DIP Episode 234 - USMLE Nov 2020 Changes Series 3: Medication/Transition of Care Errors

Okay, welcome. My name is Devine, I'm a resident. This is episode 234 of the Divine Intervention Podcasts. And in this podcast, I'll be continuing the three SP curriculum, basically the changes that are coming to the USMEL exam. I think they've either studied this month or they're coming next month, one of the two. And today I'm going to be talking about two kinds of errors that are highlighted in the USMEL content outline. So I'm going to be talking about medication errors. And if I see that the podcast is not getting too long, I'll talk about transition of care errors. So those are the two big things I'm going to talk about. So let's just jump right into it. So basically, a medication error is any error that occurs from the time a clinician prescribes a medication to the time where the medication is delivered to the patient. And there are some terms I think probably useful to try to understand before we jump into how to prevent these medication errors. And again, these are all things that could easily be tested on a USMEL exam. One thing that's important to understand is what an adverse drug event is. Right? So an adverse drug event like the name says, right? Basically, it's just any kind of harm that is experienced by a patient as a result of being exposed to drugs, right? Pretty self explanatory. And for the most part, about half of these adverse drug events actually preventable.

So for the purposes of the USMEL exam, it would be important for you to understand some risk factors for you know, you know, the way your friends at the MBME, they really love their risk factors, right? So you definitely want to make sure you know the risk factors, adverse drug events. One is something known as a polypharmacy. And if a polypharmacy, this is very high, you know, polypharmacy is the biggest risk factor for adverse drug events. I'll see that again, this is super high you to know, polypharmacy is the biggest risk factor for adverse drug events on MBME exams, right? Basically, polypharmacy means you're getting more medications than it's clinically necessary, right? So like you see, you're putting five minutes, but you're like, man, I could maybe part of two of these medications. That's polypharmacy, right? Also being elderly is an important risk factor, right? Because as people get older, they tend to get more medical problems, you know, and then they tend to get more meds for those medical problems. Another risk factor is also like just being a pediatric patient because remember, it's many of these speed strokes, they have like weak-based dose in. So you need to do a little more math to like figure out the correct medication dose. And then also having like decreased health literacy, right? Because again, many of these drug instructions kind of hard to understand for people that are not in health care, right?

And also there's another risk factor is like having like a drug that look alike, like the tablets look very similar, or the drugs sound very similar, right? Like for example, right? Like if you're looking at like these, if you're looking at these diabetes drugs, right? Like glib your right and glimmer pride, right? Those drugs sound extremely, extremely extremely similar, right? So like similar sounding medications, those are things you kind of want to be careful of. And the thing is with regards to the elderly, there are some screening tools you can use to make sure that you're prevent you're almost like predicting the risk of an adverse drug event from taking a medication. Back in the day, and you may still see this on exams, there's this thing known as the beer scryteria. So B-E-E-R-S, the beer scryteria that was previously used. Just commit that to memory. You don't need to know like specifics of that. And but there's a newer one, right? That you may also see on your test that it's now being used and it's shown to be a little better than the beer scryteria. It's called the stop STO-WP. So two P's after the like basically two P's in the stop, right? So stop criteria. It's screening tool of older persons for inappropriate prescriptions. That's a newer set of criteria that's to be used. And the thing is with these medication errors, you actually want to know something I call hot spot medications. So these are again easily testable concepts.

Essentially there are four drugs that are responsible for about 50% of adverse drug events in the healthcare industry. And those four drugs are insulin, warframe, the anti-placid agents like aspirin and clopidogrel, and also the opioids. So insulin, warframe, anti-placid agents like aspirin and clopidogrel of the end opioids, right? They're responsible for about 50% of adverse drug events that happen in healthcare. And I mean like there are just some rules that you maybe want to keep at the back of your mind as well, right? Like benzodiazepines in general on MDME exams, you don't want to prescribe them to the elderly, right? And also if a person is for example having like a dental procedure or having like a low risk surgical procedure, you don't want to prescribe opioids for those patients. That's something that's high you to know for exams. And the thing is though I think the best way to frame how to prevent medication errors is to kind of go through like a four step pathway of how a medication goes from the clinician that edition he prescribed it to the patient, right? I feel like if we talk along those pathways and then talk about how you can prevent medication errors along those different pathways, then you have like a nice system in your mind for keeping this stuff straightforward for the exam. So the thing is basically right for a medication to go from a clinician to the patient, first the medication has to be ordered, right?

So you need to order that medication, you need to prescribe that medication. And then after that, that medication order has to be prescribed, right? So basically like the pharmacist, that's like looking at the order like, oh, you're seeing 30 milligrams per day for 60 days. And then the pharmacist then has to dispense the medication, the the pneumonia can use is OTDA, right? So you order the medication, first you transcribe the medication. So that's like the pharmacist receiving the information. And then the pharmacist has to dispense the information, dispense the medication, right? That's the D. And then the A means that the medication has to be administered. It can be by a nurse, by a caregiver, stuff like that, right? And one good thing is electronic health records. They've actually helped with this whole process of ordering and transcribing of prescription orders because you know, like back in the day, people write down medications, they write things down by hand, right? You've already introduced the source of error right there with the handwriting of the of the clinician or the of the nurse or whatever, right? So that's one thing that has been very helpful, right? But I think let's maybe go by step by one of those OTD steps and kind of talk about how you can decrease medication errors along those lines, right? So the first one relates to ordering, right? So when a person is ordering when you're ordering medications, right?

As a clinician, right, you want to prescribe conservatively, right? Again, you want to try to use the least amount of medication to get the most amount of effect, right? And all these high risk drugs in the elderly, you know, you want to be careful with those, right? Then if for example, a medication is known to cause, you know, like a lot of side effects or like this person's condition can get better without being treated, right? Don't give those people medications, right? So, you know, as the ordering clinician, right? Prescribe conservatively. And if you notice, I'm using the word clinician, I'm trying to avoid the word provider. The word provider just in generally medicine is a derogatory term for physicians. So as med students, I'll encourage you to not use that. You go get chewed out in the hospital if you did that. So don't use the word provider. Use the word clinician. That's a much better term. I use the word physician, right? Your doctor is not a provider. This is all those reasons why that's the case. I'm not going to go into that. This is not a political, a political discussion. Okay. So basically, right? So ordering, right? Again, you want to prescribe conservatively, right? And also the use of computerized order entry systems that are federed to a clinical decision support system is very helpful. So what do I mean by that?

Basically, like being able to generate like medication orders and send it electronically to the pharmacy instead of having to rely on your handwriting. And then a clinical decision support system is like something that scans the medical record and sees if there's any like patient factors that meet you like prescribed one medication or not prescribed this medication or prescribed a certain dose, right? So say, for example, like, let's say, you clinical decision support system is like, if a patient, let's say like in the medical record, it's been scanned and it's been shown that all this patient has like a vaginal cause of their aphabia, right? Then Wolfring is the drug you want to prescribe as anti-coagulation for those people. It wouldn't make sense to give them any of the novel or like the no-ox, right? Like the novel or an anti-coagulant under those circumstances. And then another thing that can also help you reduce a medication error at the point of ordering is also doing a medication reconciliation. Basically, at every transition like as you're going from one clinician to the other of a clinician to a nurse or whatever, you always want to do some kind of medication reconciliation. The primary person that should be doing medrex is the pharmacist, but as a physician, you have no excuse, as a nurse, you have no excuse. Every person that is involved in a patient's care should make it a point of duty to do medication reconciliation.

And the thing is I can envision in being me questions where they talk about these different OTD steps and they'll say, well, which of the following interventions is most likely to reduce the risk of medication error at this step in medication and prescription, right? So again, you want to kind of keep track of these different steps as I logically go through them. So I've talked about everything I want to do with order. Now from the transcribing process, I've kind of talked about the major things, right? Again, a computerized audit entry system. Again, you want to try to remove human handwriting as much as is possible. The only problem with these computerized systems is that sometimes they are walk around to these systems. And the thing is there's also like this increased cognitive load that physicians and clinicians need to expend in dealing with these things, right? I mean, like I know Epic and Surner and all these things, they've done awesome, awesome outstanding jobs like big congratulations to those companies, but having like worked in healthcare systems where again, document, document, document, and you have to click through this, click through that. Nothing introduces in ridiculous amounts of mental fatigue to the process. So those are kind of like the big things with the transcribing process. Now let's go to the D, the dispensing process, right? So the dispensing process, what are some things you can do to reduce medication errors under these situations?

One is the pharmacist, a clinical pharmacist must oversee the process, right? A clinical pharmacist most absolutely oversee the process. And then the thing you can use and this is something that I don't know, I will be so crazy if this doesn't show up on an in-beam exam. Is this thing known as Toman lettering, right? So Toman lettering, Toman lettering. Basically, Toman lettering is where if you have like drugs that are similar sounding or drugs that look alike, you take part of that drug's name and write it in operacist letters to make it more obvious to the person that is handling those medications. And especially for like, high risk medications, you want to try to use like automated dispensing cabinets, right? So that you can kind of get like standardized amounts. I know this is something that's done quite frequently by anesthesiologists, right? So something to keep in mind. And then if we go from the D to the A, right? So the administration process, the administration process, the big, big, big thing, like big, big, super high-yield thing you want to know is this thing known as the five right through, the five right through, right? So the five right through means you want to make sure that you want to give the right medication, you want to give the right dose, you want to give it at the right time, you want to give it by the right route, and you want to give it to the right patient. This is very important.

I'll say that again, you want to give the right medication at the right dose, at the right time, through the right route to the right patient. Those are the five hours. That's why it's called the five right through, okay? And another thing that can also help is if you use like barcoats, so like those things you have to scan, barcoats kind of ensure they're giving the medication to the right patient at the right dose and is the right medication, right? And another thing that has also been shown to help is you want to minimize interruptions in the process of medication administration. So if, for example, as a clinician, you're seen a nurse at mainstream medication, do not interrupt her. Let her administer the medication first before you do those kinds of things. And then another thing that also helps, especially with IV medications, is to use a smart infusion pump, the use of smart infusion pumps helps significantly with decreasing the risk of medication errors when you're giving IV meds, right? And see, for example, you know, you're sending a patient home and this patient takes like tons and tons of medications. You want to try to use something that's called like a multi-compartment medication device.

Basically, like you have like different like is like you have this big box of all the patients meds and then you have these little boxes where like each separate med is placed in, especially for people that are going to like long-term acute care, that's usually something very good to do. And then you know one good thing on the part of one other thing you can go on the part of the again, the clinician administering this medication, these medications is like just good patient education, right? Just spend the time. Don't spend 30 seconds on your distract process with a patient. Go over stuff with them. And in fact, I suspect I'll have time to talk about a transition of care errors. I'll talk about some things you can do that can really help with a patient care with a patient education, right? And just I guess some other key things, right? Again, don't forget that IV meds tend to be more prone to medication errors than oral medications, right? Because IV meds have to do all these calculations, milligrams per liter, by weight of the patient, over what time interval do you want to administer, blah, blah, blah, blah, blah, blah. So you know, it kind of takes a lot of, takes a lot out of you, right? And again, the most common medication error is administering medications at the wrong time. It's very high you to know. The most common type of medication error is administering medications at the wrong time. That's very high you to know, right?

And then just a few quick words on like opioid safety, right? So the opioid safety, I mean, I mentioned opioids as one of those are four drugs. I hope you remember the others, right? Insulin, Warframe, right? And type of lead drugs like aspirin and torpedo gruel and opioids, right? So opioids, right? Like opioid safety is kind of a big topic of these these in healthcare, right? And the root cause of opioid problems, right? Rup cause of like opioid medication errors is just an over-prescribed in a behavior in the part of a many physicians, right? In fact, in the US, I think there was like a study or something that was done that shows that the US prescribes 80, like of the prescription opioids that are like, you know, sent out to patients or prescribed to patients. The US was responsible for like 80% of the world's prescription opioids, right? And in fact, they did a study that every person in every country of the world could get a four weeks like four weeks supply of opioids per year, just based on the prescribing behavior of opioid, like the prescribing behavior attached to opioids in this country. So it's a huge problem, right? The thing is in general on MBME exams, you want to give opioids, but personally has like a cute traumatic pain, right? Basically they have like a bone fracture or they were in a big car accident or something. Those people deserve opioids, right? If a person has like cancer relief at pain, right? You can use opioids for that.

If a person has shortness or breath and they have cancer, right? Like they have a malignancy, morphine is the drug of choice on that those circumstances. So what are some things you can do to reduce like these like to encourage opioid safety, right? You want to use prescription drug monitoring program, especially at the sleep level. That's very important to know, right? And as a clinician, you want to use like a short course of opioids, right? For example, I remember for me during my intern year, I really give patients more than three days worth of opioids and I really give patients opioids period on a discharge, right? And also you want to use opioids only when it's clinically warranted, right? So you don't want to give patients opioids for headaches. That is not a good thing to do, right? That is not a good thing to do. It does not help. If a patient has been because they have an infection, giving an opioid is not a good idea there. Give anti-inflammatory medications like NSAI Ds, they've been shown to be superior to opioids under those kinds of circumstances. So let me slide right into transition of care errors. And basically what is the transition of care? A transition of care is basically where you're moving a patient from one health care setting to the other, right?

So like if a patient is moving from the ambulance to the emergency room or from the emergency room to the ward or from the ward to the ICU or from the emergency room to the ICU or from the ambulance to the ICU, right? Or going from the ICU back to a ward or going from the hospital to the home or from a hospital to like a long-term care facility. Those things are all transitions of care, right? And the thing is if you do transitions of care poorly, right? The two most likely complications are one, you'll increase the re-admission rate and two, there's also a high risk of adverse stroke events. So what are some things you can do to minimize transition of care errors? One thing you want to do is to try to use clearly-reaching discharge instructions and make sure you've done a medication reconciliation before you've done this, right? Make sure you write clearly-reaching, clearly well-explained discharge instructions to the patient, whether you put like very good detailed documentation that's been sent to long-term care facilities or nursing homes and stuff like that. And again, make sure that these instructions are easy to understand. Most EM Rs have like EH Rs, have EH Rs, EM Rs, doesn't matter. But like they have like like easy to read versions of patient care instructions, right? And then you also want to make sure that you've arranged follow-up. This is very high you'll to know.

If before a patient leaves the hospital, make sure that their follow-up has been properly coordinated. Like definitely follow-up, go to this physician, this address, at this date, at this time. If you can coordinate that before the patient leaves the hospital, that reduces the risk of a transition of care error, right? And then the third thing is using teach back, right? Using teach back. So basically, after you've explained the discharge instructions to the patient or to the receiving facility, have them explain back to you, right? That has been shown to reduce or that very, I don't know, pretty sure it has been shown, but in general, that has been shown to reduce. No, that has been propagated as a means of, again, I want to speak as, be as accurate as possible, you want them to say, that has been propagated as a means of decreasing a transition of care errors, right? And also using a checklist, like a discharge checklist is something that has also been propagated and is something you want to do on an NBME to reduce the risk of a transition of errors, right? So transition of care errors, because if you have a checklist where you are like, oh, I covered this, this, this, and this with the patient, right? That really helps. Now, one thing I think I want to talk about is handoffs, like patient safety in the context of handoffs. So the thing is, why are handoffs, accurate hand dost importance?

The thing is, as a physician or as a clinician, you cannot be in the hospital forever, right? I mean, like you can't be in the hospital for like 72 hours straight, right? You know, that's a recipe for like, you know, like fatigue and then you make all these errors because you know, human beings remember robots, right? So unfortunately, one problem that that creates is something known as discontinuity of discontinuity of care, discontinuity of care, right? discontinuity of care. So the thing is, because there's a lot of handoffs in the word of medicine, you want to try to make that process as accurate and as neat as possible. And there are certain things you want to use on MBME exams, some specifics you want to know on MBME exams with regards to reducing, like, making the handoff process as error free as possible. The first thing you want to do is you want to have well-written instructions, well-written instructions that you're handing off to the other team. That's one. The second thing you want to do is you want to make sure that it's done in a separate environment that is free of interruptions. That's very important. You don't want to do it in a place where like, or like, do it in like different places. You want to have it in a place like a standardized place that is free of interruptions, right? And then probably the highest deal thing you want to keep at the back of your mind with this is you want to use something known as I pass.

So the letter I and then PAS, the I pass method, right? So what does the I stand for? When you're doing handoffs, you want to accurately communicate the illness, severity. Like, is this patient someone that you need to watch closely? Or is this a patient that's fine? Or is this a patient that you know could become high risk very quickly? Right? That's the I. The P is for patient summary, right? So you want to essentially give like a short background on the patient. I'm not saying to give like a whole presentation. Just kind of give a short background on the patient. And then that will, that will definitely help. And then so like a patient summary, that's the P. And then the A stands for action list, right? So an action list are the specific things that the new team are supposed to do during the course of their shift, right? You want to communicate that clearly? And then the first S stands for situation awareness, right? So basically like it's like the situation awareness involves like if then statements like if for example the patient's blood pressure goes above 150 over 90, give hydrolysis, right? If above SOSO and SOSO threshold then give this, right? In fact, I remember during my transitional year, I you know sometimes when I'm putting in some medication orders, I'll put under the note like if this do this, if this then do that, right? If then statements are very helpful for situation awareness. And then the S is synthesis, synthesis by receiver.

Basically this is almost like teach back from the new team. So the new team be essentially teaching back like the key components or they are summarizing the key components of the patient's case just to make sure that everyone is on the same pitch, right? And again, the thing is if clinicians are communicating with each other or if a clinician is communicating with a nurse, again, read back is something that is very helpful, right? Read back is just basically like teach back, but in this case it's clinician to clinician, communication as against, teach back which is clinician to patient communication, right? That's high autonome. And then the last thing I'll talk about is the Zbar method in conversation between healthcare, healthcare practitioners, right? So S bar SBA, right? It's very useful for communication, it's very between nurses and clinicians, right? Nurses and physicians, right? So what does S bar stand for? So the S stands for like situation, right? So let's see for example, we want to communicate if a mission about a patient, the S stands for situation, we want to do this essentially describe what's going on. Let's see, this patient's blood pressure is going down, this patient is deteriorating, and then the B stands for a background, you want to give like just like in two or three sentences, what is like some key background on this patient, right?

So like, for example, you can see this patient has a history of MI's and they've been having a recurrent ventricular tachycardias, right? And then the A is your assessment, right? So like what do you think is going on with the patient, right? I can go say, I'm beginning to see ST elevations on telemetry, right? Like what's your professional conclusion based on what you're seeing? And then the R is for recommendation. And basically the R is where you tell the clinician what you want them to do for you. Let's say for example, it's a physician, you're like, I want you the cardiologist to come down and evaluate the patient, right? So that's what S bar stands for. S is for situation, B is for background, A is for assessment, and R is for recommendation. So if you know these things, I if you know all I've talked about in this podcast, I suspect you should be able to answer pretty much any medication, uh, uh, medication, uh, error or transition of care error question you may see on your test. And as I do at the end of every podcast, I do offer one or one tutoring for many exams for step one, step two CK, step two CS and step three pre clinical medical exams, 30-ish-elf exams. If you're a medicine resident, I need tutoring for the, uh, if you're medicine or a piece resident, I need tutoring for your entry in exams or for your boy exams, I offer tutoring for all those things. And then, um, what else do I want to say? And I do two separate things, right?

So I do these things called booster courses. It's 20 hours for step one, 20 hours for step two CK, 20 hours for step three. Basically, we review the most notes, the highest of the high yields for these are respective exams. It's like in an integrated format, it's either like 21 hour sessions or two or 10 to hour sessions. And we basically review the most notes like integrated format, Q and A format, uh, for these are exams. Again, many people have had very nice score increases after going through these booster courses. And then also offer this thing called longitudinal tutoring, where, you know, if you're studying off med school or you're studying off third year, I'll kind of tutor you for all your block exams or all your shelf exams, but at the same time, I'm also tutoring you for your upcoming USMLA exam. Again, I've done this with people. They found it to be extremely helpful. And then I do like some coaching with regards to like the application process, right? So if you're a student or plan to residency, so like an ERAS application or a college student or plan to a med school, so like an AMCA application, again, I have tons of experience with helping people that, you know, like personal statement, recommendation letters, mock interviews by specialty, I've worked with people from many specialties, um, um, you know, like putting your application together nicely. Again, I've worked with tons of people.

If you have like a tricky application, like low scores, no research, foreign medical graduates, graduated from med school a long time ago, or you have like something odd about your application that you need to explain away. Just reach out to me again, I've worked with people in tricky situations and the vast majority of people have worked with have pretty much all my student first choices. So if that's something you're interested in and I've actually been on an admissions comment table for it. So I know how these games are played. I know how to make you put your best foot forward. So if that's something you're interested in, please do feel free to reach out to me. And please, if you also have like a college buddy that needs tutoring for like any of the MCAT subjects or any of the pre-med subjects reach out to me and I'll be happy to point them in the right direction. And then please subscribe to the You Tube channel. The You Tube channel is the, uh, it's called Divine Intervention USMD Podcasts and Videos. I'll post videos periodically to that You Tube channel. And then please subscribe to the Word Press website is Divine Intervention Podcasts with an Savvn.com and I also have these podcasts on Spotify, on Google Play, on Apple Podcasts. So please subscribe, that's always very helpful.

And, you know, if there are any specific podcasts you want me to make, just shoot me an email or if you want to reach out to me on visa, the one on one tutoring I offer, you can either reach out to me through the website or you can send me an email at Divine Intervention Podcasts with an Savvn.com at gmail.com. And then the last thing I want to talk about today, so my life lesson, my life lesson for today is the importance of using checklists, the importance of using checklists or should I call them maybe algorithms. The thing is clinically in medicine. Or let me put it this way. In general, if you want to accomplish anything in life that involves many moving parts and you want to be able to accomplish it with very high fidelity, you want to use checklists, you want to use like, you want to have an approach to think. This is one thing and I suspect that probably in the very near future, make a podcast on some of these things like rounding efficiently or pre rounding efficiently or writing your notes efficiently or senior admissions efficiently. But one thing that has helped me tremendously, like this was almost like my approach to every new thing in med school, where my third year rotations, during my intern year, where I was doing like ICU rotations and all that stuff. One thing that I found to be helpful is the first two or three days of a new rotation, I spent a lot of time observing things, just observing, observing, observing, observing.

And then as I observed, people doing things and doing it well, I think came up with my own checklist, with my own approach, with my own mental model, with my own algorithm, for dealing with those things. So this was almost like a constant throughout most of my rotations. The first two or three days of rotation, it took me a really long time to get things done, because I'm observing and creating my mental model and checklist. What I noticed once I created that checklist, I then committed that checklist to memory and then I used it with every patient for every situation. And that increased my efficiency significantly. Again, I'm not trying to say this to most, but I remember in my intern year, even as an ICU, when I had my ICU rotations, I may sometimes have like six patients, six, seven patients in my care. Again, obviously it depends on many factors like the severity of your condition. And I could be done with pre-rounding, writing my notes, putting in orders, interfacing with the nurses, seeing the patients, everything in like two hours or less. So that kind of efficiency comes when you have a checklist approach. Even in taking exams, I have like, I have like approaches I used to taking exams. And when I tutor people, I almost like make like a mental checklist for them to follow when they are taking exams, so that you take all the emotional out of the process. And then you you are essentially like super, super, super efficient with that process.

So I will encourage you like for many things in life, try to develop a checklist, try to develop a mental model and algorithm. It usually does help. So thank you for listening to this podcast. I will continue with this clean SP curriculum. And I will see you in the next podcast. Thank you for listening. Have a wonderful weekend. Stay safe and practice social distancing. God bless you. Thank you.

Any kind of harm experienced by a patient resulting from exposure to drugs.

Polypharmacy (taking more medications than clinically necessary).

Insulin, Warfarin, Antiplatelet agents (aspirin/clopidogrel), and Opioids.

The pharmacist.

Having the patient explain back the discharge instructions to confirm understanding.

Illness Severity (assessing if the patient needs close monitoring).

STOPP/START criteria.

Right medication, right dose, right time, right route, and right patient.

To make similar-sounding or look-alike drugs more obvious by writing parts of their names in capital letters.

Teach back is used when communicating with a patient; Read back is used during communication between clinicians (e.g., nurses to doctors).

Increased readmission rate and high risk of adverse stroke events.

IV medications.

STOPP/START criteria.

Right medication, right dose, right time, right route, and right patient.

To make similar-sounding or look-alike drugs more obvious by writing parts of their names in capital letters.

Teach back is used when communicating with a patient; Read back is used during communication between clinicians (e.g., nurses to doctors).

Increased readmission rate and high risk of adverse stroke events.

IV medications.