High Alert Medication Delivery in Paediatrics - Implementing Leading Practice

» Background
» National Action Plan -Phase 1
» National Action Plan - Phase 2
» Partner Organizations

Background

Paediatric healthcare institutions face many unique challenges in the delivery of care - among these challenges is the lack of standardization of paediatric medication dosing and delivery practice.  It is well known that medication errors and adverse events are among the most common patient safety problems in paediatrics and that certain high-risk medications pose particular risks.  Non-standardized practices are a recognized challenge across the majority of child and youth health centres in Canada across the continuum of care.

Many adult health centres have successfully adopted standardized dosing and medication delivery processes to increase efficiency and improve patient safety.  Many of these best practices are sanctioned and supported by ISMP Canada, CCHSA, JCAHO and other organizations focused on improving patient safety.  Fundamental differences in the delivery of medications in paediatrics, particularly weight-based dosing, have hindered the adoption of similar practices in paediatric care.

On October 15th 2006, a patient safety symposium entitled: “Promoting Patient Safety and Best Practices in Paediatrics through Standardization of Medication Practices and Delivery Protocols” was held at the CAPHC annual meeting in Vancouver.

» View Final Proceedings

Symposium leaders and delegates focused on current challenges and related patient safety risks with respect to paediatric standardization. The value of creating system-wide standards for high-risk medication practices across all paediatric settings was identified as a priority based on the following principles:

• Standardization of care is a key principle behind patient safety,
• Standardization forces necessary discussion and debate;
• Standardization allows for consistency across sectors; and
• Standardization has the potential to enhance learning and knowledge transfer.

In keeping with international consensus (i.e. the WHO Patient Safety High 5’s Initiative), delegates at CAPHC’s 2006 patient safety symposium supported the need to determine evidence-based paediatric medication delivery standards and the need for consistent application of these standards.
 
Going Forward: Members of CAPHC’s Patient Safety Collaborative and key partner organisations (CPSI, ISMP Canada; Accreditation Canada & the Reiss Study Group) agreed to work collaboratively to develop a national action plan to address this important issue across the paediatric continuum of care.

National Action Plan - Phase 1

CAPHC and ISMP Canada have established an important partnership intended to advance medication system safety in the delivery of high alert medications in Canadian paediatric facilities.  An Advisory Committee, with representation from across Canada, has provided direction to the project and assisted with the interpretation of findings.

Goals and Objectives

• To identify the top 3 high risk meds causing harm or potential harm in Canadian paediatric healthcare settings, based on frequency and severity of incidents
• To identify the common medication system issues, using, in part, a paediatric specific survey, that lead to ADEs; risks, challenges and barriers experienced by Canadian paediatric health care providers
• Identity and analyze existing leading practices and develop solutions that will form the basis of the intervention for Phase 2 of the SHN! Campaign – “Prevent Adverse Drug Events Related to High-Risk Medications in Paediatrics

Outcomes

The goals of the first phase were addressed in part by an analysis of medication incident data submitted to ISMP Canada by selected paediatric healthcare facilities, to determine the medications most commonly associated with harmful medication incidents and to categorize the types of incidents and contributing factors. Close to one quarter of all medication incidents reported as causing harm were associated with five medications, two of which were opiates. This suggests that a small number of medications account for a disproportionately large number of incidents and these medications may represent opportunities for targeted interventions. 

An additional analysis of harmful and non-harmful incident reports for the top five medications and for the opioid class provided information on types of incidents and contributing factors. Although the most commonly-reported incident types varied from medication to medication, "wrong dose" and "wrong drug" incidents were reported frequently. For "wrong dose" incidents, mix ups of dosage units and calculation errors were common contributing factors; while for "wrong drug" incidents, look-alike / sound-alike medications were frequently identified as a contributing factor.

A survey of selected paediatric healthcare facilities to obtain information on leading practices was also conducted. The results of the survey provide a landscape view of patient safety initiatives in place at Canadian paediatric facilities in August 2008.  The analysis of the survey data helped to identify leading practices that have been implemented in many facilities, but also suggested that safe practices are not being consistently implemented. For example, certain leading practices related to safe handling of opioids that are in place in many facilities have not been adopted by other facilities.
Based on a set of predetermined criteria and with consideration given to the results of the incident report analysis and landscape survey, the National Advisory Committee has reached a consensus on the following intervention: 

To create an intervention that will assist in the implementation of safe medication practice for the delivery of opioids in paediatric settings.  This includes all aspects of the opioid medication system from prescribing to storage and administration.

» Phase I Final Report
» Top 5 Drugs Reported as Causing Harm through Medication Error in Paediatrics

National Action Plan - Phase 2
Canadian Paediatric High Alert Medication Delivery: Opioid Safety

Goals and Objectives

Our goal is to reduce the probability of opioid-related medication harm within paediatric institutional settings, by surrounding the use of these medications with a multi-layered environment of safety.  To achieve this goal, our National Advisory Committee has adopted the following objectives:

• To develop a Paediatric Opioid Safety “Resource Guide Toolkit”;
• To develop a comprehensive set of intervention recommendations and tools to ensure safe opioid medication practice including, but not limited to, methods of standardization of prescribing and administration, calculation tools, contracting and storage;
• To utilize an innovative approach by applying Human Factors expertise and psychological theory and practice, to design strategies for developing support for professionals in safe practice.  This would include developing collateral strategies for the safe recommendations described in Objective ii, above; and
• To coordinate and host training session/workshop to engage and ensure buy-in from our Pan-Canadian paediatric community. 

 The intervention will include three fundamental elements, which represent groupings of tactics:

• Element I:       Fundamental System Safety
• Element II:       Prescribing Standardization
• Element III:      Dose Administration Standardization

The Resource Guide Toolkit that will be prepared and provided to all healthcare organizations who agree to participate in the 2 year intervention, will include relevant links to materials and support documents.  The Toolkit will include an Intervention section comprised of specific “tactics”.

These fundamental elements described above will be further enhanced by employing innovative strategies, such as:

• Human factors engineering, which will be integrated into the design of the opioid delivery processes and systems, to assist us to further minimize the opportunity for human error;
• Psychological theory and methodology, which will allow us to develop an innovative approach to an interventional tactic.  It will be designed to support the psychological aspect of practitioners who are involved in the administration of paediatric opioids; and
• “Toolkit” communications, which will be designed to enhance knowledge transfer of intervention recommendations.

 Methodology

Using the analysis from the Phase 1 report and the knowledge gathered from the work at the October 2008 expert workshop in Edmonton, a set of tactics was developed and approved by the National Advisory Committee.

Upon further review it became apparent that the proposed tactics were too broad and required a more focused approach to be achievable within the two year time frame.   There has been extensive consultation with the paediatric community in all aspects of opioid medication delivery.  The combined input from Community, Quaternary and Tertiary Hospitals has been used to refine the tactics and allow organizations to tailor a system approach that will work for them.  Information has been collected using a variety of methods including but not limited to a national survey of existing practices; a focus group of needs assessment; a community hospital survey of practice change; qualitative psychological research and human factors testing.

» Phase II Final Report

Partner Organizations

» ISMP Canada: The Institute for Safe Medication Practices Canada
ISMP Canada is an independent Canadian non-for-profit agency established in 1999 for the collection and analysis of medication incident reports and the development of recommendations for the enhancement of patient safety. Like its sister organization, the Institute for Safe Medication Practices in the USA, ISMP Canada serves as a national resource for promoting safe medication practices throughout Canada’s health care community. The ISMP Canada TM Medication Safety Self Assessment tool is referenced in the recent Canadian Council of Health Services Accreditation standards and is recommended for implementation by Canadian healthcare facilities. The self-assessment program has been widely used in both adult and paediatric settings to self-assess the status of medication safety practices against an expert consensus-based set of recommended practices. ISMP Canada has led several successful projects in two provinces assisting facilities to introduce strategies to reduce the risks associated with concentrated electrolytes and opioids. ISMP Canada manages a national database of medication error information, which is the source of data for its error prevention bulletins and programs. ISMP Canada also acts as the intervention lead for medication reconciliation in the Safer Healthcare Now! Campaign and supports over 200 frontline teams as they implement medication reconciliation. Acknowledgement of ISMP Canada’s work and contributions to this project will be included in all project-related documents.

» Accreditation Canada
Accreditation Canada is the recognized leader in raising the bar for quality in health service delivery. Accreditation Canada helps organizations across Canada and internationally, to examine and improve the quality of service they provide to their patients and clients. Accreditation Canada encourages sharing ideas and knowledge at the community, regional, national and international levels to support efforts for quality in health care service delivery. Accreditation Canada is committed to playing a major role in improving patient safety. In addition to standards that address patient safety challenges, Accreditation Canada has developed Patient Safety Goals and Required Organizational Practices (ROPs) that have been an integral part of the accreditation program since January 2006. CAPHC is currently working with Accreditation Canada in the development of accreditation standards for all health centres providing services to children and youth.

» CPSI: The Canadian Patient Safety Institute
CPSI was established in 2003 as an independent not-for-profit corporation, operating collaboratively with health professionals and organizations, regulatory bodies and governments, to build and advance a safer healthcare system for Canadians. CPSI performs a coordinating and leadership role across health sectors and systems, promotes leading practices and raises awareness with stakeholders, patients and the general public about patient safety. In partnership with CPSI and the SHN! Campaign the CAPHC Paediatric Medication Reconciliation Collaborative (PMRC) is working to expedite change and quality improvement in medication reconciliation at all paediatric centres and other related organizations across Canada. CPSI is the lead technical agency in Canada for an emerging patient safety initiative known as the “Action on Patient Safety” project or High 5s. The World Health Organization (WHO) Collaborating Centre on Patient Safety (Solutions), the World Alliance for Patient Safety and the Commonwealth Fund are internationally leading this seven-country collaborative project that will leverage the implementation of five standardized patient safety solutions (Medication Reconciliation, led by Canada, Managing Concentrated Injectable Medicines, Handover Communication, Correct Site/Correct Procedure/Correct Person and Hand Hygiene Practices) to prevent avoidable catastrophic events in hospitals. Up to ten Canadian hospitals will implement up to five of the solutions and incorporate a systematic evaluation strategy.

» REISS Study Group
The REISS Research Exchange Study Group is a team of researchers, clinicians, and decision-makers, funded by the Canadian Health Services Research Foundation (CHSRF) & CPSI to look at the implementation of patient safety practices, primarily in paediatric hospitals. The project consists of two major components:

1. Participating facilities monitor for preventable adverse events and major near misses. This part of the project includes systematic literature reviews and structured interviews with hospitals and other stakeholders across Canada; and
2. An in-depth analyses of implementation of patient safety practices across Canada including computerized provider order entry (CPOE) and/or electronic medical record (EMR) and handling and storage of concentrated potassium.

The principle investigators of this study group have agreed to work in collaboration with CAPHC by sharing data on barriers and enablers encountered by Canadian hospitals who are implementing programs to improve patient safety. Other key stakeholders and appropriate organizations will also be engaged in this process. Examples of key stakeholder organizations are (but not limited to):

• Canadian Society of Hospital Pharmacists
• Canadian Paediatric Society
• Canadian Council of Health Service Executives, and
• Canadian Anaesthesia Society