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PATIENT SAFETY INITIATIVE: MEDICATION ADMINISTRATION CROSS CHECK.
Presented by: Dr. Sabina Braithwaite, EMS System Medical Director.
RECOMMENDED ACTION: Receive and file.
Body
The Office of the Medical Director in partnership with Sedgwick County EMS would like to share a unique initiative we have developed to improve patient safety.
Awareness of safety in emergency medical services is increasing significantly, most recently with the development of the National EMS Culture of Safety Strategy. Provider safety, community safety, and patient safety are the domains being addressed within this strategy. The Institute of Medicine's (IOM) report, To Err Is Human: Building a Safer Health System, noted that medication-related errors are a significant cause of morbidity and mortality.
Through our provider credentialing process we identified an opportunity for a system level improvement in the area of patient safety, specifically the need to assure that medications are consistently correctly administered to patients we serve in the unique EMS environment. It was clear that there was no consistent approach to assuring the classic "5 rights" of medication administration: right patient, right medication, right dose, right time, right route. More current thinking from the Institute for Healthcare Improvement, Institute for Safe Medication Practices and other leaders have shown this method to be ineffective at preventing medication error as it provides no specific process.
Rather than continuing to remediate individuals or hold them responsible when no process or procedure exists, we chose a systems approach. We designed the Medication Administration Cross Check specifically for use in the EMS environment. This process has been presented at two national meetings this year (the National Association of EMS Physicians and the US Metropolitan Medical Directors Consortium Gathering of Eagles) and has garnered a considerable following across the country and even internationally, so we wanted to share an overview with the Board today.
The Medication Administration Cross Check (MACC) addresses some of the risks inherent in the EMS environment that place patients at risk of error, including lack of a written medication order, lack of cross check, high risk medications, and time-sensitive medical conditions. It was designed for moderate sensitivity and high specificity in practice-it cannot catch every error, but is designed to trap those of highest impact (such as incorrect medication).
Elements:
1. Evaluation: assessment of current practices, evaluation of magnitude and frequency of errors
2. Design and beta testing of a specific cross-check process, designed to be simple, brief, work in the EMS environment, and to trap the majority of significant potential errors before they reach the patient.
3. Educational curriculum to highlight the reasons for the MACC and how to correctly apply it. Distance learning support and videos to assure consistency of message and practice.
4. Development of a reporting mechanism and trending of errors, near misses and predicted error rates.
In alignment with the organizational shift at Sedgwick County EMS to a Just Culture approach, this initiative provides an assessment of the process of medication administration in our environment, and design of a specific process and procedural rules designed to produce the desired outcome: consistently correct medication administration.
Alternatives: N/A
Financial Considerations: N/A
Legal Considerations: The authority for this action is K.S.A. 65-6126. A simple majority vote is required.
Policy Considerations: N/A
Outside Attendees: none
Multimedia Presentation: PowerPoint