January 2010 Quarterly Meeting Presentation Highlights

Dan Ross, Pharm D, Principle of D. Ross Consulting and Loriann DeMartini, Pharm D, Chief Pharmaceutical Consultant for the California Department of Public Health had a number of clinical pointers for the participants of the the BEACON Quarterly Meeting.

• MERP Surveys are multi-disciplinary and meant to assess each individual hospital's implementation of safe medication practices (Health and Safety Code 1339.63) against their submitted 2005 plan.

• All submitted plans are on file at the California Department of Public Health (CDPH) offices and facilities should assume that the surveyor will have read the specific hospital's plan before the visit to that facility.

• Dan suggests reading the law and assuring the institution is in a state of readiness at all times.

Adverse event reporting crosses over into medication safety and MERP surveys. All hospitals should look at the frequency of events and reoccurring themes in medication errors. Trending errors by categorizing them into the 11 elements of MERP has proven effective for many organizations. Hospitals are encouraged to monitor medication error reporting and develop mechanisms to increase near miss reporting to better understand the organizational, system and human factor impacts and lead to understanding causation and root cause.

Passage of Senate Bill 1875 January 1, 2001, Health & Safety Code 1339.63, required as a condition of licensure General Acute Care Hospitals, Surgical Clinics and Special Hospitals, to adopt a formal plan to eliminate or substantially reduce medication-related errors. Medication-related Error are defined as: "Any preventable medication-related event that adversely affects a patient in a facility that is related to professional practice, or health care products, procedures, and systems, including, but are not limited to," Health and Safety Code (H&S) 1339.63 (d).

The 11 elements of the plans are to include strategies to address the following:
• Prescribing
• Prescription order communication
• Product labeling
• Packaging and nomenclature
• Compounding
• Dispensing
• Distribution
• Administration
• Education
• Monitoring
• Use

Hospitals are required to establish a process for completing an annual review of the 11 elements of the MERP plan. Data collection should support answering the following questions:

• Is the plan working?

• Is there a method in place to measure effectiveness?

• How does the facility pro-actively look for and address weaknesses or deficiencies in the plan or the medication system?

• How does the institution drive the plan to reduce medication errors?

• How has technology impacted the medication safety system.

Hospitals were encouraged to evaluate four areas of major concern:

1. Management of high risk medications is the most problematic and represents an area of concern. Loriann provided an example regarding the use of fentanyl, especially in opiate-naïve patients and noted several errors associated with current practice and the need to refine systems.

2. A second area of concern related to the provision of emergency medications-assuring an adequate supply, staff competency in handling dosing decisions of medications during pediatric codes, and rapid deployment of these medications.

3. A third area of focus was the safe storage of medications,specifically the use of automated dispensing cabinets. Technology has revolutionized medication administration, yet principles, such as, separating look alike/sound alike meds continues to be of great importance.

4. The fourth area of focus related to the appropriate refrigeration of drugs according to the manufacturer's recommended temperature, a long-standing principle of safe storage. During recent surveys, findings have included refrigerators temperatures remaining out of compliance for extended periods of time, with no documentation of remedial steps taken.

A best practice highlighted was the use of pharmacy information services, such as Micromedex or Clinical Pharmacology to assist and update clinicians in the clinical area. Ongoing review of external alerts, such as those from the Institute of Safe Medication Practices (ISMP) newsletter, were discussed. Clinicians can benefit from education of key items highlighted in these publications. They can access the organization for current processes and determine whether they meet the strategies for safe practice. Evidence of this would provide the hospital based MERP team with information to use for their improvement efforts.

Additionally, observations of the medication pass remain very helpful in detecting medication errors and hospitals were encouraged to use this strategy for internal assessment.

The Pharmaceutical consultants at CDPH have deployed a question and answer email address for your questions MERP@cdph.ca.gov

Download D. Ross Presentation

Download L. DiMartini Presentation

Download Highlights from the January 2010 Quarterly Meeting "Practical and Tactical"