Questions related to specific self-assessment items (listed in ascending order of numbered item)

#7 Our laboratory staff contacts a physician promptly if a test result falls outside of our established critical value range. Does this mean we have to establish a timeframe for reporting routine laboratory results?

Each organization should establish a time frame within which critical laboratory results that fall outside an established range are reported to a responsible caregiver. A simple example would be that patients receiving warfarin who have an INR greater than 6 should not receive another dose of medication before the practitioner has been notified and responded. Some organizations have established specific time frames (e.g., within one hour for potassium levels that fall above or below critical values) and repeat notification is done if a documented response to the test result is not received.

The Joint Commission on Accreditation of Healthcare Organization's (JC) 2005 National Patient Safety Goal "Improve the effectiveness of communication among caregivers" requires the organization to measure, assess and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. More information can be obtained by using this link to the JC website.

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsg_facts.htm

8. What does "responsible licensed healthcare provider" mean? Our laboratory notifies nursing staff immediately of all critical laboratory results.

The licensed healthcare provider would be a member of the medical staff who is responsible for the care of a patient and can write orders. The organization should have a procedure that requires that the medical staff member caring for the patient is notified within an established time frame. See the link above in FAQ #7 for further information.

15. What is meant by "dosing-corrected weight"?

For certain patients, ideal body weight or actual weight cannot be used to safely calculate the appropriate dose for an antithrombotic agent. The organization should have a medical staffapproved formula that identifies these patients (e.g., patient whose ideal or actual body weight falls outside of an established range) and provides a calculation for an adjusted weight that is used to provide the appropriate dose for the patient.

31. Explain the term "bridged" in this item.

When some patients are discharged on warfarin but have not yet achieved a therapeutic INR, physicians will prescribe a LMW heparin to be administered to the patient at home along with their warfarin therapy to provide adequate anticoagulation until their INR reaches a therapeutic level. The anticoagulation provided by the LMW heparin is often referred to as a "bridge" to the long-term anticoagulation that will be provided by warfarin. The organization should develop protocols that define when bridge therapy would be prescribed. Often the decision is based on the patient's diagnosis or type of surgical procedure that has been performed, (e.g., total joint replacement).

52. What are some examples of dose range checks that should be performed by computer systems?

Examples of medication orders to perform testing on your computer system can be found at the end of this document. These examples do not represent an exhaustive check of computer systems but can be used to identify categories (e.g., allergy checks, drug-drug interactions, maximum doses) of routine medication testing.

67. All of our prescribers directly enter orders into our CPOE system. Do I answer E for this item?

Unless your CPOE system is integrated or directly interfaced (See page 4 for a definition of interfaced) with your pharmacy computer system your answer should not exceed level C for this item. If pharmacy receives printed copies of orders from your CPOE system and/or must re-enter orders into the pharmacy system then your system is not fully integrated or interfaced.

68. Does this mean that any practitioner can screen medication orders in a computer system?

The intent of this item is that all new patient medication orders are entered and screened against the patient's total medication profile in an electronic system by a pharmacist before the medication is dispensed and administered unless it is an emergent lifesaving situation (e.g., cardiac arrest). In a hospital without 24-hour pharmacy service this process should be performed by a licensed healthcare professional when a pharmacist is not available.

78. In our facility, only saline is used to flush catheters. Do I answer E or NOT APPLICABLE (N/A) for this question?

You would answer NOT APPLICABLE (N/A) if heparin is not used as a catheter flush in your facility. Answer E only if heparin is used as a flush in catheter flushing protocols, and the pharmacy department provides ALL patient care units with either commercially prepared or pharmacyprepared prefilled heparin flush syringes.

81. Pharmacy supplies the majority of GPIIb-IIIa solutions, either premixed products or pharmacy prepared, but we also mix medications in the patient care area when pharmacy services are not available. Should I answer part (a) or part (b) of this item?

If you use manufacturer-prepared premixed GPIIb-IIIa platelet inhibitors and/or pharmacy-prepared GPIIb-IIIa platelet inhibitors then you should answer part (a). If you also prepare these products in the patient care area then you should not answer higher than a C or a D for this item.

Answer part (b) if the pharmacy does not dispense the manufacturer-prepared premixed product and/or the pharmacy does NOT prepare the product.

118. We have an interdisciplinary team that shares error experiences but we do not routinely convene in person. Should we still answer E for this item?

In our experience, organizations that have set a routine time to meet for the purpose of sharing and analyzing external and internal errors are more successful than those organizations that seldom meet or only meet when a sentinel event occurs. If you do not have routine face-to-face meetings your answer should not exceed C or D.

Sample Medication Orders for Computer Testing

Allergies and cross allergies

Lovenox 40 mg subcutaneously every 12 hours (patient with a heparin allergy)

Herbal-Drug Interactions

Patient taking Chamomile and also receiving warfarin
Patient taking St. John's Wort and also receiving warfarin

Contraindications/dose limits based on laboratory studies

Warfarin 5 mg daily (reported INR is 6)

Contraindications/dose limits based on patient age/weight

Fondaparinux 5 mg subcutaneously for 30 kg patient. (Fondaparinux should not be used in patients less than 50 kg.)

Single dose limit

Eptifibatide 30 mg IV bolus

Contraindicated route of administration

Heparin 5,000 units IM
Fondaparinux 5 mg IM

Therapeutic duplication within a drug class

Heparin infusion at a rate of 1,000 units/hr (patient on enoxaparin)
Heparin 25,000 units in 250 mL Dextrose 5% infuse at 1000 units/hr (patient received enoxaparin in emergency department within past 2 hours)