
 ED INTRODUCTION
1. ED environment is often overcrowded, fast-paced patient
care and high-acuity disease state management.
2. Inherent medication safety risks exist because of the
complexity of this practice environment.
3. Emergency medication use process (e.g., medication
selection, ordering, verifying, and dispensing; education; and
administration) may be contained in the ED without a
pharmacist’s oversight.
4. Medications may be administered according to verbal
order, and these medications may be readily available on
override in automated dispensing cabinets or floor stock to
the emergency medicine (EM) team.
 ED INTRODUCTION
5. Therefore, the process from prescribing to administration
may be done without a pharmacist’s involvement, because
legally, it is not required that pharmacists verify medications
that are needed emergently.

6. More recently the American College of Emergency

Physicians created a policy statement that supports clinical
pharmacy services in the ED and collaboration among EM
providers in order to promote safe, effective, and evidence-
based medication practices; encourage interdisciplinary EM-
related clinical research; and foster an environment
supporting EM pharmacy residency training.
 Overview of
 Unique practice setting
 Serves as point of entry, transition and exit
Emergency
 Intended for treatment and management of emergent or acutely ill
patients
Department
 May contain urgent care or fast track section
 Workflow
 Fast paced
 Chaotic
 Staff
 Primarily health techs, nurses, physician
 Expanding to other services for improved access
 Patient
 Various acuity levels
 Boarders
 Highest number of preventable adverse drug events of any hospital setting
MEDICATION SAFETY IN
THE ED
 Medication errors (MEs)
Medication errors (MEs) are defined as
any mistake at any stage of the medication
use process
•selection and procurement,
• storage,
• ordering and transcribing,
• preparing and dispensing,
• administration, or
• monitoring.
 MEDICATION ERROR
A medication error is any preventable event that may cause or
lead to inappropriate medication use or patient harm while the
medication is in the control of the healthcare professional,
patient or consumer.
Such an event may be related to professional practices,
healthcare products, procedures and systems including
prescribing, order communication, product labelling, packaging
and nomenclature, compounding, dispensing, distribution,
administration, education, monitoring and use.
Medication errors may be committed by both inexperienced and
experienced personnel like doctors, pharmacists, dentists and
other healthcare providers, patients, manufacturers, caregivers
and others.
 TYPES OF MEDICATION ERROR
General
ACEIs can be useful to prevent HF in patients at high risk for developing HF
who have a history of atherosclerotic vascular disease, diabetes mellitus, or
hypertension
Coronary Artery Disease
A b-Blockers are indicated in all patients without a history of MI who have a
reduced left ventricular systolic dysfunction and no HF symptoms
Aspirin should be started at 75–162 mg/day and continued indefinitely in all
patients unless contraindicated. Doses should not exceed 100 mg/day when
used in combination with ticagrelor.
Clopidogrel 75 mg/day should be considered and continued indefinitely when
aspirin is an absolute contraindication
Clopidogrel 75 mg/day or prasugrel 10 mg/day should be given in combination
with aspirin after PCI for at least 12 mo after implantation of a either a bare
metal stent or a drug-eluting stent
 TYPES OF MEDICATION ERROR
General
ACEIs can be useful to prevent HF in patients at high risk for developing HF
who have a history of atherosclerotic vascular disease, diabetes mellitus, or
hypertension
Coronary Artery Disease
A b-Blockers are indicated in all patients without a history of MI who have a
reduced left ventricular systolic dysfunction and no HF symptoms
Aspirin should be started at 75–162 mg/day and continued indefinitely in all
patients unless contraindicated. Doses should not exceed 100 mg/day when
used in combination with ticagrelor.
Clopidogrel 75 mg/day should be considered and continued indefinitely when
aspirin is an absolute contraindication
Clopidogrel 75 mg/day or prasugrel 10 mg/day should be given in combination
with aspirin after PCI for at least 12 mo after implantation of a either a bare
metal stent or a drug-eluting stent
 CLASSIFICATION OF MEDICATION ERROR
SEVERITY
A medication error is any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of the
healthcare professional, patient or consumer.
Such an event may be related to professional practices, healthcare products,
procedures and systems including prescribing, order communication, product labelling,
packaging and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring and use.
Medication errors may be committed by both inexperienced and experienced
personnel like doctors, pharmacists, dentists and other healthcare providers, patients,
manufacturers, caregivers and others.
 CLASSIFICATION OF MEDICATION ERROR
SEVERITY
A medication error is any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of the
healthcare professional, patient or consumer.
Such an event may be related to professional practices, healthcare products,
procedures and systems including prescribing, order communication, product labelling,
packaging and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring and use.
Medication errors may be committed by both inexperienced and experienced
personnel like doctors, pharmacists, dentists and other healthcare providers, patients,
manufacturers, caregivers and others.
 EMERGENCY
DEPARTMENT AS HIGH
RISK SITUATIONS
High-risk situations

Influencing factors

2. Provider and 3. System factors

1. Medication
patient (work environment)

2
1
MEDICATION SAFETY IN
THE ED
MEDICATION FACTORS
 1. Medication
factors
Some high-risk (high-alert) medications associated with harm when used in
error
 High Alert Medication
• Could cause an immediate life threatening condition for the patient
if an error in administration occurs.
• Labeled with a red dot.

• Inj. Adrenaline
• Inj. Digoxin
• Tab. Warfarin
• Inj. Potassium chloride 15%
• Insulin
 High Risk Medication

• Risk of causing significant patient harm when they are used in error.
• They are labeled with a yellow dot.

• Amiodarone
• Infusion. Dextrose 50%
• Inj. Metoprolol
• Inj. Phenytoin
• Tab. Glibenclamide
Look-Alike Sound-Alike (LASA)
Medication
Tall Man Lettering for Look-
Alike Drug Names
 Summary
ensure the 5 Rs

1. Drug
Prescribing 2. Dose
Dispensing RIGHT 3. Route
Administering
4. Time
5. Patient
MEDICATION SAFETY IN
THE ED
PROVIDER AND PATIENT
FACTORS
2. Provider and Patient Factors
The prescribing Partnership
 ED pharmacy team could comprise of any or all
Key
of the following:
Points
Clinical Pharmacist
Pharmacist
Technician
 Role of the ED pharmacist consist of clinical, administrative and
technical duties
Role of the ED technician is to support ED pharmacy team
Optimization involves ongoing evaluation of current practice
 ED technician role could be further optimized through utilization
in medication reconciliation process
Limitations to implementation varies from one facility to another
 Medication Histories

An accurate medication history is important to prevent medication

errors and ADEs in the hospital and during transitions of care.

A multicenter evaluation of ED pharmacist–completed medication

histories completed in a multicenter, double-blind, randomized fashion
found that discrepancies were reduced by 33% (OR 0.1055; 95% CI,
0.05–0.24) compared with physician conducted medication histories
(Becerra-Camargo 2013).

Pharmacists can obtain an accurate medication history (Patanwala

2014). A program using ED pharmacists to address errors and
inconsistencies in ED admission and discharge medication
reconciliations found that that admission medication histories obtained
by pharmacists were accurate more often than when obtained by a
nurse (90.2% vs. 66.7%, p < 0.05) (Nana 2012).
 Transitions of Care

Recent initiatives have focused on providing effective

and safe care during patient transitions.

In the ED, patients are either discharged or admitted.

The pharmacist or pharmacist- extender has many

opportunities to optimize medication management at
these transitions.
 Boarding Patients
ED overcrowding causes a derangement in the usual workflow and throughput, leading EDs and institutions
to modify normal operating procedures for increased patient volume (Jellinek 2010).

Patients may “board” in the ED, even though they are admitted to the hospital. This causes problems
because inpatient provider teams are managing care, but EM nurses are still providing bedside care to
boarding patients and new ED patients presenting.

This is not optimal and can lead to overall delays in new and routine medication therapies. One institution
changed the nursing workflow to assign nurses to either ED patients or boarding patients, to prevent mixing
both designations.

An EM clinical pharmacist was also designated to follow up on boarding patients 1 hour after the scheduled
medication administration time to identify delays or issues. Two hundred sixty-six medication
administration opportunities in 79 patients were evaluated.

The EM clinical pharmacist intervened by clarifying orders with the physician, expediting medication from
the pharmacy, directly dispensing to the nurse, providing nurse education, or procuring medication a total
of 52 times (19.5%) (Jellinek 2010).

Cardiovascular, antimicrobial, respiratory, GI, and anticoagulant agents were the most common medications
not administered on time and requiring pharmacist intervention.
 Medication Order Review and Consultative
Activities

Over 6 months with 24-hour pharmacy services to the

ED, 3482 medications were prospectively reviewed by
EM clinical pharmacists for adult and pediatric patients,
and 642 (18.4%) clinical interventions were made (Sin
2015).
Interventions described were nursing drug information
(27.7%),
Dose or frequency adjustment (21.1%),
Physician drug information (18.2%),
Antibiotic recommendations (15.1%),
Titration of intravenous drug therapy (9.3%),
Initiation/change drug therapy (5.1%), and
Duplication (3.2%).
 Medication Order Review and Consultative
Activities

A separate, multicenter, prospective study collected medication errors

intercepted over 1000 hours of EM clinical pharmacist time and focused
on the activities that led to these medication error interceptions. The
sites were geographically diverse and represented both academic and
community sites (Patanwala 2012a).
Of the 364 confirmed medication error interceptions for 16,446
patients, involvement in consultative activities resulted in the most
errors intercepted (51.4%), followed by review of medication orders
(34.9%). Most medication orders resulting in medication errors were
written or computerized (54.4%); however, 32.7% were verbal.
These data show the importance of clinical
pharmacists physically in the ED and participating in
direct patient care at the bedside.
 Medication Event Reporting

A review of medication-error reports over 3.5 years at one

academic medical center found that dedicated EM clinical
pharmacists reported 94.5% of medication errors compared
with other health care professionals (5.7%, p < 0.001)(Weant
2010b).

Moreover, adding two dedicated EM clinical pharmacists was

associated with 14.8 times the number of medication error
reports completed by pharmacy personnel compared with
when there were no dedicated ED pharmacy services.

These are important results because error reporting is

crucial for systems improvement and safeguarding
implementation.
 PHARMACIST INTEGRATION INTO THE EM
TEAM

The ED can be a difficult patient care setting.

ED has high volume, high patient acuity, wide range of
disease state management.

The evening and early overnight hours are the busiest

times, with a constant influx of patients, packed waiting
rooms, and many patients in hallway beds or chairs
because the ED or hospital is at maximum capacity at
many institutions.

In this environment, sustainability of staff is difficult, and

high turnover is evident.
 PHARMACIST INTEGRATION INTO THE EM
TEAM

.Electronic prescribing can be enhanced for:

• Disease state–specific medication order sets or order
panels
• Creation of ED-specific medication preference lists
Drive prescribing practices to formulary medications

Aid in correct formula/concentration selection and

administration of medications with alternative routes of
administration
■■ Intranasal administration of midazolam for minimal
sedation or tranexamic acid–soaked packing for
epistaxis
○○ Inclusion of medications available in the automatic dispensing
cabinets
■■ Improve time to medication administration and ED
throughput
 Education
Several opportunities exist for educating ED staff. Together with bedside
education during pharmacotherapy consults for clinicians and nurses,
other teaching opportunities are often offered.

Providing formal didactic education or whiteboard teaching for

attendings and EM medical resident, facilitating simulation activities for
EM clinicians and nurses,and providing nursing in-services and hands-
on sessions (for medication preparation or electronic smart pumps) for
nurses working with high-risk medications are examples.

It is important that EM clinical pharmacists volunteer for these

education opportunities, not only to continue improving relationships
with the interdisciplinary team but also to demonstrate expertise,
which will ultimately improve the frequency at which providers reach
out for pharmacotherapy consults.
MEDICATION SAFETY IN
THE ED
PRACTICE POINTS
STRAEGIES
 ED
 Review of study published in Annals of Emergency Medicine 2010
 Results
Pharmacist
 178 medication errors observed in 192 patients
Roles
 59.4% of patients had at least one error
 37% of errors reached the patient
 60% of all medication orders were associated with an error
 Phases of medication error occurrence

Prescribing Transcribing Dispensing Administration

Monitoring
53% of ED 11% of ED 0.6% of ED 35% of ED
med errors med errors med errors Not evaluated
med errors

Patanwala AE, Warholak TL, Sanders AB, Erstad BL. A Prospective Observational Study of Medication Errors in a Tertiary Care Emergency Department. Ann Emerg
Med. 2010 June; 55(6):522-6
 Key Strategies for medication
safety

Adapted, with the permission of the publisher, from Institute of Safe Medication Practices (73)

20/06/2019 Medication Safety in high-risk situations

 Practice Points
Key points for pharmacists involved in patient care in
the ED include the following:

• EM clinical pharmacists must be well versed in both

ambulatory and critical care disease states because most
patients are discharged from the ED.

• Clinical activities involving direct patient care should

account for the most pharmacist time in the ED.

• Time-dependent emergency response should be a priority

because these patients have a high likelihood of
decompensation, medication errors, and use of high-risk
medications.
 Practice Points

• ASPs in the ED focus on appropriate drug selection, dose,

and duration; rapid initiation of antibiotics; and prevention
of patient re-presentation to the ED and hospital
readmissions.

• Pharmacists improve medication safety and prevent ADEs

in the ED.

• Most medication errors are captured through consultative

activities compared with medication order review, showing
that pharmacists must be physically present in the ED.
 Practice Points

• Cost avoidance estimated from ADE prevention and

through pharmacist intervention is one way to justify
pharmacist services in the ED.

• Pharmacist-extenders and not EM clinical pharmacists

should complete medication histories.

• The ED provides a unique setting for pharmacists to focus

on transitions of care because patients are both being
admitted and being discharged.

• Many pathways for training and resources are available for

EM clinical pharmacists.
 ED Pharmacist Role -
Administrative
• Hierarchy of Administrative duties

Pharmacist or
Clinical pharmacist
 ED Pharmacist
Role
Hierarchy of - Clinical
Clinical Duties

Clinical Pharmacist

Pharmacist
EM Clinical Pharmacy
Practice Guidelines
 EM Clinical Pharmacy Practice Guidelines

In 2008, ASHP published a statement on ED pharmacy services

(ASHP 2008).
Regardless of institution size or needs, the core roles should include:
• Working with EM physicians, nurses, and other members of the EM team to develop
and monitor medication use systems that promote safe and effective medication use
in the ED
• Collaborating with the interdisciplinary team to promote medication use that is
aligned with national quality indicators
• Participating in the selection, implementation, and monitoring of technology used in
the medication use process
• Providing direct patient care as part of the EM team
• Participating in and leading quality improvement and emergency preparedness
efforts
• Educating not only patients but also the EM team about safe and effective
medication use
• Conducting ED-based clinical research and expanding pharmacy education and
postgraduate training focused on EM
EM Clinical Pharmacy Practice Guidelines
 CONCLUSION

Overall, the ED continues to need

direct pharmacy involvement because
EM clinical pharmacists have many
opportunities to affect patient care and
more pharmacists and increased
training opportunities are still needed in
this setting.
THANK YOU