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Extracted from Consolidated Report
This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.
⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings 4 findings
F1
Page 43
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
Page 44
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
Page 45
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
Page 46
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.
Recommendations 11
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R1Page 43The Director, Pharmacy Services, should be entrusted with the authority to carry out medication error risk and performance audits and business process reviews. Given the level of human risk and dollars involved, DHS requires a centralized approach to auditing medication errors and processes. These reviews should be coordinated with the Department of Auditing and Compliance. To avoid any potential conflict of interest, Audit staff must have direct access to the DHS top management, up to the Director, DHS. In addition, copies of the audit recommendations should be given to the Director, DHS. Audit recommendations should include proposals for standardization and process improvements in all medication-related functions. The Director, Pharmacy Services, should establish these functions as formal, centralized responsibilities. Along with the audit responsibilities should be an established schedule for performing process and performance audits annually at each Hospital. While this function will require additional staff, process improvements and technological enhancements should cover the costs of this function. In addition, the Director, Pharmacy Services, should have access to all medication error reports.
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R2Page 44DHS 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. The Technology plan being implemented deserves full funding. Major technology improvements to be implemented include: IV Smart Pumps at all facilities Complete implementation of Automated Dispensing Cabinets at all Hospitals Integration of the ADC system with the Pharmacy System Medication Barcode Carousels Pharmacy Barcode Prepackaging Electronic Health Records While these systems are expensive, it is a prudent decision to implement them. County staff members are proud of their efforts to improve patient safety, and investments in technology reinforce the County’s commitment to their efforts. Furthermore, the County’s investment in best practices in patient safety will help prevent harm to patients, and are evidence of sincere interest in the event of litigation. 2006-2007 County of Los Angeles Civil Grand Jury 32 In calculating the total costs of the system, DHS should employ the best practice of life-cycle cost accounting, which provides resources for operation and maintenance for the equipment during its life and for replacement when its useful life is completed. It is especially important when acquiring the equipment to ensure that there is sufficient staffing to program and test before implementing, because medical staff depend on the accuracy of the information and technology systems. The Director, Pharmacy Services, has been vigilant in keeping down the costs of medication. Last year, by negotiating carefully with the primary medication wholesaler and instituting prudent cost saving programs, savings of more than $150,000 each month have been realized. Careful attention to Formulary management has also led to using cost-effective medications. After years of escalating medication costs, in Fiscal Year 2006/2007 DHS is projected to avoid more than $6 million in pharmaceutical costs, devoting a significant portion of these savings to technology improvements. The ability to apply savings to further improvements is a positive incentive and should continue.
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R3Page 45As 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 33 ordering, dispensing, and administration should be subject to a thorough peer review. This peer review should: Redesign processes as necessary Ensure that Olive View has adopted best practices used elsewhere in the County Establish processes that ensure low levels of medication error are in place and in practice.
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R4Page 46DHS 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 34
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R5Page 7The Jury recommends that DHS have a system of tracking and interface between hospitals and outpatient clinics to maintain a continuity of care. Information technology should be used to facilitate this process. A similar tracking and interaction should be established between all County departments providing health and social services for the citizens of Los Angeles County, including the Jails. 2006-2007 County of Los Angeles Civil Grand Jury 18
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R6Page 1024-hour Pharmacist coverage is DHS should immediately establish a 24-hour important to Patient Safety. Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication.
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R7Page 10It is a common practice to conduct pre- The County should implement pre- employment drug testing among staff employment drug screening and should involved in the health care professions. develop a targeted program to provide for DHS does not do this. early identification and treatment of substance abuse among staff with access to controlled medications.
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R8Page 10A “Safe and Just” culture is essential to DHS should strengthen its “Safe and Just” accurate self-reporting of errors – culture. including medication errors – as well as to the rapid and effective response to error trends.
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R9Page 43elaborates on process changes required to implement changes to sharing these reports. 2006-2007 County of Los Angeles Civil Grand Jury 31 TECHNOLOGY
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R10Page 10The number of minor errors causing no DHS should consider establishing Nurse patient harm (Category A - C in “Naïve Observation” auditing to reduce University HealthSystem Consortium – dependency on self-reporting for medication the Patient Safety Net) is less than errors. expected, and raises the possibility that they are not fully self-reported.
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R11Page 11DHS does not have a regular practice DHS should recognize best practices of replicating the best practices implemented at one facility, and replicate implemented from one facility to them system-wide. another. 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 Average Daily Census Licensed Budgeted 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 23 Table 3: Specialty Services Provided Hospital ER OR Oncology ICU Neo-Natal Los Angeles County+USC Medical X X X X X Center Harbor – UCLA Medical Center X X X X X Rancho Los Amigos Rehabilitation X X Center Olive View Medical Center X X X X X MEDICATION ERRORS Medication errors are classified according to severity by the standards established by the University HealthSystem Consortium – the Patient Safety Net (UHC PSN). They include: No patient harm categories: Category A – Unsafe conditions Category B1 – No harm, near miss because of chance alone Category B2 – No harm, near miss because of active recovery Category C – No harm, and does not require increased patient monitoring More serious but no permanent harm to patient categories: Category D – Required increased monitoring to ensure no harm to patient Category E – Temporary harm to patient, which does not require treatment or intervention Category F – Temporary harm to patient which requires intervention Most severe categories: Category G – Permanent patient harm Category H – Intervention required to sustain life Category I – Patient death Undetermined Category X – Cannot assess harm at the time of error evaluation Incidents of lasting harm or deaths attributable to medication error reported by the Hospitals are rare. The goal, as always, is to minimize medication errors that actually reach patients. Responsibility for the safe prescription, dispensing and administration of medications in a hospital is shared. Physicians, Physicians’ Assistants, and Nurse Practitioners are authorized to prescribe medications. Pharmacists are responsible for acquiring, storing, reviewing prescribed medications; compounding some medications; and providing medications to the floors. Nurses, and in some cases Physicians, are responsible for administering medications to patients. At each step in the process, medications and medication orders are reviewed to ensure patient safety. 2006-2007 County of Los Angeles Civil Grand Jury 24 III – PURPOSE OBJECTIVES AND SCOPE The objective of the investigation was to review existing inpatient medication use processes at four Los Angeles County Hospitals, identify areas that pose the greatest risks of medication error, and offer recommendations that would reduce that risk. The CGJ also sought best practices at each Hospital and at medical centers outside the County that should be adopted throughout the system. The following Hospitals were reviewed: Los Angeles County+USC Medical Center Harbor-UCLA Medical Center Rancho Los Amigos Rehabilitation Center Olive View Medical Center Harbor-King was not included in this review for several reasons. As the evaluation was being developed, there were only 25 beds in the hospital, and it was in transition from being independent to being managed by Harbor-UCLA. The review included processes associated with prescription, dispensing, and administration of in- patient medications, and focused on risk of error, as contrasted with investigation of actual errors. IV – INVESTIGATION