Federal Employees Health Benefits Program

PBP Patient Safety Initiatives

Key Components of 2004-2005 PBP Patient Safety Plan

What can you do?

It is vital that PBP staff can assess the progress they make towards delivering safer care. We have set out the steps that PBP has taken and should take to improve patient safety. The steps provide a simple checklist to help PBP plan activity and measure PBP's performance in patient safety. Following these steps will help ensure that the care you provide is as safe as possible, and that when things do go wrong the right action is taken.

1. Build a Stronger Corporate Safety Culture at PBP

   Create a culture that is open and fair.

2. Lead and Support Your PBP Fellow Staffers

   Establish a clear and strong focus on patient safety throughout your organization.

3. Integrate PBP's Risk Assessment & Risk Management Actions

   Develop systems and processes to manage your risks and identify and assess things that could go wrong.

4. Promote reporting

   Ensure your staff can easily report incidents locally and nationally.

5. Involve and communicate with patients and the public

   Develop ways to communicate openly with and listen to patients.

6. Learn and share safety lessons

   Encourage staff to use root cause analysis to learn now and why incidents happen.

7. Implement solution to prevent harm

   Ensure lessons through changes to practice, processes or systems

PBP's Improvement Tracker:
Sample Patient Safety Indicators Which PBP Tracks

• Chronic Conditions: All Conditions
• Chronic Conditions: Diabetes
• ESRD: Vascular Access
• Flow: Patient Flow
• HIV / AIDS: HIV / AIDS Disease
• Office Practices: Access
• Patient Safety: Safety: General
• Patient Safety: Medication Systems
• Patient Safety: Surgical Site Infections
• Custom Measures

Chronic Conditions: All Conditions

• % of Pts w/ Self-Management Goals
• Registry Size

Chronic Conditions: Diabetes

• HbA1c Level for Patients w/ Diabetes
• of Patients Using Aspirin Daily
• Percent of Patients w/ Dental Exam in Last 12 Months
• Percent of Patients w/ Dilated Eye Exam in Last 12 Months
• Percent of Patients w/ Documented Self-Management Goals
• Percent of Patients w/ Fasting LDL Less Than 130 in Last 12 Months

PBP's Patient Safety: Medication Systems Used by PBP

• Adverse Drug Events (Ads) per 1,000 Doses
• Errors Related to Unreconciled Medications per 100 Admissions
• High-Risk Adverse Drug Events (Ads) per 1,000 Doses
• Number of Self-Reported Medication Errors
• Percent of Admissions with an Adverse Drug Event (ADE)
• Percent of Patients a Specific High-Risk Medication
• Percentage of Staff Reporting a Positive Safety Climate
• Pharmacy Interventions per 100 Admissions
• Percent of Patients w/ Foot Exam in the Last 12 Months
• Percent of Patients w/ Influenza A Vaccine During Flu Season
• Percent of Patients w/ Two HbA1c's in Last Year
• Percent of Patients Who are Current Smokers
• Percent w/ Blood Pressure Less Than 130/80
• Registry Size within Disease Class

ESRD: Vascular Access

• Percent of dialysis patients dialyzing with an AV fistula

8 Ways to Increase Medication Safety

1. Keep a current list of any food, medication or latex allergies. Be sure to discuss your allergies with your doctor, pharmacist and other health care providers.
2. Maintain an up-to-date list of all the medications you take, including vitamins, over-the-counter products and herbal remedies. Be sure to:
   • Keep a written list of the name, dose and reason you're taking each medication
   • Update the list to include new prescriptions or allergies
   • Review the list with your doctor at each office visit
   • Carry the list with you at all times
3. Read prescription labels carefully. Always follow the directions exactly. If a medication you have taken before looks different in any way, speak with your pharmacist immediately.
4. If you have questions about a prescription - including possible side effects or interactions with other medications or foods - contact your doctor or pharmacist.
5. Let your doctor or pharmacist know if you experience any problems with your medications.
   Contact your doctor immediately if you stop taking your medications for any reason.
6. Ask your doctor if a new prescription you receive replaces any of your current medications.
7. Keep medications in their original containers, except when you place them in a medication organizer.
8. Whenever possible, fill all your prescriptions at all the same pharmacy. By doing this, the pharmacy staff will be able to review your record for potential allergies or interactions with your other prescriptions. If you use both retail and mail order pharmacies to fill your prescriptions, make sure that each pharmacy is aware of all your medications and allergies.

PBP Patient Safety Goals

As of January 1, 2004, all JCAHO accredited health care organizations are surveyed for implementation of the following Requirements - or acceptable alternatives - as appropriate to the services the organization provides. Alternatives must be at least as effective as the published Requirements in achieving the goals.

1. Improve the accuracy of patient identification.
   1. Use at least two patient identifiers (neither to be the patient's room number) whenever taking blood samples or administering medications or blood products.
   2. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a " time out, to confirm the correct patient, procedure and site, using active ­ not passive ­ communication techniques.
2. Improve the effectiveness of communication among caregivers.
   1. Implement a process for taking verbal or telephone orders or critical test results that require a verification "read-back" of the complete order or test result by the person receiving the order or test result
   2. Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.
3. Improve the safety of using high-alert medications.
   1. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care units.
   2. Standardize and limit the number of drug concentrations available in the organization.
4. Eliminate wrong-site, wrong-patient, wrong procedure surgery.
   1. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g. medical records, imaging studies) are available.
   2. Implement a process to mark the surgical site and involve the patient in the marking process.
5. Improve the safety of using infusion pumps.
   1. Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.
6. Improve the effectiveness of clinical alarm systems.
   1. Implement regular preventive maintenance and testing of alarm systems.
   2. Assure the alarms are activated with appropriate settings and are sufficiently audible with respect to distance and competing noise within the unit.
7. Reduce the risk of health care-acquired infections.
   1. Comply with current CDC hand hygiene guidelines.
      1. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.

PBP Urges You Ask Your Doctor for PBP's "Brown-Bag" Check-up

If you have a chronic condition, you may routinely take many different kinds of medicines the dose or times of the medication may need to be adjusted as your health changes you may also have medications ordered by different doctors, particularly if you visit a specialists. These situations can lead to a great deal of confusion when taking med safety measure, ask to schedule a "brown-bag check-up" with your primary doctor or pharmacist. A brown-bag check-up is when you gather all of your current medication counter products into a "brown-bag" and show them to your doctor or pharmacist for any potential problems.

Schedule your brown-bag appointment in advance so the doctor or pharmacist has time for the visit. Remember to take any prescription medications, over-the-counter, herbal products or "natural products" you are using.

During the "check-up", the doctor or pharmacist will review all of the medications you are currently taking, to see if they are the same as those listed on your medical record profile. They can double check these medications for the correct dosage strength, identify if you are using outdated or discontinued medications. These practitioners see the medications and products for potential duplication of therapy or side effects. It is important to include non-prescription products in the bag.

A brown-bag check-up is not only helpful to patients, but is useful for physicians too. This review will help healthcare practitioners know whether you understand how to use medication, or if you are aware of any special precautions that you may need to know. Take time for the doctor to discuss with you any special laboratory testing needed with certain drugs. You should be prepared to ask any questions you may have about medications. Don't be afraid to write them down, so that you do not forget to ask.

Take this PBP REMINDER SHEET To YOUR NEXT DOCTOR'S VISIT

This form may assist you in getting ready to visit your doctor. Hopefully it will help you remember all those questions you've been thinking about since your last appointment, it's important that you have all the information available to you when you visit your doctor, so that you and your doctor can make informed medical decisions that are right for you. Feel free to make copies of this form to use in the future.

Reason for this doctor visit:

Question I want to ask:

Follow-up on things I need to do:

PBP's Top 10 Tips About Rx Prescription Drugs

1. Patient's full name should be printed or typed.
2. Patient's age (date of birth) and current weight should be checked.
3. Information regarding diagnosis and other patient-specific appropriate to the circumstance should be included.
4. Any known allergies should be included on the bottle or package.
5. Drug name, dosage form, and drug strength. If the medication is rarely used, the name should be printed. Concentrations should be expressed in metric units clearly printed.
6. Number or amount to be dispersed. If appropriate quantity to be dispersed should be expressed in metric units clearly written/printed.
7. Include calculations, or at least mg/kg/day dosing, so calculation can be independently double checked; i.e. amoxicillin 40 mg, po q 8 hrs (40mg/kg/day).
8. The prescriber's name and pager or telephone number should be included.
9. Complete instruction for the patient including indication (i.e., purpose of the drug), directions for use including dose, frequency of dosing route of administration, intended duration of therapy, and the number of authorized refills write or type very clearly.
10. Product to be administered by the patient or caregiver in the outpatient environment should be labeled expressing the dose in convenient units of measure. Listing equivalent measurements may be helpful to clarify the intended dose (i.e., 1 teaspoonful (5 ml) by mouth twice daily).

PBP's Five Principles and Strategies for Improving Patient Safety

Be Informed Consumer to Avoid Rx Errors

Unfortunately, medication errors happen. They happen in hospitals, pharmacies, or even at home. And sometimes people get hurt because of these errors.

The more information you have, the better able you are to prevent errors and to take care of yourself. You have to ask your pharmacists, doctors and nurses about your medications, and you have to expect answers.

Also, if you have any chronic illnesses, pick up one of the consumer guides about medications at a bookstore or from the library. Find out all that you can about your illnesses and the medications you are taking.

What you learn will help protect you later. PBP doctors, nurses and pharmacists work hard to keep you healthy, but you are also responsible. Learn what questions to ask. Expect answers - it's your life and your health!

Key questions for Doctors and Pharmacists

• Your pharmacist can be your partner to prevent medication errors. Find one who offers services like monitoring your therapy and keeping a complete list in the pharmacy computer of all your medications and chronic medical conditions.
• Include over-the-counter medications, vitamins, nutritional supplements and herbal products even if you bought them somewhere else.
• It's worth the cost. With this information in one place, your pharmacist can help to protect you against harmful drug interactions, duplicate medications and other potential problems.
• Before you leave the pharmacy, your pharmacist should give you printed information about medication and make sure that you understand the answers to more questions like those shown in this material.

Always Ask the Doctor These Questions!

1. What are the brand and generic names of my medications?
2. What does it look like?
3. Why am I taking it?
4. How much should I take, and how often?
5. When is the best time to take it?
6. How long will I need to take it?
7. What side effects should I expect; what do I do if they happen?
8. What should I do if I miss a dose?
9. Does this interact with my other medications or any foods?
10. Does this replace anything else I was taking?
11. Where and how do I store it?

When you buy over-the-counter medications, read the labels carefully because they might contain ingredients you do not want or should not take. Maybe they will interact with your other medications, cause an allergic reaction, or not be correct for your symptoms. Ask your pharmacist for help if you have trouble selecting the right product.

What Can I do at home?

• Make a list of medications you are taking now. Include the dose, how often you take them, the imprint on each tablet or capsule, and the name of the pharmacy. The imprint can help you identify a drug when you get refills.
• Any time that your medications change, change your list too. Double-check the imprints on the tablets and capsules.
• Also list your medication and food allergies, and any over-the-counter medications, vitamins, nutritional supplements or herbal products that you take regularly.
• Keep medications in their original containers. Many pills look alike, so by keeping them in their original containers, you will know which is which and how to take them.
• Never take someone else's medication. You don't know if it will interact with your medications, the dose may be wrong for you, or you may be allergic to it.
• Read the label every time you take a dose to make sure you have the right drug and that you are following the instructions.
• Turn on the lights to take your medications. If you can't see what you're taking, you may take the wrong thing.
• Don't store medications in the bathroom medicine cabinet or in direct sunlight. Humidity, heat and light can affect medications' potency and safety.
• Store medications where children can't see or reach them, for example, in a locked box or cabinet.
• Keep medications for people separate from pet's medications or household chemicals. Mix-ups are common and can be dangerous.
• Don't keep tubes of ointments or creams next to your tube of toothpaste. They feel a lot alike when you grab quickly, but a mistake could be serious.
• Flush any old medications, including used patches, down the toilet. Children and pets might get into medications that are thrown into the wastebasket, and some drugs actually become toxic after the expiration date.
• Don't chew, crush or break any capsules or tablets unless instructed. Some long-acting medications are absorbed too quickly when chewed, which could be unsafe. Other medications either won't be effective or could make you sick.
• To give liquid medication, use only the cup or other measuring device that came with it. Dosing errors can happen if you use a different cup or if you use the cup with other liquids because the cups often are different sizes or have different markings.
• Also, household teaspoons and tablespoons are not very accurate, which is important with some medications. Your pharmacist may give you a special oral syringe instead. Do NOT use spoons. Do use Teaspoons or tablespoons!

What Can I Do When in the HOSPITAL?

• Take your medications and the list of your medications with you when you go to the hospital. Your doctors and nurses will need to know what you are taking.
• After your doctor has seen them, send your medications home with your family. While you are in the hospital you may not need the same medications.
• Tell your doctor you want to know the names of each medication and the reasons you are taking them. That way, if anyone tells you anything different, you'll know to ask questions, which might prevent errors.
• Look at all medicines before you take them. If it doesn't look like what you usually take, ask why. It might be a generic drug, or it might be the wrong drug. Ask the same questions you would ask if you were in the pharmacy.
• Do not let anyone give you medications without checking your hospital ID bracelet every time. This helps prevent you from getting someone else's medications.
• Before any test or procedure, ask if it will require any dyes or medicines. Remind your nurse and doctor if you have allergies.
• When you're ready to go home, have the doctor, nurse or pharmacist for over each medication with you and a family member.
• Update your medication list from home if any prescriptions change or if new medications are added.

What Can I do at the Doctor's Office?

• Take your medication list every time you go to your doctor's office, especially if you see more than one doctor.
• They might NOT know about the medications other doctors prescribed for you.
• Ask your doctor to explain what is written on any prescription, including the drug name and how often you should take it. Then when you take the prescription to the pharmacy, you can double-check the information on the label.
• Tell your doctor you want the purpose for the medication written on the prescription. Many drug names look alike when written poorly; knowing the purpose helps you and the pharmacist double-check the prescription.
• If your doctor gives you samples, make sure that he or she checks to be sure that there are no interactions with your other medications.
• Pharmacies have computers to check for drug interactions and allergies, but when your doctor gives you samples, this important check may be missed.
• At least twice per year perform a "Brown Bag" visit to your doctor. Place all your medicines and all your herbs and all your Over-the-Counter drugs inside a Big Brown Bag.
• You take the "Brown Bag" filled with all those bottles and pills to the doctor. Ask she or he to sort through each bottle and make sure it is still safe for you to take in the weeks and months ahead.