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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.

Los Angeles County Grand Jury • 2006-2007

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Note: Missing finding numbers detected: F29, F30

Findings 79 findings

F1 Page 55
Patient and Family Handbook; Rancho Los Amigos
F2 Page 55
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Summary Report on Medication Error Related Events, February 2007
F3 Page 55
Inpatient Pharmacist Interventions; March 2007
F4 Page 55
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Medication Errors Reported per 1,000 Doses Dispensed August 2003 – February 2007
F5 Page 47
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 Page 48
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 Page 49
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 Page 50
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 Page 51
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 Page 52
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 Page 53
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 Page 55
Patient Safety and the Just Culture: County of Los Angeles DHS
F13 Page 55
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
F14 Page 55
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
F15 Page 55
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 Page 55
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 Page 55
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 43
F18 Page 56
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F19 Page 56
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F20 Page 56
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 Page 56
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F23 Page 56
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
F24 Page 56
Proposed Medication Management Automation Solution, LA DHS 1/2007
F25 Page 56
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
F26 Page 56
Pharmacy Utilization Report for FY 2006-2007
F27 Page 56
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 Page 56
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
F32 Page 56
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
F33 Page 56
Managing Medication Related Events: PowerPoint Presentation
F34 Page 56
Medication Management Process in Valley Care – PowerPoint Presentation
F35 Page 56
LAC+USC Chemotherapy Physicians Orders
F36 Page 56
LAC+USC Daily Physicians Orders – Adult Critical Care
F37 Page 56
LAC+USC Neonate Continuous Infusion Orders
F38 Page 56
LAC+USC Neonate Continuous Infusion Recipes
F39 Page 56
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
F40 Page 56
LAC+USC Adult Inpatient Rasburicase Physician Order Form
F41 Page 56
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 Page 56
LAC+USC HealthCare Network Policy: Medication Usage
F44 Page 56
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
F45 Page 56
List of High-Alert Medications
F46
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 44
F47 Page 57
LAC+USC Drug Bulletin June 2006
F48 Page 57
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
F49 Page 57
Intervention Summary Report
F50 Page 57
Harbor-UCLA – Patient Safety Bulletin October/November 2006
F51 Page 57
Harbor-UCLA – Patient Safety Bulletin July/August 2006
F52 Page 57
Harbor-UCLA – Patient Safety Bulletin May/June 2006
F53 Page 57
Harbor-UCLA – Patient Safety Bulletin January/February 2004
F54 Page 57
Harbor-UCLA – Patient Safety Bulletin November/December 2003
F55 Page 57
Harbor-UCLA – Patient Safety Bulletin October 2003
F56 Page 57
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
F57 Page 57
Los Angeles County DHS Lipid Management Algorithm
F58 Page 57
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
F59 Page 57
Wikepedia: Medical Error
F60 Page 57
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
F61 Page 57
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 Page 57
Harbor-UCLA MAR Sample
F64 Page 57
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
F65 Page 57
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
F66 Page 57
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
F67 Page 57
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
F68 Page 57
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
F69 Page 57
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 Page 57
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
F72 Page 52
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
F73 Page 57
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
F74 Page 57
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
F75 Page 57
LA County DHS Class Specification; Director of Pharmacy Services
F76 Page 57
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
F77 Page 57
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 45
F78 Page 58
DHS Pharmacy Leadership Program description
F79 Page 58
DHS Outpatient Report Card: Medication Use Performance Metric 2007
F80 Page 58
DHS Pharmacy Leadership Program proposal
F81 Page 58
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

Recommendations 11