Los Angeles County Grand Jury
2006-2007
From the annual report
The consolidated year-end volume. The individual investigations it contains are listed separately below.
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Individual reports (19)
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Findings & Recommendations
79 findings
F1:
DHS central staff Directors have established spheres of influence when working with the Hospitals, but they lack formal authority relationships and audit functions Current relationships are built on trust and collegiality and judicious use of staff authority. The authority has not encompassed all the oversight provisions included in the Job Specification for the Director, Pharmacy Services. The Director, Pharmacy Services, reports to the Departmental Chief Medical Officer. The Director, Pharmacy Services, participates in and provides staff support for major committees, including the DHS Core Pharmacy and Therapeutics Committee, the DHS Pharmacy Director’s Committee, and the DHS Pharmacy Information Systems Committee. The incumbent has been effective in funding and generating agreement about implementation of new technology. This assignment of responsibility and chain of command through the Chief Medical Officer appropriately reflects the need for central direction for the Hospitals. Nevertheless, the Hospitals do not share the full reports of all Medication Errors, which are essential for the Director to understand overall Pharmacy Performance and needed interventions. In addition, there is no formally developed Audit Schedule to review conformance with Departmental policies associated with ordering, distributing, and administering medication.
F2:
Investments in technology can result in significant reductions in medication error risks. Automated medication dispensing cabinets have proven themselves to be a good, if substantial, investment. Where they have been put into use, Hospital staff members report that errors have fallen, and the dispensing process has become more efficient. Similar results are projected for pharmacy medication carousels. Bar coding systems offer the prospect of a new level of patient medication safety that has heretofore been unavailable. A pre-requisite for the success of these systems is the implementation of standards for bar code systems across the industry. IV Smart Pumps also add a new level of medication error reduction by highlighting delivery rates or concentrations that fall outside standard parameters. Smart Pumps allow for programming of standard concentrations of IV medications, removing the burden of the unit nursing staff having to calculate flow rates, thereby eliminating an additional potential source of error. The implementation of new technology has rendered information technology staff ever more vital to Hospital operations. The medication use systems assessed here are highly dependent on contractors and internal staff members for installation, staff training, and system maintenance. The systems are expanding in both scope and complexity. DHS is aware of this issue. DHS’s Chief Information Officer (CIO) has prepared a business plan that outlines the resource needs he expects to face immediately and for several years into the future. Work remains to gain the funding needed to offer competitive salaries and deploy staff at the Hospitals.
F3:
Olive View Medical Center processes appear to be incompatible with realization of ADC benefits. Olive View’s description of its plans to install ADCs is not consistent with the approaches used by other Hospitals. Its current systems include pneumatic tube distribution of medications. Citing space limitations on the floors, Olive View staff members are designing plans that limit access to the ADCs, which limits its advantage of allowing nursing staff complete access to regular medications while maintaining controls over controlled substances. During the site visit to Olive View, it was not conclusively demonstrated that patients’ identities are always recorded on medical records before medical orders are written. There was some evidence that the patient’s last name was being written by hand on the initial order sets and then covered with a printed label. This is not a best practice, and it affords a clear opportunity for medication error, as it is possible for the order to refer to the wrong patient. When questioned about the practice, Olive View staff denied that this was the case. The denial, in fact, is more disturbing than the practice itself, since it suggests a defensiveness that could cover other errors or weaknesses. A single site visit should not be considered conclusive, and is not in itself sufficient grounds for action. It is, however, sufficient to support a review of current medication orders, dispensing, and administration to ensure that the Hospital is fully prepared to implement a more automated pharmacy system.
F4:
Electronic Health Records (EHRs) and Computerized Physician Order Entry, when properly implemented, are best practices to reduce medication error. Computerized Physician Order Entry (CPOE) has been successfully implemented in several regional hospitals. It is difficult and expensive to do. It requires extensive planning, a significant investment, and careful building of internal acceptance. Executive management must make the commitment to CPOE and consistently let people know that it will be implemented – especially when thorny issues arise or the system shows difficult growing pains. A pre-requisite for its success is the implementation of EHRs, which are currently being planned in DHR. CPOE, difficult as it is to implement, is worth the trouble. It eliminates a transcription step that generates errors. It eliminates illegible orders and unapproved abbreviations. Wrong dose and wrong drug errors are reduced. Data can be easily collected for evidence-based clinical paths, considered a best practice. Physician orders, including medication orders, can be transmitted to the responsible parties instantly. Medical records can be shared between facilities and programs, making it much faster and easier to assess patients accurately, and all but eliminating the “shopping” of medical services by patients. Productivity, quality of care, and patient safety all advance. DHS has been wise in the order of technology implementation. The technologies described in this report are well-proven innovations that impact patient safety. After the installation of Automated Pharmacy Systems, assignment of Clinical Pharmacists, acquisition of IV Smart Pumps and bar coding of medications are complete, EHRs and CPOE appear to be the next major steps in reducing the risk of medication errors.
F5:
Clinical Pharmacists are effective in reducing medication error risks. Clinical Pharmacists spend time as part of patient care teams, consulting with Physicians and the remainder of the team on the units and during rounds. They provide drug information, recommend dosage adjustments, respond to questions from nursing staff, and make suggestions regarding initiation of drug therapy. All of these activities relieve stress on the Physicians and other clinicians who must sometimes make rapid decisions about patient care in difficult circumstances. This improves the quality and speed of the decisions and reduces the likelihood of medication errors.
F6:
24-hour Pharmacist coverage is important to Patient Safety. A Pharmacist is needed on-site for in-patient care on a 24/7 basis, particularly for acute patients. If a Pharmacist is not available, a comparatively slow and cumbersome process of faxes and telephone calls to Pharmacists at home is required. A “night locker” must be maintained, under the control of a Senior Nurse. If a medication is needed that is not in the night locker, a Pharmacist must be called in from home to open the main pharmacy and dispense it. The primary disadvantage of the process is that it is not fast, and the circumstances that give rise to overnight medication orders are likely to demand prompt action. There are also evident weaknesses in the processes for the checking of medications against orders. Finally, tired Pharmacists are expected to perform their day shifts, even when their sleep is interrupted. In all professions, errors usually increase when people become sleep-deprived. Some smaller hospitals cannot support a 24-hour pharmacy. These hospitals are adopting the capabilities of automated prescription transmission, which involves scanning medication orders to a Pharmacist for verification and approval. The Pharmacist can then release the medication from the ADC at the smaller facility. 2006-2007 County of Los Angeles Civil Grand Jury 37
F7:
It is a common practice to conduct pre-employment drug testing among staff involved in the health care professions. DHS does not do this. Drug screening and random drug testing are common means of ensuring security and safety in a wide variety of sensitive business and government operations. A number of hospitals use them. Failure to conduct screening and testing exposes patients to a potential risk of not receiving prescribed medication (if an addicted employee substitutes a placebo for the particular drug), and increases the potential risk of medication errors when impaired staff members prescribe, approve, distribute, and administer medications. This is a known risk in an environment where staff members sometimes work long hours, and where there is ample knowledge of the “right” mix of drugs to take to stay alert.
F8:
A “Safe and Just” culture is essential to accurate reporting of errors – including medication errors – as well as to the rapid and effective response to error trends. A survey undertaken by DHS in December 2005 showed disturbingly high levels of concern among both Nurses and attending Physicians that errors would be held against them. Nurses also expressed high levels of concern that errors would be kept in their personnel files. Some of this concern may be traced to a long-standing policy in which managers close out reports of all types of medication errors by indicating that an employee was “counseled about the incident”. That is the first step in the County’s standard progressive discipline process. In that process, managers are advised to keep a permanent record of the counseling action for use as needed in ensuing sanctions for further errors. In April 2006, DHS engaged a contractor to deliver a training workshop, entitled “Patient Safety and the Just Culture”. It appears to have been intended to address the issue of a punitive culture by advocating a culture in which acknowledgement that errors are human and inevitable is balanced by a strong sense of professionalism and “zero tolerance” for medication errors. Before punitive actions are taken when a rule is broken or mistake is made, a Just Culture would consider: h Whether the employee knowingly violated the rule h Whether there was a compelling reason to violate the rule h Whether the employee had a good faith but mistaken belief that the violation was justified or insignificant h Whether the source of the error resided within the system or was behavioral. Based on answers to such questions, the response would vary from counseling to training to revising procedures. Perceptions of an unjust culture are crippling to any attempt to encourage the self-reporting of Category A, B and C errors, in which no measurable harm comes to a patient. If Physicians and Nurses fear retribution, they will be significantly less likely to self-report errors that have little measurable impact. DHS’s efforts to counter them are laudable, but it seems likely that they have not been sufficient. Further surveys were not available, but anecdotal evidence suggests that negative perceptions have proved to be persistent.
F9:
There is insufficient consistent, Department-wide medication error trend analysis. The identification of trends within overall medication error rates is key to reducing them. The Hospitals do some analysis now, although they do not all follow the same guidelines; and their analysis appears to be limited at times by a lack of formal training for some Hospital Risk Management staff members. For the past year-and-a-half, data have been gathered in a nationwide system run by the University HealthSystem Consortium, which permits sophisticated analysis of errors. There has been insufficient consistent reporting and analysis to take advantage of that capability. While some errors occur only within one Hospital, others may be related to overall policies, training regimens, or technology systems across the County. These error trends should be identified and corrected; this can only be done if errors are reported and analyzed consistently across the County. In addition, such a function will serve to protect the Hospitals against the possibility that a medication error trend may be missed at the Hospital level. Recently, DHS has developed a “Report Card” which tracks high level trend data. It is a good beginning, but needs additional development.
F10:
The number of errors in UHC-PSN Categories A-C is less than expected, and raises the possibility that they are not fully self-reported. A review of reported errors shows few reported errors in the A and B1 categories for all four Hospitals in the six months ending March 31, 2007. The total errors reported for “no patient harm” categories (A, B1, B2, C) were low, considering there were over 300,000 patient days at Harbor-UCLA, Olive View, and RLA, where many patients have multiple medications. Given the number of reported errors in other categories over the same period, this does not appear logical. It is understandable that staff members who make lower category errors are sometimes reluctant to report them. Even in a non-punitive atmosphere, it is easy to see that a staff member would be reluctant to report a minor mishap, such as picking up an improper medication from a shelf, noticing it immediately, and replacing it before gathering up a proper medication. This is how major trends are identified that lead to, for example, separating look alike/sound alike medications. For errors in Categories B1 and B2, the patient receives no improper medications. Self-reporting is the only source of data. Responsible staff noted that the system used to track medication errors and pharmacy interventions is very cumbersome to use, further discouraging reporting of errors. This possible underreporting is important, because identifying errors that do not result in patient harm can point the way to weaknesses in the system that pose the potential for more serious adverse events.
F11:
DHS does not have a regular practice of replicating the best practices implemented from one facility to another. As an example, Harbor-UCLA has implemented Structured Physician Order Forms for admissions and transfers requiring the use of block lettering to reduce cases of illegibility. These forms significantly reduce a broad range of medication order errors, including illegible orders, unapproved abbreviations, dosage errors, and “wrong drug” errors. The Structured Physician Order Forms are considered successful where they are now used. The balance of DHS facilities does not use block lettering on these forms. As another example, Olive View does not recognize the same medications as high risk as the other Hospitals. These are examples of processes that are low-cost and can be relatively easily implemented, as contrasted with implementation of ADCs and bar coding technology.
F12:
Patient Safety and the Just Culture: County of Los Angeles DHS
F13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
F14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
F15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
F16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
F17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 44
F18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
F22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
F24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
F25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
F26:
Pharmacy Utilization Report for FY 2006-2007
F27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
F28:
The Just Culture Algorithm 29. “Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007 30. “Med Errors = Bad Outcomes”, Nurse Week, April 2007
F31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
F32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
F33:
Managing Medication Related Events: PowerPoint Presentation
F34:
Medication Management Process in Valley Care – PowerPoint Presentation
F35:
LAC+USC Chemotherapy Physicians Orders
F36:
LAC+USC Daily Physicians Orders – Adult Critical Care
F37:
LAC+USC Neonate Continuous Infusion Orders
F38:
LAC+USC Neonate Continuous Infusion Recipes
F39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
F40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
F41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
F42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
F43:
LAC+USC HealthCare Network Policy: Medication Usage
F44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
F45:
List of High-Alert Medications
F46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 45
F47:
LAC+USC Drug Bulletin June 2006
F48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
F49:
Intervention Summary Report
F50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
F51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
F52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
F53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
F54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
F55:
Harbor-UCLA – Patient Safety Bulletin October 2003
F56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
F57:
Los Angeles County DHS Lipid Management Algorithm
F58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
F59:
Wikepedia: Medical Error
F60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
F61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
F62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
F63:
Harbor-UCLA MAR Sample
F64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
F65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
F66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
F67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
F68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
F69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
F70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
F71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
F72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
F73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
F74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
F75:
LA County DHS Class Specification; Director of Pharmacy Services
F76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
F77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 46
F78:
DHS Pharmacy Leadership Program description
F79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
F80:
DHS Pharmacy Leadership Program proposal
F81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 47 JUVENILE CUSTODIES - ARE WE PAYING TWICE?
Additional Recommendations
81
Not linked to specific findings.
R1:
DHS central staff Directors have established spheres of influence when working with the Hospitals, but they lack formal authority relationships and audit functions. The Director, Pharmacy Services, should be entrusted with the authority to carry out medication error risk, performance audits and business process reviews. 2006-2007 County of Los Angeles Civil Grand Jury 22 #
R2:
Investments in technology can result in significant reductions in medication error risks. DHS should invest in medication management technology improvements, using life cycle costing that accounts for acquisition, installation, and maintenance of equipment. Funding for these investments should be drawn in part from medication cost savings such as those attributable to improved acquisition management. 3.
R3:
As part of the implementation of ADCs at Olive View, DHS should review the complete medication order, delivery, and administration process to ensure that both the baseline process and the plan to strengthen it with ADC technology are sound. As stated in the finding supporting this recommendation, it is not clear that the processes at Olive View are as strong as those in place at sister County Hospitals. It is an axiom of technology implementation that, if the underlying processes are not completely sound, the application of technology may well make matters worse rather than better. As part of the implementation of the ADC System, the in-patient medication processes at Olive View, from prescription through 2006-2007 County of Los Angeles Civil Grand Jury 34 ordering, dispensing, and administration should be subject to a thorough peer review. This peer review should:
R4:
DHS should begin now to plan for the implementation of CPOE and EHRs. DHS should convene an inter-disciplinary team charged with: a) researching current technology, b) developing specifications and cost estimates, and c) designing implementation plans for CPOE systems that will one day serve all County medical facilities. The team should set milestones to complete research, identify preferred technologies, address implementation issues, identify offsetting savings, and submit budget requests. This is a multi-year, multi-million dollar effort. There may be physician resistance within the Hospitals that needs to be addressed and overcome. There will also be training and retraining issues. There are several interim steps that are being taken that will support the development of DHS-wide systems. Currently, Lab Directors are standardizing nomenclature across the Department for common tests in anticipation of the need to be able to share test results for a patient that visits multiple hospitals. 2006-2007 County of Los Angeles Civil Grand Jury 35 PEOPLE
R5:
0: DHS should expand the number of Clinical Pharmacists, institute a Clinical Coordinator position at each Hospital, and use Tech-Check-Tech processes to free Pharmacists to perform other pharmaceutical duties
R6:
DHS should immediately establish a 24-hour Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication. Olive View Medical Center is of sufficient size and structure to warrant a 24-hour pharmacy. While they recognize the advantages of 24/7 coverage, staff at Olive View cite the difficulty of hiring Pharmacists to work this demanding shift. It is a hurdle to be overcome rather than an insurmountable obstacle, and Olive View should work with Department of Human Resources staff to develop incentives sufficient to attract night shift pharmacists or retain pharmacists when night shifts become a requirement. Olive View is too far removed from other medical facilities to seriously consider a partnering solution. Its patient census and the existence of an emergency room indicate that there is sufficient demand for constant staffing. Rancho Los Amigos, as a rehabilitation facility, has a different patient profile, and has historically seen fewer demands for after-hours pharmacy. This may be changing. DHS should monitor off-hours pharmacy demands on a regular basis, and consider partnering with other DHS facilities or other plans to ensure coverage.
R7:
The County should implement pre-employment drug screening and should develop a targeted program to provide for early identification and treatment of substance abuse among staff with access to controlled medications Pre-employment screening will reduce the risk of hiring individuals who are addicted to narcotics or other drugs. In addition, a program should be developed, modeled on best practices, that include training managers to recognize problems associated with drug abuse, referrals to Employee Assistance Programs, development of reporting mechanisms that identify patterns of abuse, and testing for drugs with a lower threshold of evidence than for other County staff. The program should be modeled on best practices which provide for confidentiality of results, automatic retesting of positive results, counseling, and, where needed, recovery programs. This program is not, at heart, different from ensuring that medical staff members do not have chronic infectious diseases. 2006-2007 County of Los Angeles Civil Grand Jury 38
R8:
0: DHS should strengthen its “Safe and Just” culture.
R9:
elaborates on process changes required to implement changes to sharing these reports. 2006-2007 County of Los Angeles Civil Grand Jury 32 TECHNOLOGY
R10:
The number of minor errors causing no patient harm (Category A - C in University HealthSystem Consortium – the Patient Safety Net) is less than expected, and raises the possibility that they are not fully self-reported. DHS should consider establishing Nurse “Naïve Observation” auditing to reduce dependency on self-reporting for medication errors. 11. DHS does not have a regular practice of replicating the best practices implemented from one facility to another. DHS should recognize best practices implemented at one facility, and replicate them system-wide. II – HISTORY AND BACKGROUND HOSPITALS’ BACKGROUND The Los Angeles County Department of Health Services (DHS) operates four major hospitals, Harbor-UCLA Medical Center (Harbor-UCLA), Los Angeles County+USC Medical Center (LAC+USC), Rancho Los Amigos Rehabilitation Center (RLA), and Olive View Medical Center (Olive View). Together, they provide more than 300,000 patient days of care annually. Table 2: Size of Hospitals # of Beds Hospital Licensed Budgeted Average Daily Census Los Angeles County+USC Medical Center 1022 685 628 Harbor–UCLA Medical Center 570 332 355 Rancho Los Amigos Rehabilitation Center 395 147 140 Olive View Medical Center 377 195 196 The Centers provide a wide variety of services: LAC+USC is the largest single provider of health care in Los Angeles County, providing a full spectrum of emergency, inpatient and outpatient services. LAC+USC provides the community with more than 28% of its trauma care. It operates one of three burn centers in the County and one of the few Level III Neonatal Intensive Care Units in Southern California. It provides care for one-half of both AIDS patients and sickle cell anemia patients in Southern California. RLA is one of the largest comprehensive rehabilitation centers in the United States. Harbor-UCLA is a Level 1 Trauma Center with an NIH-funded General Clinical Research Center. The 72-acre facility is composed of the 8-story Hospital, and a 52,000 square foot Primary Care and Diagnostic Center. Olive View is an acute care Hospital. Table 3 includes the list of services provided at each Center. 2006-2007 County of Los Angeles Civil Grand Jury 24 Table 3: Specialty Services Provided Hospital ER OR Oncology ICU Neo-Natal Los Angeles County+USC Medical Center X X X X X Harbor – UCLA Medical Center X X X X X Rancho Los Amigos Rehabilitation Center
R11:
DHS should recognize best practices implemented at one facility, and replicate them system-wide. The best practice of Structured Physician Order Forms with block lettering spaces, currently in place at Harbor/UCLA Medical Center, should be implemented at all County Hospitals. Introducing these forms system-wide is a low-cost and low-risk item for DHS. In addition, if one or more Hospitals identify a certain medication as high risk, all Hospitals should similarly categorize that medication as high risk absent a compelling reason to the contrary. Successful best practice programs often include regular reporting on best practices at senior staff meetings, and development of tracking mechanisms for implementation of the changes.
R12:
Patient Safety and the Just Culture: County of Los Angeles DHS
R13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
R14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
R15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
R16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
R17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 44
R18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
R22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
R24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
R25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
R26:
Pharmacy Utilization Report for FY 2006-2007
R27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
R28:
The Just Culture Algorithm
R29:
“Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007
R30:
“Med Errors = Bad Outcomes”, Nurse Week, April 2007
R31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
R32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
R33:
Managing Medication Related Events: PowerPoint Presentation
R34:
Medication Management Process in Valley Care – PowerPoint Presentation
R35:
LAC+USC Chemotherapy Physicians Orders
R36:
LAC+USC Daily Physicians Orders – Adult Critical Care
R37:
LAC+USC Neonate Continuous Infusion Orders
R38:
LAC+USC Neonate Continuous Infusion Recipes
R39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
R40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
R41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
R42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
R43:
LAC+USC HealthCare Network Policy: Medication Usage
R44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
R45:
List of High-Alert Medications
R46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 45
R47:
LAC+USC Drug Bulletin June 2006
R48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
R49:
Intervention Summary Report
R50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
R51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
R52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
R53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
R54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
R55:
Harbor-UCLA – Patient Safety Bulletin October 2003
R56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
R57:
Los Angeles County DHS Lipid Management Algorithm
R58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
R59:
Wikepedia: Medical Error
R60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
R61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
R62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
R63:
Harbor-UCLA MAR Sample
R64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
R65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
R66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
R67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
R68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
R69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
R70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
R71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
R72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
R73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
R74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
R75:
LA County DHS Class Specification; Director of Pharmacy Services
R76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
R77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 46
R78:
DHS Pharmacy Leadership Program description
R79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
R80:
DHS Pharmacy Leadership Program proposal
R81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 47 JUVENILE CUSTODIES - ARE WE PAYING TWICE?
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Findings & Recommendations
79 findings
F1:
DHS central staff Directors have established spheres of influence when working with the Hospitals, but they lack formal authority relationships and audit functions Current relationships are built on trust and collegiality and judicious use of staff authority. The authority has not encompassed all the oversight provisions included in the Job Specification for the Director, Pharmacy Services. The Director, Pharmacy Services, reports to the Departmental Chief Medical Officer. The Director, Pharmacy Services, participates in and provides staff support for major committees, including the DHS Core Pharmacy and Therapeutics Committee, the DHS Pharmacy Director’s Committee, and the DHS Pharmacy Information Systems Committee. The incumbent has been effective in funding and generating agreement about implementation of new technology. This assignment of responsibility and chain of command through the Chief Medical Officer appropriately reflects the need for central direction for the Hospitals. Nevertheless, the Hospitals do not share the full reports of all Medication Errors, which are essential for the Director to understand overall Pharmacy Performance and needed interventions. In addition, there is no formally developed Audit Schedule to review conformance with Departmental policies associated with ordering, distributing, and administering medication.
F2:
Investments in technology can result in significant reductions in medication error risks. Automated medication dispensing cabinets have proven themselves to be a good, if substantial, investment. Where they have been put into use, Hospital staff members report that errors have fallen, and the dispensing process has become more efficient. Similar results are projected for pharmacy medication carousels. Bar coding systems offer the prospect of a new level of patient medication safety that has heretofore been unavailable. A pre-requisite for the success of these systems is the implementation of standards for bar code systems across the industry. IV Smart Pumps also add a new level of medication error reduction by highlighting delivery rates or concentrations that fall outside standard parameters. Smart Pumps allow for programming of standard concentrations of IV medications, removing the burden of the unit nursing staff having to calculate flow rates, thereby eliminating an additional potential source of error. The implementation of new technology has rendered information technology staff ever more vital to Hospital operations. The medication use systems assessed here are highly dependent on contractors and internal staff members for installation, staff training, and system maintenance. The systems are expanding in both scope and complexity. DHS is aware of this issue. DHS’s Chief Information Officer (CIO) has prepared a business plan that outlines the resource needs he expects to face immediately and for several years into the future. Work remains to gain the funding needed to offer competitive salaries and deploy staff at the Hospitals.
F3:
Olive View Medical Center processes appear to be incompatible with realization of ADC benefits. Olive View’s description of its plans to install ADCs is not consistent with the approaches used by other Hospitals. Its current systems include pneumatic tube distribution of medications. Citing space limitations on the floors, Olive View staff members are designing plans that limit access to the ADCs, which limits its advantage of allowing nursing staff complete access to regular medications while maintaining controls over controlled substances. During the site visit to Olive View, it was not conclusively demonstrated that patients’ identities are always recorded on medical records before medical orders are written. There was some evidence that the patient’s last name was being written by hand on the initial order sets and then covered with a printed label. This is not a best practice, and it affords a clear opportunity for medication error, as it is possible for the order to refer to the wrong patient. When questioned about the practice, Olive View staff denied that this was the case. The denial, in fact, is more disturbing than the practice itself, since it suggests a defensiveness that could cover other errors or weaknesses. A single site visit should not be considered conclusive, and is not in itself sufficient grounds for action. It is, however, sufficient to support a review of current medication orders, dispensing, and administration to ensure that the Hospital is fully prepared to implement a more automated pharmacy system.
F4:
Electronic Health Records (EHRs) and Computerized Physician Order Entry, when properly implemented, are best practices to reduce medication error. Computerized Physician Order Entry (CPOE) has been successfully implemented in several regional hospitals. It is difficult and expensive to do. It requires extensive planning, a significant investment, and careful building of internal acceptance. Executive management must make the commitment to CPOE and consistently let people know that it will be implemented – especially when thorny issues arise or the system shows difficult growing pains. A pre-requisite for its success is the implementation of EHRs, which are currently being planned in DHR. CPOE, difficult as it is to implement, is worth the trouble. It eliminates a transcription step that generates errors. It eliminates illegible orders and unapproved abbreviations. Wrong dose and wrong drug errors are reduced. Data can be easily collected for evidence-based clinical paths, considered a best practice. Physician orders, including medication orders, can be transmitted to the responsible parties instantly. Medical records can be shared between facilities and programs, making it much faster and easier to assess patients accurately, and all but eliminating the “shopping” of medical services by patients. Productivity, quality of care, and patient safety all advance. DHS has been wise in the order of technology implementation. The technologies described in this report are well-proven innovations that impact patient safety. After the installation of Automated Pharmacy Systems, assignment of Clinical Pharmacists, acquisition of IV Smart Pumps and bar coding of medications are complete, EHRs and CPOE appear to be the next major steps in reducing the risk of medication errors.
F5:
Clinical Pharmacists are effective in reducing medication error risks. Clinical Pharmacists spend time as part of patient care teams, consulting with Physicians and the remainder of the team on the units and during rounds. They provide drug information, recommend dosage adjustments, respond to questions from nursing staff, and make suggestions regarding initiation of drug therapy. All of these activities relieve stress on the Physicians and other clinicians who must sometimes make rapid decisions about patient care in difficult circumstances. This improves the quality and speed of the decisions and reduces the likelihood of medication errors.
F6:
24-hour Pharmacist coverage is important to Patient Safety. A Pharmacist is needed on-site for in-patient care on a 24/7 basis, particularly for acute patients. If a Pharmacist is not available, a comparatively slow and cumbersome process of faxes and telephone calls to Pharmacists at home is required. A “night locker” must be maintained, under the control of a Senior Nurse. If a medication is needed that is not in the night locker, a Pharmacist must be called in from home to open the main pharmacy and dispense it. The primary disadvantage of the process is that it is not fast, and the circumstances that give rise to overnight medication orders are likely to demand prompt action. There are also evident weaknesses in the processes for the checking of medications against orders. Finally, tired Pharmacists are expected to perform their day shifts, even when their sleep is interrupted. In all professions, errors usually increase when people become sleep-deprived. Some smaller hospitals cannot support a 24-hour pharmacy. These hospitals are adopting the capabilities of automated prescription transmission, which involves scanning medication orders to a Pharmacist for verification and approval. The Pharmacist can then release the medication from the ADC at the smaller facility. 2006-2007 County of Los Angeles Civil Grand Jury 37
F7:
It is a common practice to conduct pre-employment drug testing among staff involved in the health care professions. DHS does not do this. Drug screening and random drug testing are common means of ensuring security and safety in a wide variety of sensitive business and government operations. A number of hospitals use them. Failure to conduct screening and testing exposes patients to a potential risk of not receiving prescribed medication (if an addicted employee substitutes a placebo for the particular drug), and increases the potential risk of medication errors when impaired staff members prescribe, approve, distribute, and administer medications. This is a known risk in an environment where staff members sometimes work long hours, and where there is ample knowledge of the “right” mix of drugs to take to stay alert.
F8:
A “Safe and Just” culture is essential to accurate reporting of errors – including medication errors – as well as to the rapid and effective response to error trends. A survey undertaken by DHS in December 2005 showed disturbingly high levels of concern among both Nurses and attending Physicians that errors would be held against them. Nurses also expressed high levels of concern that errors would be kept in their personnel files. Some of this concern may be traced to a long-standing policy in which managers close out reports of all types of medication errors by indicating that an employee was “counseled about the incident”. That is the first step in the County’s standard progressive discipline process. In that process, managers are advised to keep a permanent record of the counseling action for use as needed in ensuing sanctions for further errors. In April 2006, DHS engaged a contractor to deliver a training workshop, entitled “Patient Safety and the Just Culture”. It appears to have been intended to address the issue of a punitive culture by advocating a culture in which acknowledgement that errors are human and inevitable is balanced by a strong sense of professionalism and “zero tolerance” for medication errors. Before punitive actions are taken when a rule is broken or mistake is made, a Just Culture would consider: h Whether the employee knowingly violated the rule h Whether there was a compelling reason to violate the rule h Whether the employee had a good faith but mistaken belief that the violation was justified or insignificant h Whether the source of the error resided within the system or was behavioral. Based on answers to such questions, the response would vary from counseling to training to revising procedures. Perceptions of an unjust culture are crippling to any attempt to encourage the self-reporting of Category A, B and C errors, in which no measurable harm comes to a patient. If Physicians and Nurses fear retribution, they will be significantly less likely to self-report errors that have little measurable impact. DHS’s efforts to counter them are laudable, but it seems likely that they have not been sufficient. Further surveys were not available, but anecdotal evidence suggests that negative perceptions have proved to be persistent.
F9:
There is insufficient consistent, Department-wide medication error trend analysis. The identification of trends within overall medication error rates is key to reducing them. The Hospitals do some analysis now, although they do not all follow the same guidelines; and their analysis appears to be limited at times by a lack of formal training for some Hospital Risk Management staff members. For the past year-and-a-half, data have been gathered in a nationwide system run by the University HealthSystem Consortium, which permits sophisticated analysis of errors. There has been insufficient consistent reporting and analysis to take advantage of that capability. While some errors occur only within one Hospital, others may be related to overall policies, training regimens, or technology systems across the County. These error trends should be identified and corrected; this can only be done if errors are reported and analyzed consistently across the County. In addition, such a function will serve to protect the Hospitals against the possibility that a medication error trend may be missed at the Hospital level. Recently, DHS has developed a “Report Card” which tracks high level trend data. It is a good beginning, but needs additional development.
F10:
The number of errors in UHC-PSN Categories A-C is less than expected, and raises the possibility that they are not fully self-reported. A review of reported errors shows few reported errors in the A and B1 categories for all four Hospitals in the six months ending March 31, 2007. The total errors reported for “no patient harm” categories (A, B1, B2, C) were low, considering there were over 300,000 patient days at Harbor-UCLA, Olive View, and RLA, where many patients have multiple medications. Given the number of reported errors in other categories over the same period, this does not appear logical. It is understandable that staff members who make lower category errors are sometimes reluctant to report them. Even in a non-punitive atmosphere, it is easy to see that a staff member would be reluctant to report a minor mishap, such as picking up an improper medication from a shelf, noticing it immediately, and replacing it before gathering up a proper medication. This is how major trends are identified that lead to, for example, separating look alike/sound alike medications. For errors in Categories B1 and B2, the patient receives no improper medications. Self-reporting is the only source of data. Responsible staff noted that the system used to track medication errors and pharmacy interventions is very cumbersome to use, further discouraging reporting of errors. This possible underreporting is important, because identifying errors that do not result in patient harm can point the way to weaknesses in the system that pose the potential for more serious adverse events.
F11:
DHS does not have a regular practice of replicating the best practices implemented from one facility to another. As an example, Harbor-UCLA has implemented Structured Physician Order Forms for admissions and transfers requiring the use of block lettering to reduce cases of illegibility. These forms significantly reduce a broad range of medication order errors, including illegible orders, unapproved abbreviations, dosage errors, and “wrong drug” errors. The Structured Physician Order Forms are considered successful where they are now used. The balance of DHS facilities does not use block lettering on these forms. As another example, Olive View does not recognize the same medications as high risk as the other Hospitals. These are examples of processes that are low-cost and can be relatively easily implemented, as contrasted with implementation of ADCs and bar coding technology.
F12:
Patient Safety and the Just Culture: County of Los Angeles DHS
F13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
F14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
F15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
F16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
F17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 44
F18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
F22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
F24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
F25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
F26:
Pharmacy Utilization Report for FY 2006-2007
F27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
F28:
The Just Culture Algorithm 29. “Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007 30. “Med Errors = Bad Outcomes”, Nurse Week, April 2007
F31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
F32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
F33:
Managing Medication Related Events: PowerPoint Presentation
F34:
Medication Management Process in Valley Care – PowerPoint Presentation
F35:
LAC+USC Chemotherapy Physicians Orders
F36:
LAC+USC Daily Physicians Orders – Adult Critical Care
F37:
LAC+USC Neonate Continuous Infusion Orders
F38:
LAC+USC Neonate Continuous Infusion Recipes
F39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
F40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
F41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
F42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
F43:
LAC+USC HealthCare Network Policy: Medication Usage
F44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
F45:
List of High-Alert Medications
F46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 45
F47:
LAC+USC Drug Bulletin June 2006
F48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
F49:
Intervention Summary Report
F50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
F51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
F52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
F53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
F54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
F55:
Harbor-UCLA – Patient Safety Bulletin October 2003
F56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
F57:
Los Angeles County DHS Lipid Management Algorithm
F58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
F59:
Wikepedia: Medical Error
F60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
F61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
F62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
F63:
Harbor-UCLA MAR Sample
F64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
F65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
F66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
F67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
F68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
F69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
F70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
F71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
F72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
F73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
F74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
F75:
LA County DHS Class Specification; Director of Pharmacy Services
F76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
F77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 46
F78:
DHS Pharmacy Leadership Program description
F79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
F80:
DHS Pharmacy Leadership Program proposal
F81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 47 JUVENILE CUSTODIES - ARE WE PAYING TWICE?
Additional Recommendations
81
Not linked to specific findings.
R1:
DHS central staff Directors have established spheres of influence when working with the Hospitals, but they lack formal authority relationships and audit functions. The Director, Pharmacy Services, should be entrusted with the authority to carry out medication error risk, performance audits and business process reviews. 2006-2007 County of Los Angeles Civil Grand Jury 22 #
R2:
Investments in technology can result in significant reductions in medication error risks. DHS should invest in medication management technology improvements, using life cycle costing that accounts for acquisition, installation, and maintenance of equipment. Funding for these investments should be drawn in part from medication cost savings such as those attributable to improved acquisition management. 3.
R3:
As part of the implementation of ADCs at Olive View, DHS should review the complete medication order, delivery, and administration process to ensure that both the baseline process and the plan to strengthen it with ADC technology are sound. As stated in the finding supporting this recommendation, it is not clear that the processes at Olive View are as strong as those in place at sister County Hospitals. It is an axiom of technology implementation that, if the underlying processes are not completely sound, the application of technology may well make matters worse rather than better. As part of the implementation of the ADC System, the in-patient medication processes at Olive View, from prescription through 2006-2007 County of Los Angeles Civil Grand Jury 34 ordering, dispensing, and administration should be subject to a thorough peer review. This peer review should:
R4:
DHS should begin now to plan for the implementation of CPOE and EHRs. DHS should convene an inter-disciplinary team charged with: a) researching current technology, b) developing specifications and cost estimates, and c) designing implementation plans for CPOE systems that will one day serve all County medical facilities. The team should set milestones to complete research, identify preferred technologies, address implementation issues, identify offsetting savings, and submit budget requests. This is a multi-year, multi-million dollar effort. There may be physician resistance within the Hospitals that needs to be addressed and overcome. There will also be training and retraining issues. There are several interim steps that are being taken that will support the development of DHS-wide systems. Currently, Lab Directors are standardizing nomenclature across the Department for common tests in anticipation of the need to be able to share test results for a patient that visits multiple hospitals. 2006-2007 County of Los Angeles Civil Grand Jury 35 PEOPLE
R5:
0: DHS should expand the number of Clinical Pharmacists, institute a Clinical Coordinator position at each Hospital, and use Tech-Check-Tech processes to free Pharmacists to perform other pharmaceutical duties
R6:
DHS should immediately establish a 24-hour Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication. Olive View Medical Center is of sufficient size and structure to warrant a 24-hour pharmacy. While they recognize the advantages of 24/7 coverage, staff at Olive View cite the difficulty of hiring Pharmacists to work this demanding shift. It is a hurdle to be overcome rather than an insurmountable obstacle, and Olive View should work with Department of Human Resources staff to develop incentives sufficient to attract night shift pharmacists or retain pharmacists when night shifts become a requirement. Olive View is too far removed from other medical facilities to seriously consider a partnering solution. Its patient census and the existence of an emergency room indicate that there is sufficient demand for constant staffing. Rancho Los Amigos, as a rehabilitation facility, has a different patient profile, and has historically seen fewer demands for after-hours pharmacy. This may be changing. DHS should monitor off-hours pharmacy demands on a regular basis, and consider partnering with other DHS facilities or other plans to ensure coverage.
R7:
The County should implement pre-employment drug screening and should develop a targeted program to provide for early identification and treatment of substance abuse among staff with access to controlled medications Pre-employment screening will reduce the risk of hiring individuals who are addicted to narcotics or other drugs. In addition, a program should be developed, modeled on best practices, that include training managers to recognize problems associated with drug abuse, referrals to Employee Assistance Programs, development of reporting mechanisms that identify patterns of abuse, and testing for drugs with a lower threshold of evidence than for other County staff. The program should be modeled on best practices which provide for confidentiality of results, automatic retesting of positive results, counseling, and, where needed, recovery programs. This program is not, at heart, different from ensuring that medical staff members do not have chronic infectious diseases. 2006-2007 County of Los Angeles Civil Grand Jury 38
R8:
0: DHS should strengthen its “Safe and Just” culture.
R9:
elaborates on process changes required to implement changes to sharing these reports. 2006-2007 County of Los Angeles Civil Grand Jury 32 TECHNOLOGY
R10:
The number of minor errors causing no patient harm (Category A - C in University HealthSystem Consortium – the Patient Safety Net) is less than expected, and raises the possibility that they are not fully self-reported. DHS should consider establishing Nurse “Naïve Observation” auditing to reduce dependency on self-reporting for medication errors. 11. DHS does not have a regular practice of replicating the best practices implemented from one facility to another. DHS should recognize best practices implemented at one facility, and replicate them system-wide. II – HISTORY AND BACKGROUND HOSPITALS’ BACKGROUND The Los Angeles County Department of Health Services (DHS) operates four major hospitals, Harbor-UCLA Medical Center (Harbor-UCLA), Los Angeles County+USC Medical Center (LAC+USC), Rancho Los Amigos Rehabilitation Center (RLA), and Olive View Medical Center (Olive View). Together, they provide more than 300,000 patient days of care annually. Table 2: Size of Hospitals # of Beds Hospital Licensed Budgeted Average Daily Census Los Angeles County+USC Medical Center 1022 685 628 Harbor–UCLA Medical Center 570 332 355 Rancho Los Amigos Rehabilitation Center 395 147 140 Olive View Medical Center 377 195 196 The Centers provide a wide variety of services: LAC+USC is the largest single provider of health care in Los Angeles County, providing a full spectrum of emergency, inpatient and outpatient services. LAC+USC provides the community with more than 28% of its trauma care. It operates one of three burn centers in the County and one of the few Level III Neonatal Intensive Care Units in Southern California. It provides care for one-half of both AIDS patients and sickle cell anemia patients in Southern California. RLA is one of the largest comprehensive rehabilitation centers in the United States. Harbor-UCLA is a Level 1 Trauma Center with an NIH-funded General Clinical Research Center. The 72-acre facility is composed of the 8-story Hospital, and a 52,000 square foot Primary Care and Diagnostic Center. Olive View is an acute care Hospital. Table 3 includes the list of services provided at each Center. 2006-2007 County of Los Angeles Civil Grand Jury 24 Table 3: Specialty Services Provided Hospital ER OR Oncology ICU Neo-Natal Los Angeles County+USC Medical Center X X X X X Harbor – UCLA Medical Center X X X X X Rancho Los Amigos Rehabilitation Center
R11:
DHS should recognize best practices implemented at one facility, and replicate them system-wide. The best practice of Structured Physician Order Forms with block lettering spaces, currently in place at Harbor/UCLA Medical Center, should be implemented at all County Hospitals. Introducing these forms system-wide is a low-cost and low-risk item for DHS. In addition, if one or more Hospitals identify a certain medication as high risk, all Hospitals should similarly categorize that medication as high risk absent a compelling reason to the contrary. Successful best practice programs often include regular reporting on best practices at senior staff meetings, and development of tracking mechanisms for implementation of the changes.
R12:
Patient Safety and the Just Culture: County of Los Angeles DHS
R13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
R14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
R15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
R16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
R17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 44
R18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
R22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
R23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
R24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
R25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
R26:
Pharmacy Utilization Report for FY 2006-2007
R27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
R28:
The Just Culture Algorithm
R29:
“Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007
R30:
“Med Errors = Bad Outcomes”, Nurse Week, April 2007
R31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
R32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
R33:
Managing Medication Related Events: PowerPoint Presentation
R34:
Medication Management Process in Valley Care – PowerPoint Presentation
R35:
LAC+USC Chemotherapy Physicians Orders
R36:
LAC+USC Daily Physicians Orders – Adult Critical Care
R37:
LAC+USC Neonate Continuous Infusion Orders
R38:
LAC+USC Neonate Continuous Infusion Recipes
R39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
R40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
R41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
R42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
R43:
LAC+USC HealthCare Network Policy: Medication Usage
R44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
R45:
List of High-Alert Medications
R46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 45
R47:
LAC+USC Drug Bulletin June 2006
R48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
R49:
Intervention Summary Report
R50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
R51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
R52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
R53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
R54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
R55:
Harbor-UCLA – Patient Safety Bulletin October 2003
R56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
R57:
Los Angeles County DHS Lipid Management Algorithm
R58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
R59:
Wikepedia: Medical Error
R60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
R61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
R62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
R63:
Harbor-UCLA MAR Sample
R64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
R65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
R66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
R67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
R68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
R69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
R70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
R71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
R72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
R73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
R74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
R75:
LA County DHS Class Specification; Director of Pharmacy Services
R76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
R77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 46
R78:
DHS Pharmacy Leadership Program description
R79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
R80:
DHS Pharmacy Leadership Program proposal
R81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 47 JUVENILE CUSTODIES - ARE WE PAYING TWICE?
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Full Details →
Findings & Recommendations
79 findings
F1:
Patient and Family Handbook; Rancho Los Amigos
F2:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Summary Report on Medication Error Related Events, February 2007
F3:
Inpatient Pharmacist Interventions; March 2007
F4:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Medication Errors Reported per 1,000 Doses Dispensed August 2003 – February 2007
F5:
Clinical Pharmacists are effective in reducing medication error risks. Clinical Pharmacists spend time as part of patient care teams, consulting with Physicians and the remainder of the team on the units and during rounds. They provide drug information, recommend dosage adjustments, respond to questions from nursing staff, and make suggestions regarding initiation of drug therapy. All of these activities relieve stress on the Physicians and other clinicians who must sometimes make rapid decisions about patient care in difficult circumstances. This improves the quality and speed of the decisions and reduces the likelihood of medication errors.
F6:
24-hour Pharmacist coverage is important to Patient Safety. A Pharmacist is needed on-site for in-patient care on a 24/7 basis, particularly for acute patients. If a Pharmacist is not available, a comparatively slow and cumbersome process of faxes and telephone calls to Pharmacists at home is required. A “night locker” must be maintained, under the control of a Senior Nurse. If a medication is needed that is not in the night locker, a Pharmacist must be called in from home to open the main pharmacy and dispense it. The primary disadvantage of the process is that it is not fast, and the circumstances that give rise to overnight medication orders are likely to demand prompt action. There are also evident weaknesses in the processes for the checking of medications against orders. Finally, tired Pharmacists are expected to perform their day shifts, even when their sleep is interrupted. In all professions, errors usually increase when people become sleep-deprived. Some smaller hospitals cannot support a 24-hour pharmacy. These hospitals are adopting the capabilities of automated prescription transmission, which involves scanning medication orders to a Pharmacist for verification and approval. The Pharmacist can then release the medication from the ADC at the smaller facility. 2006-2007 County of Los Angeles Civil Grand Jury 36
F7:
It is a common practice to conduct pre-employment drug testing among staff involved in the health care professions. DHS does not do this. Drug screening and random drug testing are common means of ensuring security and safety in a wide variety of sensitive business and government operations. A number of hospitals use them. Failure to conduct screening and testing exposes patients to a potential risk of not receiving prescribed medication (if an addicted employee substitutes a placebo for the particular drug), and increases the potential risk of medication errors when impaired staff members prescribe, approve, distribute, and administer medications. This is a known risk in an environment where staff members sometimes work long hours, and where there is ample knowledge of the “right” mix of drugs to take to stay alert.
F8:
A “Safe and Just” culture is essential to accurate reporting of errors – including medication errors – as well as to the rapid and effective response to error trends. A survey undertaken by DHS in December 2005 showed disturbingly high levels of concern among both Nurses and attending Physicians that errors would be held against them. Nurses also expressed high levels of concern that errors would be kept in their personnel files. Some of this concern may be traced to a long-standing policy in which managers close out reports of all types of medication errors by indicating that an employee was “counseled about the incident”. That is the first step in the County’s standard progressive discipline process. In that process, managers are advised to keep a permanent record of the counseling action for use as needed in ensuing sanctions for further errors. In April 2006, DHS engaged a contractor to deliver a training workshop, entitled “Patient Safety and the Just Culture”. It appears to have been intended to address the issue of a punitive culture by advocating a culture in which acknowledgement that errors are human and inevitable is balanced by a strong sense of professionalism and “zero tolerance” for medication errors. Before punitive actions are taken when a rule is broken or mistake is made, a Just Culture would consider: Whether the employee knowingly violated the rule (cid:104) Whether there was a compelling reason to violate the rule (cid:104) Whether the employee had a good faith but mistaken belief that the violation (cid:104) was justified or insignificant Whether the source of the error resided within the system or was behavioral. (cid:104) Based on answers to such questions, the response would vary from counseling to training to revising procedures. Perceptions of an unjust culture are crippling to any attempt to encourage the self-reporting of Category A, B and C errors, in which no measurable harm comes to a patient. If Physicians and Nurses fear retribution, they will be significantly less likely to self-report errors that have little measurable impact. DHS’s efforts to counter them are laudable, but it seems likely that they have not been sufficient. Further surveys were not available, but anecdotal evidence suggests that negative perceptions have proved to be persistent.
F9:
There is insufficient consistent, Department-wide medication error trend analysis. The identification of trends within overall medication error rates is key to reducing them. The Hospitals do some analysis now, although they do not all follow the same guidelines; and their analysis appears to be limited at times by a lack of formal training for some Hospital Risk Management staff members. For the past year-and-a-half, data have been gathered in a nationwide system run by the University HealthSystem Consortium, which permits sophisticated analysis of errors. There has been insufficient consistent reporting and analysis to take advantage of that capability. While some errors occur only within one Hospital, others may be related to overall policies, training regimens, or technology systems across the County. These error trends should be identified and corrected; this can only be done if errors are reported and analyzed consistently across the County. In addition, such a function will serve to protect the Hospitals against the possibility that a medication error trend may be missed at the Hospital level. Recently, DHS has developed a “Report Card” which tracks high level trend data. It is a good beginning, but needs additional development.
F10:
The number of errors in UHC-PSN Categories A-C is less than expected, and raises the possibility that they are not fully self-reported. A review of reported errors shows few reported errors in the A and B1 categories for all four Hospitals in the six months ending March 31, 2007. The total errors reported for “no patient harm” categories (A, B1, B2, C) were low, considering there were over 300,000 patient days at Harbor-UCLA, Olive View, and RLA, where many patients have multiple medications. Given the number of reported errors in other categories over the same period, this does not appear logical. It is understandable that staff members who make lower category errors are sometimes reluctant to report them. Even in a non-punitive atmosphere, it is easy to see that a staff member would be reluctant to report a minor mishap, such as picking up an improper medication from a shelf, noticing it immediately, and replacing it before gathering up a proper medication. This is how major trends are identified that lead to, for example, separating look alike/sound alike medications. For errors in Categories B1 and B2, the patient receives no improper medications. Self-reporting is the only source of data. Responsible staff noted that the system used to track medication errors and pharmacy interventions is very cumbersome to use, further discouraging reporting of errors. This possible underreporting is important, because identifying errors that do not result in patient harm can point the way to weaknesses in the system that pose the potential for more serious adverse events.
F11:
DHS does not have a regular practice of replicating the best practices implemented from one facility to another. As an example, Harbor-UCLA has implemented Structured Physician Order Forms for admissions and transfers requiring the use of block lettering to reduce cases of illegibility. These forms significantly reduce a broad range of medication order errors, including illegible orders, unapproved abbreviations, dosage errors, and “wrong drug” errors. The Structured Physician Order Forms are considered successful where they are now used. The balance of DHS facilities does not use block lettering on these forms. As another example, Olive View does not recognize the same medications as high risk as the other Hospitals. These are examples of processes that are low-cost and can be relatively easily implemented, as contrasted with implementation of ADCs and bar coding technology.
F12:
Patient Safety and the Just Culture: County of Los Angeles DHS
F13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
F14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
F15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
F16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
F17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 43
F18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
F22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
F24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
F25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
F26:
Pharmacy Utilization Report for FY 2006-2007
F27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
F28:
The Just Culture Algorithm 29. “Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007 30. “Med Errors = Bad Outcomes”, Nurse Week, April 2007
F31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
F32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
F33:
Managing Medication Related Events: PowerPoint Presentation
F34:
Medication Management Process in Valley Care – PowerPoint Presentation
F35:
LAC+USC Chemotherapy Physicians Orders
F36:
LAC+USC Daily Physicians Orders – Adult Critical Care
F37:
LAC+USC Neonate Continuous Infusion Orders
F38:
LAC+USC Neonate Continuous Infusion Recipes
F39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
F40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
F41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
F42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
F43:
LAC+USC HealthCare Network Policy: Medication Usage
F44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
F45:
List of High-Alert Medications
F46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 44
F47:
LAC+USC Drug Bulletin June 2006
F48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
F49:
Intervention Summary Report
F50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
F51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
F52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
F53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
F54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
F55:
Harbor-UCLA – Patient Safety Bulletin October 2003
F56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
F57:
Los Angeles County DHS Lipid Management Algorithm
F58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
F59:
Wikepedia: Medical Error
F60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
F61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
F62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
F63:
Harbor-UCLA MAR Sample
F64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
F65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
F66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
F67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
F68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
F69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
F70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
F71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
F72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
F73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
F74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
F75:
LA County DHS Class Specification; Director of Pharmacy Services
F76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
F77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 45
F78:
DHS Pharmacy Leadership Program description
F79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
F80:
DHS Pharmacy Leadership Program proposal
F81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 46 JUVENILE CUSTODIES - ARE WE PAYING TWICE? EXECUTIVE SUMMARY State law requires that whenever a minor is in custody in a juvenile hall or other county juvenile facility for thirty consecutive days, the county welfare agency needs to be informed. The law requires that the welfare department determine whether these minors are part of a family receiving cash aid benefits and, if so, make reductions in the family’s aid payments to reflect the period of time the minor received care in the facility. Yet, there appears to be no liaisons between these agencies to share information and to stop the cash aid. The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and budget of $630 million. Costs of an individual minor in custody are approaching $200 a day. The Department does a financial screening of the parents or other responsible relative and bills for the cost of care. If the family is receiving financial assistance, the family is not billed; this information should be sent to the welfare agencies. The welfare agencies in Los Angeles County are the Department of Public Social Services and the Department of Children and Family Services. DPSS has over a million clients and over 13,000 employees. There is no direct supervision of the individuals receiving the cash aid and the agency relies on self reporting to find out when a child is no longer residing in the home. DCFS monitors families directly and should have knowledge of where a child is residing. Recent legislation prohibits simultaneous or duplicative case management or services provided by the county probation department and the child welfare services department. The recommendations are designed to co-ordinate county agencies so that they will be in compliance with state law. The lack of communication between the Probation Department and the public assistance agencies may result in replicated support for the same minor. If there is no “Stop Order” issued in a timely manner, or not issued at all, it may take months for funding to be halted and realize that substantial taxpayer funds may be wasted. DPSS, DCFS and Probation need to work together and implement an information sharing process. Probation needs to inform the child support agencies when a minor is in custody for thirty days. A protocol needs to be developed to avoid replicate funding. If payments are not discontinued or unjustified payments are made, attempts should be made to recover such overpayments. The Probation Department’s responsibility is to expeditiously complete the financial screening of the family and communicate this information to the appropriate agencies. HISTORY The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and a budget of $6301 million. The size and transient nature of the custodies underscores the responsibility and diverse services required of the Department while adhering to the myriad federal, state and local laws. Within this oversight they must provide medical care, mental health, education, behavioral rehabilitation and be involved with any other agency 2006-2007 County of Los Angeles Civil Grand Jury 47 providing care for a minor’s custody. Within this area lies a responsibility to report to the supportive agencies (DPSS and DCFS) to prevent replication of costs for those minors adjudicated and sentenced to juvenile hall, camps or probation group homes. California’s Welfare and Institutions Codes Sections 900-914 covers the above issues. With the cost of maintaining a minor in custody spiralling upwards, approaching $200 a day1, there is a need to address the lack of communication and oversight between supportive services and the Probation Department. Due to the layering of department and service providers, it is difficult to pinpoint who is charged with this reporting and at what point the information should be submitted. There is no statistical data available for the numbers of minors coming from DCFS funded units, group homes and foster care, or from DPSS comprised of CALWORKS funded units. Along with DPSS funding is the availability of food stamps, medical care, housing assistance and childcare, all of which is based on the number of individuals residing in the unit. PURPOSE In accordance with California Welfare and Institution Codes Sections 900-914 when minors are placed in the custody of the Juvenile Probation Department for thirty days or more, any agency providing funding for that minor must be notified so as to terminate funding for that minor. This notification ensures that the taxpayers are not paying twice for the minor’s care and support while being held. The investigation attempted to: • Determine what mechanism is in place to avoid funding of minors in custody when their homes are simultaneously receiving support from various social service agencies. • Identify the appropriate mechanism to be implemented to stop the replication of funding. • To determine what agencies are involved and who is responsible for triggering that mechanism. • Recover any monies that have been inappropriately paid, creating a duplicated taxpayer support of the minor in custody. • Make sure measures are in place to aggressively seek reimbursement of overpaid funding. Probation Department, Administrative Services, 5/1/07 2006-2007 County of Los Angeles Civil Grand Jury 48
Additional Recommendations
11
Not linked to specific findings.
R1:
Federal, state and local law and policy issues Some other California counties have had better success in information sharing. Los 2006-2007 County of Los Angeles Civil Grand Jury 57 Angeles County has recently adopted an interagency Memorandum of Understanding stating that DCFS and DHS will develop protocols to improve data sharing.
R2:
Information technology issues Existing systems within DCFS and DHS do not enable information sharing. Development of new systems that could facilitate this sharing is lagging.
R3:
Interdepartmental collaboration, information sharing and the HUB clinics While such limited approaches as multidisciplinary teams (combining several technical and social workers) and HUB clinics (specializing in services for abused and neglected children) have represented some improvement in care, there is a need for enhanced management oversight of the two departments coordination and information sharing.
R4:
Public health nurses Public Health Nurses represent an improvement in the care of some children, but their effectiveness is limited by the inadequate access to patient records and the fact that their management is divided (half report to the Department of Public Health, half to the Department of Children and Family Services).
R5:
0: DHS should expand the number of Clinical Pharmacists, institute a Clinical Coordinator position at each Hospital, and use Tech-Check-Tech processes to free Pharmacists to perform other pharmaceutical duties
R6:
DHS should immediately establish a 24-hour Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication. Olive View Medical Center is of sufficient size and structure to warrant a 24-hour pharmacy. While they recognize the advantages of 24/7 coverage, staff at Olive View cite the difficulty of hiring Pharmacists to work this demanding shift. It is a hurdle to be overcome rather than an insurmountable obstacle, and Olive View should work with Department of Human Resources staff to develop incentives sufficient to attract night shift pharmacists or retain pharmacists when night shifts become a requirement. Olive View is too far removed from other medical facilities to seriously consider a partnering solution. Its patient census and the existence of an emergency room indicate that there is sufficient demand for constant staffing. Rancho Los Amigos, as a rehabilitation facility, has a different patient profile, and has historically seen fewer demands for after-hours pharmacy. This may be changing. DHS should monitor off-hours pharmacy demands on a regular basis, and consider partnering with other DHS facilities or other plans to ensure coverage.
R7:
The County should implement pre-employment drug screening and should develop a targeted program to provide for early identification and treatment of substance abuse among staff with access to controlled medications Pre-employment screening will reduce the risk of hiring individuals who are addicted to narcotics or other drugs. In addition, a program should be developed, modeled on best practices, that include training managers to recognize problems associated with drug abuse, referrals to Employee Assistance Programs, development of reporting mechanisms that identify patterns of abuse, and testing for drugs with a lower threshold of evidence than for other County staff. The program should be modeled on best practices which provide for confidentiality of results, automatic retesting of positive results, counseling, and, where needed, recovery programs. This program is not, at heart, different from ensuring that medical staff members do not have chronic infectious diseases. 2006-2007 County of Los Angeles Civil Grand Jury 37
R8:
0: DHS should strengthen its “Safe and Just” culture.
R9:
0: DHS should analyze medication error trends, share aggregated information with Departmental and Facility leadership, and allow central review of medication error reports.
R10:
DHS should consider establishing Nurse “Naïve Observation” auditing to reduce dependency on self-reporting for medication errors. In this practice, at random intervals Nurses observe other Nurses administering medications. Afterwards, the observing Nurse checks the Medical Administration Record (MAR) and patient records to determine whether any errors were made. A 2002 study comparing methods of detecting medication errors found independent observation by Nurses to be the most efficient and accurate method of doing so.18 18 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities” American Journal of Health-System Pharmacy, Vol 59 2006-2007 County of Los Angeles Civil Grand Jury 40
R11:
DHS should recognize best practices implemented at one facility, and replicate them system-wide. The best practice of Structured Physician Order Forms with block lettering spaces, currently in place at Harbor/UCLA Medical Center, should be implemented at all County Hospitals. Introducing these forms system-wide is a low-cost and low-risk item for DHS. In addition, if one or more Hospitals identify a certain medication as high risk, all Hospitals should similarly categorize that medication as high risk absent a compelling reason to the contrary. Successful best practice programs often include regular reporting on best practices at senior staff meetings, and development of tracking mechanisms for implementation of the changes.
Quick View
Full Details →
Findings & Recommendations
79 findings
F1:
Patient and Family Handbook; Rancho Los Amigos
F2:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Summary Report on Medication Error Related Events, February 2007
F3:
Inpatient Pharmacist Interventions; March 2007
F4:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Medication Errors Reported per 1,000 Doses Dispensed August 2003 – February 2007
F5:
Clinical Pharmacists are effective in reducing medication error risks. Clinical Pharmacists spend time as part of patient care teams, consulting with Physicians and the remainder of the team on the units and during rounds. They provide drug information, recommend dosage adjustments, respond to questions from nursing staff, and make suggestions regarding initiation of drug therapy. All of these activities relieve stress on the Physicians and other clinicians who must sometimes make rapid decisions about patient care in difficult circumstances. This improves the quality and speed of the decisions and reduces the likelihood of medication errors.
F6:
24-hour Pharmacist coverage is important to Patient Safety. A Pharmacist is needed on-site for in-patient care on a 24/7 basis, particularly for acute patients. If a Pharmacist is not available, a comparatively slow and cumbersome process of faxes and telephone calls to Pharmacists at home is required. A “night locker” must be maintained, under the control of a Senior Nurse. If a medication is needed that is not in the night locker, a Pharmacist must be called in from home to open the main pharmacy and dispense it. The primary disadvantage of the process is that it is not fast, and the circumstances that give rise to overnight medication orders are likely to demand prompt action. There are also evident weaknesses in the processes for the checking of medications against orders. Finally, tired Pharmacists are expected to perform their day shifts, even when their sleep is interrupted. In all professions, errors usually increase when people become sleep-deprived. Some smaller hospitals cannot support a 24-hour pharmacy. These hospitals are adopting the capabilities of automated prescription transmission, which involves scanning medication orders to a Pharmacist for verification and approval. The Pharmacist can then release the medication from the ADC at the smaller facility. 2006-2007 County of Los Angeles Civil Grand Jury 36
F7:
It is a common practice to conduct pre-employment drug testing among staff involved in the health care professions. DHS does not do this. Drug screening and random drug testing are common means of ensuring security and safety in a wide variety of sensitive business and government operations. A number of hospitals use them. Failure to conduct screening and testing exposes patients to a potential risk of not receiving prescribed medication (if an addicted employee substitutes a placebo for the particular drug), and increases the potential risk of medication errors when impaired staff members prescribe, approve, distribute, and administer medications. This is a known risk in an environment where staff members sometimes work long hours, and where there is ample knowledge of the “right” mix of drugs to take to stay alert.
F8:
A “Safe and Just” culture is essential to accurate reporting of errors – including medication errors – as well as to the rapid and effective response to error trends. A survey undertaken by DHS in December 2005 showed disturbingly high levels of concern among both Nurses and attending Physicians that errors would be held against them. Nurses also expressed high levels of concern that errors would be kept in their personnel files. Some of this concern may be traced to a long-standing policy in which managers close out reports of all types of medication errors by indicating that an employee was “counseled about the incident”. That is the first step in the County’s standard progressive discipline process. In that process, managers are advised to keep a permanent record of the counseling action for use as needed in ensuing sanctions for further errors. In April 2006, DHS engaged a contractor to deliver a training workshop, entitled “Patient Safety and the Just Culture”. It appears to have been intended to address the issue of a punitive culture by advocating a culture in which acknowledgement that errors are human and inevitable is balanced by a strong sense of professionalism and “zero tolerance” for medication errors. Before punitive actions are taken when a rule is broken or mistake is made, a Just Culture would consider: Whether the employee knowingly violated the rule (cid:104) Whether there was a compelling reason to violate the rule (cid:104) Whether the employee had a good faith but mistaken belief that the violation (cid:104) was justified or insignificant Whether the source of the error resided within the system or was behavioral. (cid:104) Based on answers to such questions, the response would vary from counseling to training to revising procedures. Perceptions of an unjust culture are crippling to any attempt to encourage the self-reporting of Category A, B and C errors, in which no measurable harm comes to a patient. If Physicians and Nurses fear retribution, they will be significantly less likely to self-report errors that have little measurable impact. DHS’s efforts to counter them are laudable, but it seems likely that they have not been sufficient. Further surveys were not available, but anecdotal evidence suggests that negative perceptions have proved to be persistent.
F9:
There is insufficient consistent, Department-wide medication error trend analysis. The identification of trends within overall medication error rates is key to reducing them. The Hospitals do some analysis now, although they do not all follow the same guidelines; and their analysis appears to be limited at times by a lack of formal training for some Hospital Risk Management staff members. For the past year-and-a-half, data have been gathered in a nationwide system run by the University HealthSystem Consortium, which permits sophisticated analysis of errors. There has been insufficient consistent reporting and analysis to take advantage of that capability. While some errors occur only within one Hospital, others may be related to overall policies, training regimens, or technology systems across the County. These error trends should be identified and corrected; this can only be done if errors are reported and analyzed consistently across the County. In addition, such a function will serve to protect the Hospitals against the possibility that a medication error trend may be missed at the Hospital level. Recently, DHS has developed a “Report Card” which tracks high level trend data. It is a good beginning, but needs additional development.
F10:
The number of errors in UHC-PSN Categories A-C is less than expected, and raises the possibility that they are not fully self-reported. A review of reported errors shows few reported errors in the A and B1 categories for all four Hospitals in the six months ending March 31, 2007. The total errors reported for “no patient harm” categories (A, B1, B2, C) were low, considering there were over 300,000 patient days at Harbor-UCLA, Olive View, and RLA, where many patients have multiple medications. Given the number of reported errors in other categories over the same period, this does not appear logical. It is understandable that staff members who make lower category errors are sometimes reluctant to report them. Even in a non-punitive atmosphere, it is easy to see that a staff member would be reluctant to report a minor mishap, such as picking up an improper medication from a shelf, noticing it immediately, and replacing it before gathering up a proper medication. This is how major trends are identified that lead to, for example, separating look alike/sound alike medications. For errors in Categories B1 and B2, the patient receives no improper medications. Self-reporting is the only source of data. Responsible staff noted that the system used to track medication errors and pharmacy interventions is very cumbersome to use, further discouraging reporting of errors. This possible underreporting is important, because identifying errors that do not result in patient harm can point the way to weaknesses in the system that pose the potential for more serious adverse events.
F11:
DHS does not have a regular practice of replicating the best practices implemented from one facility to another. As an example, Harbor-UCLA has implemented Structured Physician Order Forms for admissions and transfers requiring the use of block lettering to reduce cases of illegibility. These forms significantly reduce a broad range of medication order errors, including illegible orders, unapproved abbreviations, dosage errors, and “wrong drug” errors. The Structured Physician Order Forms are considered successful where they are now used. The balance of DHS facilities does not use block lettering on these forms. As another example, Olive View does not recognize the same medications as high risk as the other Hospitals. These are examples of processes that are low-cost and can be relatively easily implemented, as contrasted with implementation of ADCs and bar coding technology.
F12:
Patient Safety and the Just Culture: County of Los Angeles DHS
F13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
F14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
F15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
F16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
F17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 43
F18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
F22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
F24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
F25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
F26:
Pharmacy Utilization Report for FY 2006-2007
F27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
F28:
The Just Culture Algorithm 29. “Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007 30. “Med Errors = Bad Outcomes”, Nurse Week, April 2007
F31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
F32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
F33:
Managing Medication Related Events: PowerPoint Presentation
F34:
Medication Management Process in Valley Care – PowerPoint Presentation
F35:
LAC+USC Chemotherapy Physicians Orders
F36:
LAC+USC Daily Physicians Orders – Adult Critical Care
F37:
LAC+USC Neonate Continuous Infusion Orders
F38:
LAC+USC Neonate Continuous Infusion Recipes
F39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
F40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
F41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
F42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
F43:
LAC+USC HealthCare Network Policy: Medication Usage
F44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
F45:
List of High-Alert Medications
F46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 44
F47:
LAC+USC Drug Bulletin June 2006
F48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
F49:
Intervention Summary Report
F50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
F51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
F52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
F53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
F54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
F55:
Harbor-UCLA – Patient Safety Bulletin October 2003
F56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
F57:
Los Angeles County DHS Lipid Management Algorithm
F58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
F59:
Wikepedia: Medical Error
F60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
F61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
F62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
F63:
Harbor-UCLA MAR Sample
F64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
F65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
F66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
F67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
F68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
F69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
F70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
F71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
F72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
F73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
F74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
F75:
LA County DHS Class Specification; Director of Pharmacy Services
F76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
F77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 45
F78:
DHS Pharmacy Leadership Program description
F79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
F80:
DHS Pharmacy Leadership Program proposal
F81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 46 JUVENILE CUSTODIES - ARE WE PAYING TWICE? EXECUTIVE SUMMARY State law requires that whenever a minor is in custody in a juvenile hall or other county juvenile facility for thirty consecutive days, the county welfare agency needs to be informed. The law requires that the welfare department determine whether these minors are part of a family receiving cash aid benefits and, if so, make reductions in the family’s aid payments to reflect the period of time the minor received care in the facility. Yet, there appears to be no liaisons between these agencies to share information and to stop the cash aid. The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and budget of $630 million. Costs of an individual minor in custody are approaching $200 a day. The Department does a financial screening of the parents or other responsible relative and bills for the cost of care. If the family is receiving financial assistance, the family is not billed; this information should be sent to the welfare agencies. The welfare agencies in Los Angeles County are the Department of Public Social Services and the Department of Children and Family Services. DPSS has over a million clients and over 13,000 employees. There is no direct supervision of the individuals receiving the cash aid and the agency relies on self reporting to find out when a child is no longer residing in the home. DCFS monitors families directly and should have knowledge of where a child is residing. Recent legislation prohibits simultaneous or duplicative case management or services provided by the county probation department and the child welfare services department. The recommendations are designed to co-ordinate county agencies so that they will be in compliance with state law. The lack of communication between the Probation Department and the public assistance agencies may result in replicated support for the same minor. If there is no “Stop Order” issued in a timely manner, or not issued at all, it may take months for funding to be halted and realize that substantial taxpayer funds may be wasted. DPSS, DCFS and Probation need to work together and implement an information sharing process. Probation needs to inform the child support agencies when a minor is in custody for thirty days. A protocol needs to be developed to avoid replicate funding. If payments are not discontinued or unjustified payments are made, attempts should be made to recover such overpayments. The Probation Department’s responsibility is to expeditiously complete the financial screening of the family and communicate this information to the appropriate agencies. HISTORY The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and a budget of $6301 million. The size and transient nature of the custodies underscores the responsibility and diverse services required of the Department while adhering to the myriad federal, state and local laws. Within this oversight they must provide medical care, mental health, education, behavioral rehabilitation and be involved with any other agency 2006-2007 County of Los Angeles Civil Grand Jury 47 providing care for a minor’s custody. Within this area lies a responsibility to report to the supportive agencies (DPSS and DCFS) to prevent replication of costs for those minors adjudicated and sentenced to juvenile hall, camps or probation group homes. California’s Welfare and Institutions Codes Sections 900-914 covers the above issues. With the cost of maintaining a minor in custody spiralling upwards, approaching $200 a day1, there is a need to address the lack of communication and oversight between supportive services and the Probation Department. Due to the layering of department and service providers, it is difficult to pinpoint who is charged with this reporting and at what point the information should be submitted. There is no statistical data available for the numbers of minors coming from DCFS funded units, group homes and foster care, or from DPSS comprised of CALWORKS funded units. Along with DPSS funding is the availability of food stamps, medical care, housing assistance and childcare, all of which is based on the number of individuals residing in the unit. PURPOSE In accordance with California Welfare and Institution Codes Sections 900-914 when minors are placed in the custody of the Juvenile Probation Department for thirty days or more, any agency providing funding for that minor must be notified so as to terminate funding for that minor. This notification ensures that the taxpayers are not paying twice for the minor’s care and support while being held. The investigation attempted to: • Determine what mechanism is in place to avoid funding of minors in custody when their homes are simultaneously receiving support from various social service agencies. • Identify the appropriate mechanism to be implemented to stop the replication of funding. • To determine what agencies are involved and who is responsible for triggering that mechanism. • Recover any monies that have been inappropriately paid, creating a duplicated taxpayer support of the minor in custody. • Make sure measures are in place to aggressively seek reimbursement of overpaid funding. Probation Department, Administrative Services, 5/1/07 2006-2007 County of Los Angeles Civil Grand Jury 48
Additional Recommendations
11
Not linked to specific findings.
R1:
Federal, state and local law and policy issues Some other California counties have had better success in information sharing. Los 2006-2007 County of Los Angeles Civil Grand Jury 57 Angeles County has recently adopted an interagency Memorandum of Understanding stating that DCFS and DHS will develop protocols to improve data sharing.
R2:
Information technology issues Existing systems within DCFS and DHS do not enable information sharing. Development of new systems that could facilitate this sharing is lagging.
R3:
Interdepartmental collaboration, information sharing and the HUB clinics While such limited approaches as multidisciplinary teams (combining several technical and social workers) and HUB clinics (specializing in services for abused and neglected children) have represented some improvement in care, there is a need for enhanced management oversight of the two departments coordination and information sharing.
R4:
Public health nurses Public Health Nurses represent an improvement in the care of some children, but their effectiveness is limited by the inadequate access to patient records and the fact that their management is divided (half report to the Department of Public Health, half to the Department of Children and Family Services).
R5:
0: DHS should expand the number of Clinical Pharmacists, institute a Clinical Coordinator position at each Hospital, and use Tech-Check-Tech processes to free Pharmacists to perform other pharmaceutical duties
R6:
DHS should immediately establish a 24-hour Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication. Olive View Medical Center is of sufficient size and structure to warrant a 24-hour pharmacy. While they recognize the advantages of 24/7 coverage, staff at Olive View cite the difficulty of hiring Pharmacists to work this demanding shift. It is a hurdle to be overcome rather than an insurmountable obstacle, and Olive View should work with Department of Human Resources staff to develop incentives sufficient to attract night shift pharmacists or retain pharmacists when night shifts become a requirement. Olive View is too far removed from other medical facilities to seriously consider a partnering solution. Its patient census and the existence of an emergency room indicate that there is sufficient demand for constant staffing. Rancho Los Amigos, as a rehabilitation facility, has a different patient profile, and has historically seen fewer demands for after-hours pharmacy. This may be changing. DHS should monitor off-hours pharmacy demands on a regular basis, and consider partnering with other DHS facilities or other plans to ensure coverage.
R7:
The County should implement pre-employment drug screening and should develop a targeted program to provide for early identification and treatment of substance abuse among staff with access to controlled medications Pre-employment screening will reduce the risk of hiring individuals who are addicted to narcotics or other drugs. In addition, a program should be developed, modeled on best practices, that include training managers to recognize problems associated with drug abuse, referrals to Employee Assistance Programs, development of reporting mechanisms that identify patterns of abuse, and testing for drugs with a lower threshold of evidence than for other County staff. The program should be modeled on best practices which provide for confidentiality of results, automatic retesting of positive results, counseling, and, where needed, recovery programs. This program is not, at heart, different from ensuring that medical staff members do not have chronic infectious diseases. 2006-2007 County of Los Angeles Civil Grand Jury 37
R8:
0: DHS should strengthen its “Safe and Just” culture.
R9:
0: DHS should analyze medication error trends, share aggregated information with Departmental and Facility leadership, and allow central review of medication error reports.
R10:
DHS should consider establishing Nurse “Naïve Observation” auditing to reduce dependency on self-reporting for medication errors. In this practice, at random intervals Nurses observe other Nurses administering medications. Afterwards, the observing Nurse checks the Medical Administration Record (MAR) and patient records to determine whether any errors were made. A 2002 study comparing methods of detecting medication errors found independent observation by Nurses to be the most efficient and accurate method of doing so.18 18 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities” American Journal of Health-System Pharmacy, Vol 59 2006-2007 County of Los Angeles Civil Grand Jury 40
R11:
DHS should recognize best practices implemented at one facility, and replicate them system-wide. The best practice of Structured Physician Order Forms with block lettering spaces, currently in place at Harbor/UCLA Medical Center, should be implemented at all County Hospitals. Introducing these forms system-wide is a low-cost and low-risk item for DHS. In addition, if one or more Hospitals identify a certain medication as high risk, all Hospitals should similarly categorize that medication as high risk absent a compelling reason to the contrary. Successful best practice programs often include regular reporting on best practices at senior staff meetings, and development of tracking mechanisms for implementation of the changes.
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Findings & Recommendations
7 findings
F1:
Medi-Cal Medi-Cal coverage is automatic for low income people receiving supplemental Social Security Income “SSI” (Currently $836 per month maximum for an individual and no more then $2000 total assets, excluding home, car for transportation, and personal belongings, and a small allowance for incidentals). One can also receive Medi-Cal through the Aged and Disabled Federal Poverty Level Program. Again, income must be low (currently $1047 maximum for an individual and no more than $2000 in assets). Some people with higher incomes may qualify for Medi-Cal with a share of cost if their medical costs leave them with less than $600 for an individual with assets of no more than $2000.Some have other forms of insurance or a share of cost, which are paid before Medi-Cal. Some undocumented aliens may have restricted Medi-Cal benefits as specified on their Medi-Cal card and these usually include only emergency care. Medi-Cal partially finances Healthy Families, a specialized program. This program provides health coverage for children in families without insurance. Participants pay $4-9 per child up to a maximum of $27 per family. There is a $5 co-pay for visit, prescription medication, and emergency room services.
F2:
Prenatal services for the first seven visits remaining prenatal visits at no charge. $ 50.
F3:
County Hospital Outpatient Clinics, except Emergency Room visits $ 60.
F4:
Multi-Service Ambulatory Care Center $ 60.
F5:
Comprehensive Health Center Urgent Care Center $ 65.
F6:
County Hospital Emergency Rooms $100.
F7:
Outpatient Surgery Clinics $300.
Additional Recommendations
4
Not linked to specific findings.
R1:
Mandate the completion and upgrade of electronic records for emergency rooms.
R2:
Encourage changes in regulations and support the development of nonprofit private clinics and programs. Camino de Salud is a program where the patient is encouraged to visit a County or private clinic in his or her neighborhood.
R3:
Lobby for the modification of EMTALA regulations and funding because of the burden it places on the taxpayers of Los Angeles County.
R4:
Develop a system of associated urgent care clinics where patients can be directed, rather than utilizing emergency rooms. 2006-2007 County of Los Angeles Civil Grand Jury 138 TABLE OF CONTENTS
Findings & Recommendations
7 findings
F1:
Medi-Cal Medi-Cal coverage is automatic for low income people receiving supplemental Social Security Income “SSI” (Currently $836 per month maximum for an individual and no more then $2000 total assets, excluding home, car for transportation, and personal belongings, and a small allowance for incidentals). One can also receive Medi-Cal through the Aged and Disabled Federal Poverty Level Program. Again, income must be low (currently $1047 maximum for an individual and no more than $2000 in assets). Some people with higher incomes may qualify for Medi-Cal with a share of cost if their medical costs leave them with less than $600 for an individual with assets of no more than $2000.Some have other forms of insurance or a share of cost, which are paid before Medi-Cal. Some undocumented aliens may have restricted Medi-Cal benefits as specified on their Medi-Cal card and these usually include only emergency care. Medi-Cal partially finances Healthy Families, a specialized program. This program provides health coverage for children in families without insurance. Participants pay $4-9 per child up to a maximum of $27 per family. There is a $5 co-pay for visit, prescription medication, and emergency room services.
F2:
Prenatal services for the first seven visits remaining prenatal visits at no charge. $ 50.
F3:
County Hospital Outpatient Clinics, except Emergency Room visits $ 60.
F4:
Multi-Service Ambulatory Care Center $ 60.
F5:
Comprehensive Health Center Urgent Care Center $ 65.
F6:
County Hospital Emergency Rooms $100.
F7:
Outpatient Surgery Clinics $300.
Additional Recommendations
4
Not linked to specific findings.
R1:
Mandate the completion and upgrade of electronic records for emergency rooms.
R2:
Encourage changes in regulations and support the development of nonprofit private clinics and programs. Camino de Salud is a program where the patient is encouraged to visit a County or private clinic in his or her neighborhood.
R3:
Lobby for the modification of EMTALA regulations and funding because of the burden it places on the taxpayers of Los Angeles County.
R4:
Develop a system of associated urgent care clinics where patients can be directed, rather than utilizing emergency rooms. 2006-2007 County of Los Angeles Civil Grand Jury 138 TABLE OF CONTENTS
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Additional Recommendations
13
Not linked to specific findings.
R1:
The Board of Supervisors should study ways for Probation and DCFS to develop and evaluate up to 5 pilot projects designed to prevent and reduce the number of new dependents and wards in the system. The standard approaches to prevention are general public education and intervention in high-risk homes (when they can be identified). Successful prevention strategies in both delinquency and dependence cases is likely to require a multi-faceted approach. The Board has previously provided funding to the Service Integration Board (SIB) and some projects are underway in the District Attorney, CAO, and other departmental offices to mitigate some of the factors that effect the generation of new cases. Both Probation and DCFS need to study how to best accomplish this priority and participate effectively in the important integration efforts. The purpose of this recommendation is to challenge the Departments to experiment with and propose new ideas.128 Such innovation should be accomplished by bringing together multidisciplinary teams from within and outside the Departments to develop new prevention strategies on a pilot basis. Relevant nonprofit organizations, community groups, academicians, and professional consultants should also be involved. The pilot projects should include a strong evaluation component with assessments at the end of two years; at which time, the County determines the level of success of the pilots and the viability for sustaining or replicating these pilots elsewhere. The County should undertake at least 5 pilots to increase the chances of developing and implementing effective solutions quickly. One of the key parts of the effort, led by the County Auditor-Controller, should be the development of an estimate of what an average child entering the system costs. The estimate should include all potential cost components, including: a) lost productivity over a life-time as a result of a negative life trajectory and b) the explicit “out of pocket” costs while these children are in the child welfare, juvenile justice, and possibly adult justice and welfare systems. This estimate will help the Board make its “investment in prevention” decision once the pilots identify the most effective prevention strategies.
R2:
Probation and DCFS should develop more sophisticated approaches to evaluate, monitor, and measure success. The Departments should establish holistic evaluation approaches that consider both quantitative and qualitative components.
R3:
DCFS should implement new treatment models that are evidence-based and proven to be successful.
R4:
The CEO needs to assist DCFS and Probation in developing a comprehensive and integrated information system.
R5:
The CEO should immediately commission an organizational review to assess the CSW and DPO structure, staffing levels, and compensation. From this CGJ investigation, the Departments had insufficient staffing and funding to care adequately for their dependents and wards. The staffing ratios of 50-55 wards per DPO in Probation and 30-35 dependents per CSW in DCFS speak for themselves. Average rates do not tell the whole story. Best practices recognize that a tiered approach linked to the type of case is optimal. In some types, a ratio of 4-8 cases per CSW may be appropriate. CWLA131 recommends the following caseloads per social worker: Initial assessment: 12 active cases per month Ongoing case: 17 active families per month and no more than 1 new case for every 6 open cases 131 CWLA Standards of Excellence for Services or Abused or Neglected Children and their Families, Revised 1999 (www.cwla.org). 2006-2007 County of Los Angeles Civil Grand Jury 181 Combined cases: 10 active on-going and 4 active investigations Foster family care: 12-15 cases Supervisors: 1 for every 5 social workers Probation also has structural problems, which make it more difficult to fill current vacancies (25 DPO vacancies in March 2007). There are a variety of staffing models to evaluate, including staggered hours, work from home, and longer but fewer shifts that might attract more recruits to this position. After the initial assessment, it is a ‘best practice’ to have the assigned CSW or DPO remain with the child throughout the child’s stay in the system. Children who have multiple CSWs and DPOs tend to develop trust issues with adults and the system. Staffing, remuneration, and organizational supports should be set at levels that optimize the attainment of this continuity goal. The County should create a more highly skilled case manager position for the children with the most complex and difficult problems, such as those who are currently placed in an RCL- 12 level or higher. Realistic staffing levels should also be developed for the after-hours requirements of the DCFS Command Post.
R6:
In consultation with the congregate-care facilities’ staff, DCFS and Probation management should develop and implement comprehensive assessment tools for making placement and exit decisions. Poor initial placement decisions can often result in many changes of residence. This destabilization of the child’s environment can have serious negative impacts, as statistically proven in this CGJ investigation. Other children exit the system without well-thought through transition plans or before they are ready.
R8:
The CEO should ensure that DCFS and Probation’s current practice of assigning dependents and wards to the same facilities ceases immediately. This CGJ investigation has discussed the potentially adverse impact of congregate-care facilities on children’s increased propensity to commit crimes. According to senior officials in both Departments, separation of dependents and wards will provide more appropriate environments for the children. This recommendation will cause disruption, particularly for group home facilities. Some of the excess capacity may be taken up by Probation. Some capital support may be required to help congregate-care facilities accommodate the shift to being an all-Probation or all-DCFS group facility. But nevertheless, dependents and wards should be served in different facilities.
R9:
DCFS and Probation should strategically use congregate care facilities that meet quality assurance standards and provide awards for achieving meaningful outcomes. DCFS and Probation should retain its relationships with the high-quality, congregate-care facilities that they currently have, as long as those settings meet quality assurance standards and are the least restrictive for specific dependents and wards to thrive. Other congregate-care facilities should be phased out – either because of the poor quality or because of reduced demand for their services with the new treatment models to be implemented. The transition may take 2 to 5 years. During this period, there will be disruptions, spare capacity, and other operating problems. To ensure that congregate-care performance does not deteriorate over this period, the Board should consider extra funding support.
R10:
DCFS and Probation should meet at least annually with congregate- care providers to share best practices. DCFS and Probation should establish their own separate annual or semi-annual meetings with all congregate-care providers to exchange best practices, share successful outcomes, act as an educational forum, and deal with common issues. Awards can be given out to: a) successful outcomes at congregate-care facilities and b) DCFS and Probation employees who have made extra efforts to transform children’s lives. County recognition of special efforts and ideas would go a long way with those that do provide exceptional service and make super efforts on behalf of the children. DCFS and Probation management should communicate with each other and share the results, information, and recommendations formulated during these conferences. DCFS also needs to establish better, consistent, and scheduled communication with providers.
R11:
The CEO should establish an inter-departmental task force charged with implementing these recommendations and the shift outlined in its Foundation white paper. Well-intentioned managers and professionals currently have good ideas and intensions, which often do not get implemented because those involved are too busy with their day-to-day duties to carry out the intense work of creating real change in the system. DCFS, Probation, and DMH should create an interdepartmental task force whose sole responsibility is to develop and launch these recommendations and other new child-focused programs. This task force should also collect and analyze factors related to resilience and educational success of former youth in congregate care facilities. If the system is to be effective in its role as a custodian for wards and dependents, it needs to move beyond correcting deficiencies to a focus on systematically nurturing the strengths and talents of those children served by Los Angeles County. This task 2006-2007 County of Los Angeles Civil Grand Jury 186 force would enable a group of experienced, dedicated people to focus all of their attention on shifting the child welfare system in Los Angeles County to the new model. VII – CONCLUSIONS DCFS, Probation Department, and congregate-care facility staff members are hard-working and dedicated to the well-being of the children in their charge. The number of children who annually enter the child welfare and juvenile justice systems is staggering. Many are victims of unfortunate family or environmental situations. Each of these young lives is precious. More must be done to ensure these assets do not become community liabilities. Even more disappointing is the estimate by Probation officials that 40% of the wards that enter their system were once dependents in the child welfare system. This is a poor outcome, given the dedication and hard work of all involved. It draws into question the efficacy of the County’s current programs and methods of care for these children. Regardless of one’s parenting philosophy or views on the relative responsibility of the child for his/her actions, most agree these children are at great disadvantage mainly because of circumstances largely beyond their control (family, environmental, educational, or mental health). While some may be lost, most children have remarkable resiliency if given the right nurturing. The County can make a difference in their life trajectory in three ways: Prevention and Early Intervention – Intervene early to minimize the number of children who enter the system Permanency – Provide exemplary programs that stabilize the children, help them learn and thrive, and get them permanently placed or prepared for emancipation Continuous Improvement – Provide follow-up services to maintain and enhance the gains On the basis of these findings, DCFS and Probation have some key opportunities to address to improve the current system: PREVENTION AND EARLY INTERVENTION: Minimize the number of children entering the system PERMANENCY: For those in the system, stabilize children and find permanent placements for them or enable them to achieve self-sufficiency once emancipated CONTINUOUS IMPROVEMENT: Follow up, maintain the gains, and make needed improvements 2006-2007 County of Los Angeles Civil Grand Jury 187 Introduce prevention and early intervention initiatives and measures that will reduce the number of children that enter the system each year Focus the system to measure both the on-going activities and also the actual long-term impact these activities and programs are having on the life trajectories of the children; use data, trends, and outcomes to make empirically based decisions Improve the staffing, information systems, and information sharing across County departments involved in health and social support services (i.e., DCFS, Probation, Department of Health Services (DHS), and Department of Public Social Services (DPSS) and with congregate-care facilities Phase out over time congregate-care facilities that are not providing full services, ensure that children (particularly dependents) placed in group home facilities can benefit from such a setting as the least restrictive environment for them; and maintain and improve the programming and effectiveness of congregate-care services during the transition Develop stronger and integrated communication mechanisms across the system, which will not only improve efficiency but effectiveness of serving children Collaborate more with the schools to ensure that children can complete their school terms, earn high school diplomas, and have complete, implemented, monitored, and updated IEPs Focus on the total needs of the child – emotional, social, educational, and mental Reduce the DCFS and Probation caseloads 2006-2007 County of Los Angeles Civil Grand Jury 188
R10-13:
Years 7,769 20.5 73 5.3
R14-15:
Years 4,670 12.3 431 31.2
R16-17:
Years 4,576 12.0 813 59.0 18 Years and Older 1,930 5.1 61 4.5 Age Total 37,979 100.0 1,378 100.0 Ethnicity
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Additional Recommendations
13
Not linked to specific findings.
R1:
The Board of Supervisors should study ways for Probation and DCFS to develop and evaluate up to 5 pilot projects designed to prevent and reduce the number of new dependents and wards in the system. The standard approaches to prevention are general public education and intervention in high-risk homes (when they can be identified). Successful prevention strategies in both delinquency and dependence cases is likely to require a multi-faceted approach. The Board has previously provided funding to the Service Integration Board (SIB) and some projects are underway in the District Attorney, CAO, and other departmental offices to mitigate some of the factors that effect the generation of new cases. Both Probation and DCFS need to study how to best accomplish this priority and participate effectively in the important integration efforts. The purpose of this recommendation is to challenge the Departments to experiment with and propose new ideas.128 Such innovation should be accomplished by bringing together multidisciplinary teams from within and outside the Departments to develop new prevention strategies on a pilot basis. Relevant nonprofit organizations, community groups, academicians, and professional consultants should also be involved. The pilot projects should include a strong evaluation component with assessments at the end of two years; at which time, the County determines the level of success of the pilots and the viability for sustaining or replicating these pilots elsewhere. The County should undertake at least 5 pilots to increase the chances of developing and implementing effective solutions quickly. One of the key parts of the effort, led by the County Auditor-Controller, should be the development of an estimate of what an average child entering the system costs. The estimate should include all potential cost components, including: a) lost productivity over a life-time as a result of a negative life trajectory and b) the explicit “out of pocket” costs while these children are in the child welfare, juvenile justice, and possibly adult justice and welfare systems. This estimate will help the Board make its “investment in prevention” decision once the pilots identify the most effective prevention strategies.
R2:
Probation and DCFS should develop more sophisticated approaches to evaluate, monitor, and measure success. The Departments should establish holistic evaluation approaches that consider both quantitative and qualitative components.
R3:
DCFS should implement new treatment models that are evidence-based and proven to be successful.
R4:
The CEO needs to assist DCFS and Probation in developing a comprehensive and integrated information system.
R5:
The CEO should immediately commission an organizational review to assess the CSW and DPO structure, staffing levels, and compensation. From this CGJ investigation, the Departments had insufficient staffing and funding to care adequately for their dependents and wards. The staffing ratios of 50-55 wards per DPO in Probation and 30-35 dependents per CSW in DCFS speak for themselves. Average rates do not tell the whole story. Best practices recognize that a tiered approach linked to the type of case is optimal. In some types, a ratio of 4-8 cases per CSW may be appropriate. CWLA131 recommends the following caseloads per social worker: Initial assessment: 12 active cases per month Ongoing case: 17 active families per month and no more than 1 new case for every 6 open cases 131 CWLA Standards of Excellence for Services or Abused or Neglected Children and their Families, Revised 1999 (www.cwla.org). 2006-2007 County of Los Angeles Civil Grand Jury 181 Combined cases: 10 active on-going and 4 active investigations Foster family care: 12-15 cases Supervisors: 1 for every 5 social workers Probation also has structural problems, which make it more difficult to fill current vacancies (25 DPO vacancies in March 2007). There are a variety of staffing models to evaluate, including staggered hours, work from home, and longer but fewer shifts that might attract more recruits to this position. After the initial assessment, it is a ‘best practice’ to have the assigned CSW or DPO remain with the child throughout the child’s stay in the system. Children who have multiple CSWs and DPOs tend to develop trust issues with adults and the system. Staffing, remuneration, and organizational supports should be set at levels that optimize the attainment of this continuity goal. The County should create a more highly skilled case manager position for the children with the most complex and difficult problems, such as those who are currently placed in an RCL- 12 level or higher. Realistic staffing levels should also be developed for the after-hours requirements of the DCFS Command Post.
R6:
In consultation with the congregate-care facilities’ staff, DCFS and Probation management should develop and implement comprehensive assessment tools for making placement and exit decisions. Poor initial placement decisions can often result in many changes of residence. This destabilization of the child’s environment can have serious negative impacts, as statistically proven in this CGJ investigation. Other children exit the system without well-thought through transition plans or before they are ready.
R8:
The CEO should ensure that DCFS and Probation’s current practice of assigning dependents and wards to the same facilities ceases immediately. This CGJ investigation has discussed the potentially adverse impact of congregate-care facilities on children’s increased propensity to commit crimes. According to senior officials in both Departments, separation of dependents and wards will provide more appropriate environments for the children. This recommendation will cause disruption, particularly for group home facilities. Some of the excess capacity may be taken up by Probation. Some capital support may be required to help congregate-care facilities accommodate the shift to being an all-Probation or all-DCFS group facility. But nevertheless, dependents and wards should be served in different facilities.
R9:
DCFS and Probation should strategically use congregate care facilities that meet quality assurance standards and provide awards for achieving meaningful outcomes. DCFS and Probation should retain its relationships with the high-quality, congregate-care facilities that they currently have, as long as those settings meet quality assurance standards and are the least restrictive for specific dependents and wards to thrive. Other congregate-care facilities should be phased out – either because of the poor quality or because of reduced demand for their services with the new treatment models to be implemented. The transition may take 2 to 5 years. During this period, there will be disruptions, spare capacity, and other operating problems. To ensure that congregate-care performance does not deteriorate over this period, the Board should consider extra funding support.
R10:
DCFS and Probation should meet at least annually with congregate- care providers to share best practices. DCFS and Probation should establish their own separate annual or semi-annual meetings with all congregate-care providers to exchange best practices, share successful outcomes, act as an educational forum, and deal with common issues. Awards can be given out to: a) successful outcomes at congregate-care facilities and b) DCFS and Probation employees who have made extra efforts to transform children’s lives. County recognition of special efforts and ideas would go a long way with those that do provide exceptional service and make super efforts on behalf of the children. DCFS and Probation management should communicate with each other and share the results, information, and recommendations formulated during these conferences. DCFS also needs to establish better, consistent, and scheduled communication with providers.
R11:
The CEO should establish an inter-departmental task force charged with implementing these recommendations and the shift outlined in its Foundation white paper. Well-intentioned managers and professionals currently have good ideas and intensions, which often do not get implemented because those involved are too busy with their day-to-day duties to carry out the intense work of creating real change in the system. DCFS, Probation, and DMH should create an interdepartmental task force whose sole responsibility is to develop and launch these recommendations and other new child-focused programs. This task force should also collect and analyze factors related to resilience and educational success of former youth in congregate care facilities. If the system is to be effective in its role as a custodian for wards and dependents, it needs to move beyond correcting deficiencies to a focus on systematically nurturing the strengths and talents of those children served by Los Angeles County. This task 2006-2007 County of Los Angeles Civil Grand Jury 186 force would enable a group of experienced, dedicated people to focus all of their attention on shifting the child welfare system in Los Angeles County to the new model. VII – CONCLUSIONS DCFS, Probation Department, and congregate-care facility staff members are hard-working and dedicated to the well-being of the children in their charge. The number of children who annually enter the child welfare and juvenile justice systems is staggering. Many are victims of unfortunate family or environmental situations. Each of these young lives is precious. More must be done to ensure these assets do not become community liabilities. Even more disappointing is the estimate by Probation officials that 40% of the wards that enter their system were once dependents in the child welfare system. This is a poor outcome, given the dedication and hard work of all involved. It draws into question the efficacy of the County’s current programs and methods of care for these children. Regardless of one’s parenting philosophy or views on the relative responsibility of the child for his/her actions, most agree these children are at great disadvantage mainly because of circumstances largely beyond their control (family, environmental, educational, or mental health). While some may be lost, most children have remarkable resiliency if given the right nurturing. The County can make a difference in their life trajectory in three ways: Prevention and Early Intervention – Intervene early to minimize the number of children who enter the system Permanency – Provide exemplary programs that stabilize the children, help them learn and thrive, and get them permanently placed or prepared for emancipation Continuous Improvement – Provide follow-up services to maintain and enhance the gains On the basis of these findings, DCFS and Probation have some key opportunities to address to improve the current system: PREVENTION AND EARLY INTERVENTION: Minimize the number of children entering the system PERMANENCY: For those in the system, stabilize children and find permanent placements for them or enable them to achieve self-sufficiency once emancipated CONTINUOUS IMPROVEMENT: Follow up, maintain the gains, and make needed improvements 2006-2007 County of Los Angeles Civil Grand Jury 187 Introduce prevention and early intervention initiatives and measures that will reduce the number of children that enter the system each year Focus the system to measure both the on-going activities and also the actual long-term impact these activities and programs are having on the life trajectories of the children; use data, trends, and outcomes to make empirically based decisions Improve the staffing, information systems, and information sharing across County departments involved in health and social support services (i.e., DCFS, Probation, Department of Health Services (DHS), and Department of Public Social Services (DPSS) and with congregate-care facilities Phase out over time congregate-care facilities that are not providing full services, ensure that children (particularly dependents) placed in group home facilities can benefit from such a setting as the least restrictive environment for them; and maintain and improve the programming and effectiveness of congregate-care services during the transition Develop stronger and integrated communication mechanisms across the system, which will not only improve efficiency but effectiveness of serving children Collaborate more with the schools to ensure that children can complete their school terms, earn high school diplomas, and have complete, implemented, monitored, and updated IEPs Focus on the total needs of the child – emotional, social, educational, and mental Reduce the DCFS and Probation caseloads 2006-2007 County of Los Angeles Civil Grand Jury 188
R10-13:
Years 7,769 20.5 73 5.3
R14-15:
Years 4,670 12.3 431 31.2
R16-17:
Years 4,576 12.0 813 59.0 18 Years and Older 1,930 5.1 61 4.5 Age Total 37,979 100.0 1,378 100.0 Ethnicity
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Additional Recommendations
9
Not linked to specific findings.
R1:
COUNTY AND CITY OVERSIGHT
R2:
STAFF INCREASE A careful evaluation should be done by LAHSA to identify the numbers and types of
R4:
ADMINISTRATIVE ADDITION A Director of Operations position should be created and filled by LAHSA. This position to have direction over both the Fiscal and the Contract Departments. This will enhance their
R5:
CHIEF FINANCIAL OFFICER
R7:
REVIEW OF STRINGENT FUND REQUEST ACCOUNTING
R8:
LAHSA CONTRACTOR MONITORING SECTION
R9:
CENTRALIZED PROCESS FOR EXTERNAL AGENCY MONITORING REPORTS A centralized process should be developed by LAHSA to manage and follow up on external agency reports to LAHSA. These external monitoring findings and recommendations should be integrated into the LAHSA management process.
R10:
IMPLEMENT THE HOMELESS MANAGEMENT INFORMATION SYSTEM This system has not been able to be properly implemented by LAHSA because of its
R11:
Until the time it can effectively audit the effectiveness of major contractors with its own designated staff, LAHSA should seek budget approval to hire an audit firm to perform this task
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Additional Recommendations
9
Not linked to specific findings.
R1:
COUNTY AND CITY OVERSIGHT
R2:
STAFF INCREASE A careful evaluation should be done by LAHSA to identify the numbers and types of
R4:
ADMINISTRATIVE ADDITION A Director of Operations position should be created and filled by LAHSA. This position to have direction over both the Fiscal and the Contract Departments. This will enhance their
R5:
CHIEF FINANCIAL OFFICER
R7:
REVIEW OF STRINGENT FUND REQUEST ACCOUNTING
R8:
LAHSA CONTRACTOR MONITORING SECTION
R9:
CENTRALIZED PROCESS FOR EXTERNAL AGENCY MONITORING REPORTS A centralized process should be developed by LAHSA to manage and follow up on external agency reports to LAHSA. These external monitoring findings and recommendations should be integrated into the LAHSA management process.
R10:
IMPLEMENT THE HOMELESS MANAGEMENT INFORMATION SYSTEM This system has not been able to be properly implemented by LAHSA because of its
R11:
Until the time it can effectively audit the effectiveness of major contractors with its own designated staff, LAHSA should seek budget approval to hire an audit firm to perform this task
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Additional Recommendations
7
Not linked to specific findings.
R1:
Men’s Central Jail: Increase treatment of cell areas to remove infestation of vermin. 2006-2007 County of Los Angeles Civil Grand Jury 278
R2:
Men’s Central Jail: Repair the escalator or remove and replace with a safe walkway that meets commercial building codes and ADA requirements.
R3:
Camp Scudder: The place needs to be cleaned, repaired, and painted.
R4:
Mental Health: Develop a formal academic training program for the speciality of providing mental health services in a jail environment. (The Department of Mental Health has already applied for a couple of research grants to study specific populations - women prisoners, 18-24 year old inmates). Currently the academic training of mental health professionals does not really have curricula for this speciality.
R5:
Electronic Records: Medical electronic records available within the jail should be accessible when the inmate transfers to another facility.
R6:
Medical Care: Complete and activate the telemedicine system in order to decrease the number of inmates transferred out of the jail system.
R7:
Medical Care: A system to need to document medical indications for transfer to LAC/USC for emergency, inpatient and outpatient care. Analysis of this data should facilitate a decrease of inmates transferred. 2006-2007 County of Los Angeles Civil Grand Jury 279
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Additional Recommendations
7
Not linked to specific findings.
R1:
Men’s Central Jail: Increase treatment of cell areas to remove infestation of vermin. 2006-2007 County of Los Angeles Civil Grand Jury 278
R2:
Men’s Central Jail: Repair the escalator or remove and replace with a safe walkway that meets commercial building codes and ADA requirements.
R3:
Camp Scudder: The place needs to be cleaned, repaired, and painted.
R4:
Mental Health: Develop a formal academic training program for the speciality of providing mental health services in a jail environment. (The Department of Mental Health has already applied for a couple of research grants to study specific populations - women prisoners, 18-24 year old inmates). Currently the academic training of mental health professionals does not really have curricula for this speciality.
R5:
Electronic Records: Medical electronic records available within the jail should be accessible when the inmate transfers to another facility.
R6:
Medical Care: Complete and activate the telemedicine system in order to decrease the number of inmates transferred out of the jail system.
R7:
Medical Care: A system to need to document medical indications for transfer to LAC/USC for emergency, inpatient and outpatient care. Analysis of this data should facilitate a decrease of inmates transferred. 2006-2007 County of Los Angeles Civil Grand Jury 279
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Findings & Recommendations
10 findings
F1:
NO RESPONSE Question 2 Total Number of Responses Population Yes No No Response Total <50,000 10 34 4 48 50,000+ 18 16 4 38 2006-2007 County of Los Angeles Civil Grand Jury 244 Some Cities Using Solar (photovoltaic) Power for Structures:
F2:
Develop recommendations for energy conservation and environmental initiatives for approval by the Board of Supervisors.
F3:
Implement and monitor the Board of Supervisors’ approved targets for reduction of energy usage Countywide.
F4:
Provide regular reports on status of energy programs to the Board of Supervisors and the public.
F5:
Join the California Climate Registry to assist the County in establishing goals for reduction of Green House gasses.
F6:
Approve the Sustainable Design Program for Countywide capital improvement and refurbishment projects. The County has over sixty million square feet of existing office and facility space. The County is the largest single customer of Southern California Edison. The County of Los Angeles is not a provider or reseller of energy. There is no individual County department responsible for all solar or other renewable alternative energy program areas. The proposed Energy and Environmental Policy provides a structure for development of energy efficiency. Solar and other renewable power will also be a key element of achieving LEED certification for certain types of new and existing buildings. The Energy and Water Efficiency Program conservation program seeks to further reduce County facilities energy and water consumption. The Environmental Stewardship Program is designed to measure the County’s “environmental footprint”, including minimization of air pollutants. The County’s Internal Services Division/Energy Management Department recognizes most other local governments and public agencies and constituents within the County have limited knowledge on energy issues. The Public Outreach program will utilize the County’s communication and outreach channels to share information with the utility industry, as well as facilitate implementation of subsidy and assistance programs. 2006-2007 County of Los Angeles Civil Grand Jury 253 The Sustainable Design Program provides for the integration of sustainable “green building” technologies into the County’s capital improvement and refurbishment projects. The Sustainable Component will encompass projects that can feasibly incorporate appropriate Design Components. In addition, some projects such as the County Data Center will be eligible for the LEED certification based on innovative design.
F7:
Certify new buildings of a certain size to LEED Silver-level eligibility;
F8:
Reduce County energy consumption by 20% by 2017;
F9:
Reduce greenhouse gas emissions the County is adjudged responsible for; and
F10:
Develop a renewable energy strategy under the Policy. The County’s plans include all new construction, as well as the refurbishment of existing facilities such as has been underway. The new designs will contain energy efficient components. The refurbishment projects will continue to require time and funding resources. 2006-2007 County of Los Angeles Civil Grand Jury 255 CONCLUSION In the future, each of us will be participating in multiple forms of recycling and alternative energy. It will become part of our routine at home and at work. The need to reduce our dependence on coal and fossil fuel will eventually affect many more parts of our lives than are now evident.
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Findings & Recommendations
10 findings
F1:
NO RESPONSE Question 2 Total Number of Responses Population Yes No No Response Total <50,000 10 34 4 48 50,000+ 18 16 4 38 2006-2007 County of Los Angeles Civil Grand Jury 244 Some Cities Using Solar (photovoltaic) Power for Structures:
F2:
Develop recommendations for energy conservation and environmental initiatives for approval by the Board of Supervisors.
F3:
Implement and monitor the Board of Supervisors’ approved targets for reduction of energy usage Countywide.
F4:
Provide regular reports on status of energy programs to the Board of Supervisors and the public.
F5:
Join the California Climate Registry to assist the County in establishing goals for reduction of Green House gasses.
F6:
Approve the Sustainable Design Program for Countywide capital improvement and refurbishment projects. The County has over sixty million square feet of existing office and facility space. The County is the largest single customer of Southern California Edison. The County of Los Angeles is not a provider or reseller of energy. There is no individual County department responsible for all solar or other renewable alternative energy program areas. The proposed Energy and Environmental Policy provides a structure for development of energy efficiency. Solar and other renewable power will also be a key element of achieving LEED certification for certain types of new and existing buildings. The Energy and Water Efficiency Program conservation program seeks to further reduce County facilities energy and water consumption. The Environmental Stewardship Program is designed to measure the County’s “environmental footprint”, including minimization of air pollutants. The County’s Internal Services Division/Energy Management Department recognizes most other local governments and public agencies and constituents within the County have limited knowledge on energy issues. The Public Outreach program will utilize the County’s communication and outreach channels to share information with the utility industry, as well as facilitate implementation of subsidy and assistance programs. 2006-2007 County of Los Angeles Civil Grand Jury 253 The Sustainable Design Program provides for the integration of sustainable “green building” technologies into the County’s capital improvement and refurbishment projects. The Sustainable Component will encompass projects that can feasibly incorporate appropriate Design Components. In addition, some projects such as the County Data Center will be eligible for the LEED certification based on innovative design.
F7:
Certify new buildings of a certain size to LEED Silver-level eligibility;
F8:
Reduce County energy consumption by 20% by 2017;
F9:
Reduce greenhouse gas emissions the County is adjudged responsible for; and
F10:
Develop a renewable energy strategy under the Policy. The County’s plans include all new construction, as well as the refurbishment of existing facilities such as has been underway. The new designs will contain energy efficient components. The refurbishment projects will continue to require time and funding resources. 2006-2007 County of Los Angeles Civil Grand Jury 255 CONCLUSION In the future, each of us will be participating in multiple forms of recycling and alternative energy. It will become part of our routine at home and at work. The need to reduce our dependence on coal and fossil fuel will eventually affect many more parts of our lives than are now evident.
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Findings and recommendations not yet extracted.