A Systems Approach To Quality Improvement In Long-Term .

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A Systems Approach to Quality Improvement in Long-Term Care:Safe Medication Practices WorkbookThis project is funded by the Betsy Lehman Center forPatient Safety and Medical Error Reduction and theMassachusetts Department of Public Health.Betsy Lehman Center forPatient Safety and Medical Error ReductionProject Director:Patrick O’Reilly, PhD, MPHEdited by:Yvonne Michaud, MS, RNAssistant Project DirectorContributing Authors:Laurie Herndon, MSN, APRN, BCProject ConsultantJane Niemi, MSN, RN, LNHALayout and Design:Lorraine DeVaux, Graphics Specialist

A Systems Approach to Quality Improvement in Long-Term Care:Safe Medication Practices WorkbookTable of ContentsHow to Use This Workbook. 5Acknowledgments. 7Introduction to the Safe Medication Practices Workbook. 10Tab 1 - Organizational Commitment to Medication Safety. 15Importance of Leadership Commitment. 16Creating a Culture of Safety Key Points. 21System Plan of Action - Medication Error Prevention. 22Checklist for Action Planning. 23Reduction in Medication Errors in Long-Term Care Facilities. 23Tab 2 - Medication Management Policies. 24Medication Management Policies: Key Points. 25Checklist for Medication Management and Policies. 26Tab 3 - Educating Staff. 31Planning Learning Activities. 32Establish Learning Outcomes for Safe Medication Practices. 32Case Study as a Teaching Strategy. 32Checklist for Assessing Staff Education and Training. 34Principles of Adult Learning. 42Checklist: Medication Administration Competency. 51Tab 4 - Prescribing. 52The Prescribing Process. 53Types of Prescribing Errors. 53Lack of Medication Knowledge Increases Prescribing Errors. 53Drugs Frequently Associated with Adverse Drug Events. 53Components of a Complete Medication Order. 54Checklist for Assessing Medication Use Process: Prescribing. 56(Continued)A Systems Approach to Quality Improvement in Long-Term Care:Safe Medication Practices Workbook 2007Property of the Commonwealth of MassachusettsPage

Tab 5 - Documenting – Transcribing. 74Transcription /Documentation. 75Factors Affecting Transcribing. 75Checklist for Assessing Medication Use Processes: Transcribing. 77Steps to Consider to Reduce Transcription Errors. 78Tab 6 - Dispensing. 79Dispensing. 80Checklist for Assessing Medication Use Processes: Dispensing. 82Tab 7 - Administering. 83Medication Administration. 84High-Alert Medications. 84Administration Tips. 85Checklist for Assessing Medication Administration Processes:. 86Tab 8 - Monitoring. 99Medication Monitoring. 101Types of Monitoring Errors. 101Types of Adverse Drug Events Related to Monitoring. 101Any New Symptom Should Prompt Evaluation for Adverse Drug Event. 102Monitoring for the Use of Unnecessary Drugs. 102Risk of Adverse Drug Events Increases as Number of Medications Increase. 102Tools and Measures for Medication Monitoring. 102Monitoring for Appropriate Discontinuation of Medication. 103Who is Responsible for Medication Monitoring?. 103Medication Monitoring and Technology. 103High-Risk Drugs and Medication Monitoring. 103Checklist for Assessing the Medication Use Process: Monitoring. 105Tab 9 - Error Tracking and Analysis. 115Improving the Safety of the Medication Use Process and Creating a Culture of Safety. 116Error Tracking and Analysis. 116Making the Most of the Incident Report. 117Near Misses. 117National Medication Error Reporting . 118Additional Methods of Error Detection. 118Tab 10 - Quality Improvement . 126Rapid Cycle Change Model. 143Data Tracking Tool. 145(Continued)A Systems Approach to Quality Improvement in Long-Term Care:Safe Medication Practices Workbook 2007Property of the Commonwealth of MassachusettsPage

Tab 11 - Warfarin. 151Warfarin Audit Tool. 160Tab 12 - Reconciliation. 168Incident Reporting of Medication Errors - STEP 1. 170Tab 13 - Monthly Edits. 180The Process. 181The Problem. 181Effective Practices for Monthly Edits. 181Workload Issues. 182Issues with the Editing Process. 182Environment. 183A Note About “House Stock” Medications. 183Sample Monthly Edit Procedure. 184Checklist: Monthly Edits. 185Tab 14 - Educating Residents and Families. 186Tab 15 - Resources and Regulations. 196National Organizations. 197A Systems Approach to Quality Improvement in Long-Term Care:Safe Medication Practices Workbook 2007Property of the Commonwealth of MassachusettsPage

How to Use This WorkbookThis resource manual outlines a medication management system in long-term care. Each of the 15tabbed sections focuses on specific processes that make up the system. Each tab includes an explanationof the material found within the tab. Tools that apply to the particular section are listed, as well as“Reminders” and “Resources” to assist the reader in moving through the various sections.Improving outcomes with regard to medication errors and adverse drug events requires assessmentand planning within the major areas of focus addressed in each tab. As you work through the sections,determine your facility’s needs and the areas that are your priorities for improvement.Major Areas of Focus:Tab 1Organizational Commitment to Medication SafetyTab 2Medication Management PoliciesTab 3Educating StaffTab 4PrescribingTab 5Documenting - TranscribingTab 6DispensingTab 7AdministeringTab 8MonitoringTab 9Error Tracking and AnalysisTab 10 Quality ImprovementTab 11 WarfarinTab 12 ReconciliationTab 13 Monthly EditsTab 14 Educating Residents and FamiliesTab 15 Regulations and ResourcesThere are a number of Web site listings in the workbook where you can access additional tools andmaterials. If you want direct access to these sites, you can view this workbook online at www.masspro.org/NH/tools.php. When you come to a Web site in the workbook that you want to visit, simply click onthe URL (the address of the site), and you will be sent there directly.A Systems Approach to Quality Improvement in Long-Term Care:Safe Medication Practices Workbook 2007Property of the Commonwealth of MassachusettsPage

IntroductionIn 2005 Masspro, the Massachusetts Extended CareFederation (MECF), the Massachusetts Coalitionfor the Prevention of Medication Errors (Coalition),and the Betsy Lehman Center for Patient Saf