Medication Management Council Identifies Top 10 Safety Best Practices

There are many regulatory boards and foundations that strive to educate and advise about proper medication use.  Bodies such as the Institute for Safe Medication Practices (ISMP), the American Society of Health-System Pharmacists (ASHP) and the National Patient Safety Foundation (NPSF) provide good information, but a lot of it.  When trying to aggregate and prioritize recommendations to determine which to implement, one could easily become overwhelmed.  Enter the Medication Management Council (MMC).

Mission

The Council’s mission is to identify medication management best practices.  Through open forums which serve as unbiased and objective discussions, the Council will look to meet its 2014-2015 goals of generating lists of top 10 best practices in the areas of:

  • Safety
  • Compliance
  • Efficiency

Background

Formed in June 2014, the MMC is a thought leadership initiative of Omnicell. The Council is composed of individuals committed to improving medication management for better patient outcomes. The Council consists of pharmacy and nursing professionals from healthcare provider organizations and academic institutions. It also includes some Omnicell members, including two who previously had careers in pharmacy.

Desired Outcomes

The central goal of the MMC’s best practices lists is to improve medication management processes (which are error prone) across the industry, leading to better outcomes for healthcare stakeholders. The hope is for hospitals and health systems to be able to look at each list and quickly assess which aspects of their medication management practices they need to improve upon and which areas may be missing altogether.

Top 10 Safety Best Practices

In December 2014, the Council produced the first of its three lists, Top 10 Safety Best Practices.  The practices are listed below in rank order.

  1. Smart pump technology integration with the electronic health record
  2. Identification of high-risk compounding and dispensing processes, incorporating technology to ensure a safe product
  3. Real-time availability of dispensing information for use in medication reconciliation during the discharge process
  4. Minimum requirements for labeling pharmacy-prepared doses
  5. Standardized barcodes on all medications
  6. Effective, rather than unnecessary or unhelpful, alerts in the electronic health record
  7. Minimization of interruptions and distractions during the medication administration process
  8. Nursing adherence to the six safe practices to improve the accuracy of medication administration
  9. Scanning of all medications against the order or label when leaving the pharmacy and when restocked at the automated dispensing cabinet, and scanning of all items during the shelf-stocking process
  10. Use of biometrics to access automated dispensing cabinets wherever feasible

Because there are hundreds of guidelines available on safe medication management, this list is by no means all-inclusive. Rather, the best practices list suggests the base-level criteria that should be met for patient safety. The list enables committees and advocates to take practical first steps in instituting policies that make managing patient safety easier for hospitals and healthcare systems.

We look forward to presenting subsequent lists as they are released. Are there other subjects you feel the Council should be addressing? What do you feel the challenges are in implementing such recommendations at your facility?

3 Comments on “Medication Management Council Identifies Top 10 Safety Best Practices

  1. This list is helpful, but it failed to mention the best safety practice for preventing serious patient harm and potentially death during the IV admixture preparation process.

    Currently, over 90% of the IV admixtures prepared today are done so withOUT any form of technology to help prevent human slip errors. Prior to preparing an IV admixture, the pharmacy technician will assemble the ingredients needed to prepare a particular IV admixture, often using the computer-generated, patient-specific IV label as the recipe. The technician then draws up the dose of medication(s) needed to prepare the IV admixture. After preparation, the technician’s work is then checked by a pharmacist.

    As evidenced by the recent medication error that occurred in Bend, Oregon, it is very easy for a pharmacy technician to accidently grab and use the wrong vial of medication to prepare an IV admixture. In this case, the pharmacist checking the IV admixture also failed to detect that the technician used the neuromuscular-blocking drug, rocuronium, in place of the prescribed anti-convulsant medication, fosphenytoin. This patient’s fosphenytoin drip (that actually contained rocuronium) was sent to the nursing unit where it was barcode scanned by the nurse (the label was correct, even thought the contents were NOT) and then administered to the patient. Within minutes of receiving this IV solution, the patient went into cardiac arrest, suffered cerebral anoxia (lack of oxygen to the brain), and was later determined to be brain dead, taken off life support, and died.

    Over 90% of hospitals have implemented barcode scanning of medications and IV solutions at the bedside to prevent human slip errors by nursing staff (i.e., the nurse thinks they have the correct medication item, but they don’t). This same simple barcode scanning technology should be used during the preparation of EVERY IV admixture, for EVERY patient, in EVERY hospital in the country. In this particular case, if the pharmacy was using barcode scanning in the IV room, they would have been warned at the time that they scanned the barcode on the rocuronium vial that they had the WRONG medication for this patient’s IV admixture.

    While hospital pharmacies have adopted barcode based medication automation technologies for many other “Lower Risk” areas of the medication management process (e.g., inventory, automated dispensing cabinet stocking), they have failed to embrace this technology for the “Highest Risk” segment of their pharmacy operation. It’s as if they must think that pharmacists and pharmacy technicians are incapable of making a simple slip error. I would like them to try to explain that to the two sons who lost their mother in the Bend, Oregon hospital because of a simple slip error (i.e., using rocuronium in place of fosphenytoin).

    Without IV Workflow Management (IVWM) systems that use the barcode scanning for the accurate identification of IV admixture ingredients, how can any nurse or patient feel comfortable that the “clear-looking solution” in the patient-specific IV bag contains what it is supposed to? In the absence of IVWM systems utilizing ingredient barcode scanning, they can’t because pharmacy staff are human too, and humans are very capable of making simple, but deadly, slip errors.

    Therefore, I would strongly urge this group to add barcode scanning IVWM systems to the top of this list of Safety Best Practices. Our patients deserve it…!!!

    Like

    • Thank you for sharing your perspective and advocating about this critical safety issue. We have communicated your response to the Medication Management Council.

      Liked by 1 person

      • The Medication Management Council appreciates this comment. As with all of the Council’s best practice lists, the Top 10 Safety Best Practices are deliberately high-level and intended to be interpreted broadly. The suggested best safety practice for preventing serious patient harm and potential death during the IV admixture preparation process—with which the Council absolutely agrees—is an example of the application of two of the Top 10 Safety Best Practices: #2, Identification of high-risk compounding and dispensing processes, incorporating technology to ensure a safe product; and #5, Standardized barcodes on all medications. Click here to read descriptions of each of the Top 10 Safety Best Practices as well as background information on the Council.

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