High Risk Medication Delivery in Paediatrics - Implementing Leading Practice

» Background
» Partner Organizations
» National Action Plan

Patient safety is one of CAPHC’s national priorities.  Under the direction of the CAPHC Board of Directors, CAPHC’s National Patient Safety Collaborative provides a national forum to unite individuals, groups, and organizations to facilitate partnerships, improve communication, and, when appropriate, undertake collective action to improve patient safety for all children and youth.  Membership in the collaborative is open to all members of CAPHC, Health Canada, the Canadian Patient Safety Institute (CPSI), as well as other provincial and national organizations with a specific expertise and/or interest in patient safety.  The Collaborative membership represents multidisciplinary child and youth health organizations from coast to coast.

CAPHC is currently facilitating two national paediatric patient safety programmes. Details of these national programs are posted on the CAPHC web site:

» CAPHC – Safer Health Care Now! Paediatric Medication Reconciliation Collaborative
» Reducing Harm in Paediatric Care: Learning About Adverse Events and Near Misses, Using a Validated Canadian Paediatric Trigger Tool

A third national paediatric patient safety programme is being proposed: Implementing Leading Practice for High Risk Medication Delivery.

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 recognised 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

The symposium featured current best practices, medication dosing and delivery protocol challenges, and opportunities to develop and implement consistent leading practice(s) within paediatric healthcare settings.

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; CCHSA & 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.  

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.

» CCHSA: The Canadian Council on Health Services Accreditation
CCHSA is the recognized leader in raising the bar for quality in health service delivery. CCHSA helps organizations across Canada, and internationally, examine and improve the quality of service they provide to their patients and clients. CCHSA encourages sharing ideas and knowledge at the community, regional, national and international levels to support efforts for quality in health care service delivery. CCHSA is committed to playing a major role in improving patient safety. In addition to standards that address patient safety challenges, CCHSA 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 CCHSA 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
  

National Action Plan - Proposed 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

National Action Plan - Outcomes

• Analysis and interpretation of the environmental scan and the national paediatric survey will inform the national quality improvement intervention for Phase 2 of the SHN! Campaign – “Prevent Adverse Drug Events Related to High-Risk Medications in Paediatrics”

The results will determine:

• Variability in current practice across the continuum of care
• Leading practices that can be recommended for a national quality improvement initiative (National quality improvement intervention for Phase 2 of the SHN! Campaign)
• Risks, Barriers
• Enablers for sustainable change

The results of the environmental scan, paediatric survey and subsequent recommendation for the national paediatric intervention will be presented at CAPHC’s 2008 Annual Patient Safety Symposium, during CAPHC’s annual meeting in Edmonton (October 19, 2008.