Los Angeles County Grand Jury • 2006-2007 • Agency Response

Final Report - 2006 - 2007

Published: June 15, 2007 353 pages Consolidated Report

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⚠️ Aviso de traducción: Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Note: Missing finding numbers detected: F29, F30

Findings 79 findings

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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

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

Recommendations 90

R1

The 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.
R2

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. 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. 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.
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 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.
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. 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.
R07

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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.
R8

0: DHS should strengthen its “Safe and Just” culture.
R9

elaborates on process changes required to implement changes to sharing these reports. TECHNOLOGY
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
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
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
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
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DHS Pharmacy Leadership Program description
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DHS Outpatient Report Card: Medication Use Performance Metric 2007
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DHS Pharmacy Leadership Program proposal
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DHS Report Card: Medication Use Performance Metrics 2007
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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 Hispanic 19,347 50.9 804 58.3 African-American 12,039 31.7 432 31.3 Dependents Wards Child Characteristics # % # % White 5,101 13.4 107 7.8 Asian/Pacific Islander 956 2.5 9 0.7 Filipino, American Indian/Alaskan Native, Other 536 1.5 26 1.9 Ethnicity Total 37,979 100.0 1,378 100.0 Group Home Classifications Vendors must fulfill the administrative requirements to bid for Los Angeles County FFA and group home contracts. Once it has been determined that the minimum requirements have been satisfied, the County selects those vendors they deem to be qualified. The California Department of Social Services (CDSS) rates and licenses group homes via a Rate Classification Level (RCL), based on a 14-point system. The RCL determines the number of weighted staff hours per child per month for providing social work activities and mental health treatment services. In turn, the County of Los Angeles contracts with these State-licensed facilities. Most children receive RCL-10 through RCL-12 services. The RCL pay schedule is: Monthly RCL payments per child 14 $6,371 13 $5,994 12 $5,613 11 $5,234 10 $4,858 9 $4,479 8 $4,102 7 $3,723 6 $3,344 5 $2,966 4 $2,589 Los Angeles County 2002-2005 Trends To gain an understanding of trends, this CGJ investigation did a statistical review of the child welfare records of all dependents (n=91,860) involved102 with DCFS between 2002 and 2005. The delinquency records originate with Probation and include all arrests (n=230,259) for all minors (n=82,376) in Los Angeles County between 2002 and 2005. On average, during the five- year period studied (2002-2005): Ethnicity profile. 48% were male; most were minorities: 43% African-American, 40% Hispanic, 15% White, and 2% Asian. Note: This ethnic profile differs from that of March 2007, where the majority of the dependents were Hispanic (51%). Involvement with child welfare in Los Angeles County includes any open or ongoing case between 2002 and 2005. Placement trends. Dependents were 8.8 years old at the time of their first placement. 71% had at least one placement in foster care, 53% had at least one placement in a relative’s care. and 23% had at least one congregate-care placement. Length of stay and instability trends. Dependents stayed in care a total of 46 months. 49% of the dependents (n=20,309) experienced at least three different placements. Approximately 9% of them experienced a change in placement due to running away, referred to as Away Without Leave (AWOL), and 7% experienced a change in placement due to child behavioral problems. Delinquency trends. 2,106 (10.4%) of 20,309 adolescents in placement had at least one arrest subsequent to their first placement episode. In this CGJ investigation, the County database had approximately 6,400 adolescents with at least one congregate-care placement between 2002 and 2005. In contrast, the County had approximately 47,000 adolescents in other placement settings during the same period. Placement Patterns Table 4 compares In-Home Care and Out-of-Home Care for DCFS dependents. Since 2004, the percent of dependents served in-home has decreased. Table 4: Number of DCFS Cases Opened Out of Referrals by In-Home Care and Out-of-Home Care (Foster Care) (2004 Through 2006) Placement 2004 % 2005 % 2006 % In-Home Care 12,110 66.9 13,425 65.3 12,407 62.8 Out-of-Home Care (Foster Care) 5,981 33.1 7,132 34.7 7,346 37.2 Total 18,091 100.0 20,557 100.0 19,753 100.0 Notes: 1. The table contains dependents who had a case opening out of referrals. 2. Data source is CWS/CMS Datamart as of 4/16/2007. Congregate-Care Facility Profile In Los Angeles County, congregate-care facilities range from 5 to 143 dependents or wards. The larger facilities are residential-based facilities. Group facilities have an average of 5.9 dependents per facility. Non-group homes – such as foster family homes, small family homes, and FFA- certified homes – average just 2.1 dependents per home.103 Approximately 56 group homes serve both dependents (n=355) and wards (n=680) in the same setting; numerous homes have children from other counties as well. More than 50% of DCFS dependents and 67% of Probation’s wards are placed in RCL-12 homes.104 Despite repeated requests, CGJ was unable to obtain the amount budgeted for congregate care facilities. One DCFS official estimated that $200 million + per year was spent on these facilities; however this amount was not verified. DCFS data, as of December 31, 2006. See DCFS RCL table in “Findings” section. III – PURPOSE Congregate-care placements are an essential service option along the continuum within child welfare and juvenile justice systems because they serve some of the more complicated and difficult to place cases. In this investigation, the CGJ observed profound differences in the types of facility options available. Most of the research clumps outcomes together under a broad heading of “group homes” and does not distinguish about how they vary in their scope and services rendered. Therefore, in the remaining sections of this report, CGJ distinguishes among congregate-care facilities as: Residential-based facilities – offer a breadth of support services: staff with specialized expertise, specially designed programs, on-site school programs, transition planning and support, community involvement, supervised activities, transitional housing, and enhancement activities (e.g., art, music, outreach programs, cooking, summer camps, and field trips). Campus-like settings with a range of services – treatment centers, schools, and transitional programs Multi-faceted agencies, which include campus-like settings and foster family services, adoption services, and residential facilities Multi-faceted agencies with central administrative facility and multiple home facilities Agency-operated with multiple residential facilities Stand-alone, small group facilities (<10 beds) This CGJ investigation has attempted to understand the true nature of congregate-care facilities. Three questions related to such placements were statistically investigated: Question 1: How do children placed in congregate-care facilities compare with children placed in other out-of-home placement settings? Question 2: Are children in congregate-care facilities at higher risk for delinquency? Question 3: What is the relationship between congregate-care placement and permanency outcomes (e.g., family reunification, adoption, or guardianship – all measurements of permanence placement for the children)? This CGJ investigation also reviewed system-wide management issues and processes – communications, placement, staffing, and performance monitoring. IV – INVESTIGATION Our qualitative fact-finding involved: Formal Entrance and Exit Conferences with senior DCFS and Probation officials DCFS and Probation data collection of trends pertaining to dependents in the child welfare system and wards in the juvenile justice system 20 Interviews with County department management and representatives: DCFS, Probation, the Ombudsperson, County Counsel, the courts, and Auditor-Controller 2 focus groups with 10 CSWs in DCFS and 5 DPOs in Probation 5 interviews or meetings with involved stakeholders and non-profit agencies: Association of County Human Service Agencies (ACHSA), Children’s Law Center, CHAMPS, Alliance for Children’s Rights, and Education Coordinating Council (ECC) 15 site visits and interviews at congregate-care settings, representing a range of facilities: 6- bed, stand-alone group home facilities; agency-operated, multiple 6-bed group home facilities; multi-faceted agency operated with foster family services and 6-bed home facilities; and campus-based facilities with 6-beds, treatment centers, schools, FFAs, and transitional programs. The site visits entailed the completion of a “Site Visit Assessment” form, commenting on the facilities, the children, the staffing, programs offered, schooling, transitional plans and housing, supervised activities, community involvement, enhancement activities, and other comments.