Monday, May 9, 2016

Improving Medication Safety at Transitions of Care

Hi fellow Informatics colleagues (and supporters)!

At some point, most CMIOs, CNIOs, and other informatics professionals get asked to speak about topics related to healthcare technology. One of the topics I'm very passionate about is medication safety, so when I was recently asked by HomeWatch Caregivers and CareOne at Northampton to present on medication safety at transitions of care - I jumped at the chance!
At CareOne Northampton MA - May 4, 2016

Why do medication errors occur? What human factors and systems issues contribute to medication safety issues? And what can organizations do to help reduce them? To help answer these questions, I've posted the slides from my May 4th, 2016 CEU presentation at CareOne in Northampton below, along with some commentary (and helpful links) in between them. If you're looking for ways to further improve medication safety in your organization, I hope these slides are helpful to you!

First, to open the talk - a few slides about the presentation, and who I am : 

And a brief introduction to the important concept of non-maleficence, a principle which helps guide medical professionals in their interactions with patients. (Beneficience = Do good, non-maleficience = Do no harm) - along with an introduction to the landmark IOM report, To Err is Human (Kohn, Corrigan, Donaldson), which to me is a must-read for informatics and other clinical professionals :

Talk about topical - The day before my presentation, Dr. Martin Makary reported in the BMJBMJ 2016;353:i2139, published 3 May 2016) that medical errors are now the third leading cause of death (behind heart disease and cancer) - This article underscores the importance of understanding where errors come from, and how to prevent them!

So first, to understand how to talk about medication errors, it's helpful to talk about how to manage medications correctly : I call it the "Five RIGHTS of medication safety" - Giving the RIGHT medication at the RIGHT dose via the RIGHT route/method to the RIGHT patient at the RIGHT date/time. One could even add the Right Manner, and Right Reason/indication to this discussion, but to keep things simple, I've presented the five biggest sources :

So given that understanding of the goal, why do errors occur? Heuristics aside, what are the challenges in assembling and reconciling a "home medication list" on admission? Let's first look at the Five Rights, which will then help us understand where errors can occur :

Thank you to the Institute of Safe Medication Practices ( for providing the samples of illegible handwriting above - I highly recommend their web site, which is a treasure trove of important information about medication safety...
Finally, a few other potential sources of error : 

Which then brings us to the discussion on single source-of-truth (SSOT) - A discussion which is key in understanding the challenges, pitfalls, and opportunities in managing medications at transitions of care, and inside an organization : 

... and the importance of maintaining this/these source(s)-of-truth at all times :

This then brings us to the important discussion about medication safety at transitions-of-care - Again, a recent (April 29th, 2016) Washington Post article by Jordon Rau : "Hospital discharge: It's one of the most dangerous periods for patients" - provided the right context for this part of the discussion : 

And finally, this brings us to the very important discussion about polypharmacy and its unique contribution to patient safety issues : 

... which is also supported by this April 22, 2016 NYTimes article on "The Dangers of 'Polypharmacy', the Ever-Mounting Pile of Pills"

So what can people and/or organizations do to turn these safety challenges into great opportunities to reduce error? My five recommendations

And other resources to look for more information on medication safety : 

For those reading this blog, the above references (with hyperlinks) include : 
  1. Institute for Safe Medication Practices (ISMP) - 
  2. - Office of Disease Prevention and Health Promotion -
  3. National Academies Press - Institute of Medicine : To Err is Human Report :
  4. Agency for Healthcare Research and Quality (AHRQ) : 
I hope this discussion (and these slides) are helpful to you as you start to explore ways to further improve medication safety in your own organization!

Have other recommendations? Other lessons learned? Feel free to leave them in the comments section below!


Heather Leslie said...

Hi Dirk,

Great post highlighting the complexities we face, especially when we add technology into the mix.

Just a head up for some of related data standardisation work that the openEHR #clinicaljedi have been doing:
- Our adverse reaction risk archetype has just been published - the result of a journey lasting 9 years, and involving 92 reviewers from 16 countries PLUS an unknown number of reviewers from the HL7 CIMI and Patient Care communities. This represents agreed clinical content across the FHIR & openEHR standards and you can see the aligned information models here: and A description about that journey of cross-SDO collaboration is explained here:
- Our next major effort is standardising a medication order - from a simple take '1 tablet three times a day after food' through to complex IV administration, conditional orders, and sliding scales. This archetype has just commenced the review process and you can see it here:

I think the problems you have outlined are hard to solve, but certainly if we can start to standardise the data definitions we use for these tasks then we can mitigate some of the technical issues you raise. Standardised data specifications for our clinical content is critical if we want to do clever stuff with our health data outside proprietary application silos.

Would love to see more of your US #clinicaljedi colleagues join our community!



Dirk Stanley, MD, MPH said...

Heather - I remain a loyal fan of your work!! I need to check out your medical order archetype - Can't wait to see it1 May the Force continue to be with you1 ;)

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