Patient Medication Safety Resources Audit

Prepared by: Hill & Knowlton

September 30, 2003

Resource Audit Table of Contents

Web Resources

AHRQ…………………………………………………………….…………5

American Academy of Pediatrics…………………………………………...7

American Association of Health Plans……………………………………...7

American College of Physicians…………………………………………… 7

American Geriatric Society………………………………………………… 8

American Hospital Association……………………………………………. 8

American Optometric Association…………………………………………. 9

American Society of Health-System Pharmacists…………………………. 10

Arthritis Foundation………………………………………………………... 10

Association for Professionals in Infection Control and Epidemiology……. 10

California Department of Consumer Affairs………………………………. 11

Canada DIRC………………………………………………………………. 11

Cardinal Health……………………………………………………………. 11

Centers for Disease Control…………………………………………………11

Central Ohio Area Agency on Aging……………………………………….12

Consumer Healthcare Products Association……………………………….. 12

Council on Family Health………………………………………………….. 12

Ethical Aspects of Clinical Error and Patient Safety ...……………………..13

Drug Digest.org/Express Scripts ……………………………..……………. 13

Food and Drug Administration…………………………………………….. 13

Hanley-Hazelden Center at St. Mary’s …………………………………..…15

Hospital and Health System Association of Pennsylvania………………….15

Illinois Hospital Association……………………………………………….. 16

Institute for the Advancement of Community Pharmacists…………………16

Institute for Healthcare Improvement…………………………………..….. 16

Institute for Safe Medicine Practices………………………………………..17

Institute of Medicine……………………………………………………….. 18

Janssen Risperdal Medication Diary………………………………………...18

Joint Commission on Accreditation of Healthcare Organizations…………..18

The Leapfrog Group……………………………………………………..…. 19

McKesson Information Solutions………………………………………..…..19

Massachusetts Coalition for the Prevention of Medical Errors………….…. 19

Maryland Patient Safety……………………………………………………..20

Minnesota Alliance for Patient Safety…………………….………………...20

National Academy for State Health Policy………………………………….21

National Consumers League ………………………………………………. 21

The National Council on Aging ………………………………………….... 21

National Institute on Aging …………………………………………………22

National Institute on Drug Abuse……………………………………..…….22

Older Women’s League …………………………………………………… 22

Ontario Pharmacists’ Association………………………………………..….22

Peter Lamy Center (UMD)………………………………………………… 22

Pharmaceutical Supply Chain Integrity………………………………….….23

Quality Interagency Coordination Task Force…………………………..….23

Quality and Safety in Health Care……………………………………….… 24

RxHub……………………………………………………………………… 24

Rx Intelligence…………………………………………………………..…. 24

San Leandro Hospital……………………………………………………….25

TREA Senior Citizen League……………………………………………… 25

United Healthcare………………………………………………………..… 25

United Seniors Health Cooperative ……………………………………..… 26

United States Pharmacopeia……………………………………………….. 26

Veterans Administration…………………………………………………… 26

Vision Council of America …………………………………………………27

Wellmark/Blue Cross Blue Shield…………………………………….…… 27

World Health Organization………………………………………………… 27

Women’s Heart Foundation……………………………………………..… 27

Current Initiatives

American College of Clinical Pharmacy……………………………………29

American Pharmaceutical Association…………………………………..… 29

American Society for Health-System Pharmacists………………………… 30

Baltimore County Department of Aging …………………………………... 33

CDC/FDA…………………………………………………………………...33

Council for Affordable Quality Healthcare……………………………..… 33

Marshfield Clinic/Marshfield Medical Research Foundation……………… 34

National Council on Patient Information and Education……………………34

National Quality Forum……………………………………………………. 35

Pharmaceutical Research and Manufacturers of America……………….… 35

UMD School of Medicine …………………………………………. ……... 36

Past Initiatives

AARP……………………………………………………………………… 37

Aetna……………………………………………………………………..… 37

Agency for Healthcare Research and Quality………………………………37

Food and Drug Administration………………………………………..…… 38

Institute of Medicine…………………………………………………..…… 38

Joint Commission on Accreditation of Healthcare Organizations………… 38

National Council on Patient Information and Education………………...… 39

National Institute on Drug Abuse………………………………………..… 39

The National Patient Safety Foundation…………………………………… 40

World Health Organization………………………………………………… 41

Books

The Pharmacist’s Guide to Your Medication……………………………… 42

Pills That Work, Pills That Don’t………………………………………..… 42

Medication Safety and Cost Recovery…………………………………..… 42

Without Prescription…………………………………………………….… 43

The Handbook of Heart Drugs…………………………………………..… 43

Complete Guide to Prescription & Nonprescription Drugs……………..… 43

Coping With Medications……………………………………………….… 44

First Do No Harm………………………………………………………..… 44

The Family Prescription & Medication Guide…………………………..… 44

Every Woman’s Pharmacy………………………………………………… 45

The Essential Guide to Prescription Drugs 2003………………………..… 45

The Pill Book………………………………………………………….…… 46

Surveys

Summary Surveys…………………………………………………………...47

Web Resources

Agency for Healthcare Quality and Research (AHRQ)

Making Health Care Safer: A Critical Analysis of Patient Safety
http://www.ahcpr.gov/clinic/ptsafety/spotlight.htm

• Report designed "to let the nation's healthcare leaders know what the science says about where the opportunities exist to make patient care safer right now." It covers 73 patient safety practices that are likely to improve patient safety, based on an analysis of published evidence, and describes 11 that the researchers considered "highly proven to work but not performed routinely in the nation's hospitals and nursing homes."
• Published in 2001 by the University of California-San Francisco/Stanford University Evidence-Based Practice Center, the Making Health Care Safer report opens with an executive summary, guidance on how to use the compendium, and an explanation of evidence-based review methodology

Medical Errors & Patient Safety
http://www.ahcpr.gov/qual/errorsix.htm

• Offers a collection of links to information and resources that support the reduction of medical errors and improvement of patient safety.
• Web M&M, or Morbidity and Mortality Rounds on the Web, launched in February 2003, this site features interactive learning modules called "Spotlight Cases," online discussion forums, and expert analysis of medical errors reported anonymously by readers.
• Other links, which include a mix of items for professionals and consumers, are listed under documents, press releases, patient safety task forces, workshops, speeches and statements on medical errors, and Congressional hearings.

New Research Projects Awarded to Improve Patient Safety
http://www.ahrq.gov/qual/newgrants

• Detailed information on scores of patient safety programs funded by the Agency for Healthcare Research and Quality, part of Health & Human Services.
• The projects are listed in six categories:

1. Supporting demonstration projects to report medical errors data

2. Using computers and information technology to prevent medical errors

3. Understanding the impact of working conditions on patient safety

4. Innovative approaches to improving patient safety

5. Dissemination of research results

6. Additional patient safety research programs

Quality Indicators
http://www.qualityindicators.ahrq.gov/

· Offers hospitals online access to measures of patient care quality-quality indicators-developed by AHRQ. Tools consist of downloadable software and user guides, and are free of charge, but require the use of SAS or SPSS software (commercially available statistical programs)

· Three sets of indicators offered at this site: Inpatient Quality Indicators, Patient Safety Indicators, and Prevention Quality Indicators.

· The Inpatient Quality Indicators tool measures "inpatient mortality for certain procedures and medical conditions, utilization of procedures for which there are questions of overuse, underuse, or misuse, and volume of procedures for which there is evidence that a higher volume of procedures is associated with lower mortality."

· The Patient Safety Indicators tool is a set of measures that use secondary diagnosis codes to detect 26 types of adverse events, such as complications of anesthesia, blood clots in the legs or lungs following surgery, fracture following surgery, and four types of birth-related injuries. Six of the measures can be calculated as either hospital-level or area-level indicators

· The Prevention Quality Indicators tool is a set of measures "that can be used with hospital inpatient discharge data to identify 'ambulatory care-sensitive conditions.' These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease."

WebM&M: Morbidity and Mortality Rounds on the Web
http://www.webmm.ahrq.gov/

• "Online journal and forum on patient safety and healthcare quality," launched in February 2003. Developed by the Agency for Healthcare Research and Quality (AHRQ) with technical support from DoctorQuality, this site offers cases, CME, forums, and links on healthcare quality, patient safety, and medical errors.
• Two goals: To bring expert knowledge and research to bear on specific cases, and to develop a non-punitive culture where medical practitioners are able to learn from medical mistakes.
• Key site feature- "Spotlight Cases" that offer CME credits based on polls and quizzes for interested users; online discussion forums; and expert analysis of medical errors reported anonymously by readers in a set of specialty-specific "Current Cases & Commentaries."

• Garnered a positive response, with about 1,000 visits per day. And in a matter of weeks, more than 1,500 people had downloaded an educational slide set for use in training sessions on patient safety

American Academy of Pediatrics
http://www.aap.org/policy/re060027.html

Patient-safety principles adopted by the American Academy for Pediatrics (AAP):

· Drug dose calculation errors, which are determined by weight and typically involve more calculations than in adults.

· The lack of drug testing for pediatrics use.

· Limited capacity for cooperation in pediatric patients

· The rarity of many pediatric illnesses.

· Children's reliance on others for medications

American Association of Health Plans

http://www.aahp.org/Content/ContentGroups/Reports_Fact_Sheets/Reports_Fact_Sheets_Briefs_(after_2_2003)/Pharmacy_Prgms.pdf

Report entitled “Health Plan Pharmacy Programs: A Focus on Patient Safety, Quality, and Access”

· Highlights the positive effects of health plan programs on patient health and safety. Emphasis is placed on:

· Reducing adverse drug reactions

· Avoiding medication dosage errors

· Promoting patient compliance

· Addressing potential substance abuse problems

· Notifying physicians and patients about FDA warnings and alerts

American College of Physicians (ACP) – American Society of Internal Medicine (ASIM)
http://www.acponline.org/ptsafety

• Offers information to help physicians improve patient safety. Developed by the American College of Physicians (ACP)/American Society of Internal Medicine (ASIM), the site features information about patient safety-related training, online learning, safety tips and guidelines, useful links, and opportunities for involvement in patient safety programs.
• The ACP-ASIM physician "train-the-trainer" safety sessions, presented to designated physician trainers by leaders in the field, are designed to ripple knowledge out to physicians in various venues, including grand rounds and professional meetings. They're part of Patient Safety: The Other Side of the Quality Equation—a three-year program funded by the Agency for Healthcare Research and Quality (AHRQ). The three training modules developed to date treat system thinking in ambulatory care, office design, and medication errors. Further modules will address electronics, communication, the role of the patient, and human cognition.
• The online Patient Safety Interactive Learning Community allows participants to review safety CME courses online, answer self-assessment questions hyperlinked to the appropriate information in the CME materials, and participate in online discussions.
• Patient safety tips focus on topics such as medication samples and patient compliance.
• News about new patient safety guidelines, links to safety resources, and opportunities to be involved in patient safety programs launched by the ACP-ASIM Physicians Quality Network (Q-Net) are offered in a "scientific policy" section.

American Geriatric Society

http://www.healthinaging.org/public_education/pef/over_the_counter_drugs.php

· Article in the American Geriatric Society’s Patient Education Forum section of web site, entitled “Over-the-counter and Prescription Drugs”

· Provides very basic information on the differences between prescription drugs and over-the-counter drugs.

· Has answers to frequently asked questions and links for further information

American Hospital Association (AHA)
http://www.hospitalconnect.com/aha/key_issues/patient_safety

• Inpatient tools including: 1) measure quality of care, 2) continually improve patient safety and quality, and 3) create a "culture of safety" that supports candid analysis of errors and error prevention. Key features include:
• Information on the AHA's Quality Initiative: A public resource on hospital performance. This voluntary system for public reporting of U.S. hospitals' performance on 10 quality measures for myocardial infarction, pneumonia, and heart failure will begin in July 2003 and ramp up through July 2004.
• Links to the full text of recent publications, articles, and news on patient safety and quality

American Hospital Association (AHA) Medication Safety Series ‘03

Medication Safety Issue Briefs are designed to help senior management take concrete steps to reduce errors in their hospitals. The series is a joint project of the AHA’s Quality Agenda, the ASHSP, Hospitals and Health Networks, and Aventis.

• Information about a Measurement “Toolkit” to identify and measure errors to improve safety. Suggests voluntary reporting, computerized alerts, chart review, observation, and executive walk rounds. Also includes Cleveland Clinic case study.
• Creating an Alert and Active Team includes case studies from Missouri Baptist Medical Center, The Johns Hopkins Hospital, and Fairview Health Services.
• Change your Culture Forever offers information about sustaining medication safety change, and includes a case study from Iowa Health System.

American Hospital Association (AHA) Medication Safety Series ‘01

Medication Safety Issue Briefs are a joint project of the AHA’s Quality Agenda, the ASHSP, Hospitals and Health Networks, and McKessonHBOC

· Creating a Culture of Safety includes information and case studies from Dana-Farber Cancer Institute and Veterans Health Administration.

· Using Automation to Reduce Errors includes information about the potential of technology to prevent medication errors, as well as case studies from Vanderbilt University Medical Center, Children’s Hospitals of Minneapolis, and offers additional web sites and articles as resources.

· Asking Consumers for Help focuses on enlisting patients to prevent medication errors, and includes case studies from University of Colorado Hospital and St. Luke’s Hospital

· Using a System-wide Approach explains how hospitals are using a systems approach to analyze errors and improve patient safety, and includes case studies from St. Luke’s Episcopal Hospital and Legacy Good Samaritan Hospital and Medical Center

· Crucial Role of Therapeutic Guidelines explores role of therapeutic guidelines in ensuring safe and consistent medical care, and includes case studies from New York Presbyterian Hospital and Memorial Medical Center.

· Finding and Using Resources provides resources on patient safety and discusses how they can be used best, and includes case studies from Sentara Healthcare, University of Wisconsin Hospital and Clinics, and Trinity Health.

American Optometric Association

www.aoanet.org

· This site include a pamphlet entitled “Use your Head and Your Eyes” with tips on careful reading of medicine labels

American Society of Health-System Pharmacists (ASHP) http://www.ashp.org/patient-safety

This site is devoted to providing resources to support "fail-safe medication use in health systems through the leadership of pharmacists." Sponsored by the American Society of Health-System Pharmacists (ASHP), the site offers:

• A Drug Product Shortages Management Resource Center.
• Problem reporting
• Medication safety issue briefs
• Computerized physician order entry (CPOE) system information
• Information on the Medication-use safety coordinator position
• News on developments and trends
• Product listings
• References to books, articles, conference proceedings
• Links to resources such as SafeMedication.com, the ASHP's consumer site on safe medication practices

Arthritis Foundation

www.arthritis.org

· This site includes a pamphlet titled “Medications: Using them Wisely” on proper medication use and how and why medications are used.

Association for Professionals in Infection Control and Epidemiology (APIC) Patient Safety Resources
http://www.apic.org/safety

• Infection-control/patient safety resources for professionals and consumers
• Offerings include e-learning courses and news about non-virtual courses; links to resources and publications; news; the opportunity to order products online such as videos, texts, toolkits, catalogs, and newsletters; job listings; and annotated links to patient safety organization sites
• Collection of patient safety resources includes well-annotated links to case studies, research, reports, systems information, brochures, conference proceedings, consumer resources, cost analyses, practice guidelines, information technology, medical devices, medication errors, policies and procedures, and products and services.

· January 2003 issue of Perspectives on Patient Safety, which focuses on compliance with the Joint Commission's National Patient Safety Goals; and a succinct one-page "backgrounder" on patient safety initiatives in the U.S.

California Department of Consumer Affairs

http://www.dca.ca.gov/press_releases/20021021_pharmacy.htm

• October 2002 press release entitled “Can We Talk? October is ‘Talk With Your Pharmacist Month’”
• Provides list of reasons to talk with your pharmacist as well as a list of questions you should be asking
• Provides a link to the California State Board of Pharmcy for further information

Canada DIRC

http://www.dirc-canada.org

• Drug Information and Research Centre (DIRC) web site includes information about the center, members, and links of interest compiled by DIRC. Also includes service access contact information to pharmacists via phone, fax, email and mail.
• Offers consultant services, contracted drug information services, training and research information.

Cardinal Health

http://www.hctproject.com

• Offers information about Pyxis products and services form Cardinal Health geared towards improving patient safety, reducing medication errors, driving down the cost of supply management, and market innovation. Also includes resources such as white papers, case studies, vendors, partners, and press releases.

Centers for Disease Control (CDC)
http://www.cdc.gov/ncidod/hip

• Division of Healthcare Quality Promotion (DHQP) is dedicated to reducing adverse events, or "safety issues," in healthcare settings. To that end, the site provides links to CDC-generated and other information on a wide variety of topics.

Central Ohio Area Agency on Aging

http://www.medcohealth.com

· The Central Ohio Area Agency on Aging, sponsored by Medco Health Solutions, established “Ask the Pharmacist,” a public service program for senior and community groups.

· Program offers tips on safe use of medications at free sessions at senior, civic and religious institutions.

· Medco gives out “Medication Guidebook for Healthy Aging” to all attendees. This is a large print reference guide to educate older adults, their caregivers about various aspects of the prevalent health conditions and treatments they may face as they age.

Consumer Healthcare Products Association

www.ndmainfo.org

Nonprescription Medicines: Modern Medicines for Mature Americans

· Pamphlet developed with the National Council on the Aging- contains key messages for older people to keep in mind when using prescriptions

To Your Good Health

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