- Email: [email protected]
A Multidisciplinary Team Approach to Reducing Medication Variance
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The medication safety team worked toward promoting a nonpunitive reporting environment, developing a collaborative medication administration policy, and designing an education and communication plan that promoted safe medication practices.
A Multidisciplinary Team Approach to Reducing Medication Variance TERRI A. SIM, RPH JULIE JOYNER, RN
A
t Williamsburg Community Hospital, for everyone from the board of directors to the clinician, patient safety has been identified as a top priority. This article describes the hospital’s initiative to improve medication safety, with a focus on work undertaken to reduce medication variance.
Establishing the Initiative to Improve Medication Safety Setting Williamsburg Community Hospital is a 139-bed acute care hospital located in Williamsburg, Virginia. The hospital employs approximately 900 full-time equivalents (FTEs), including 28 employed physicians, and has a medical staff of approximately 150 physicians. The hospital provides a wide variety of acute care, critical care, emergency care, and surgical and diagnostic services. Terri A. Sim, RPh, is Chief Operating Officer, Williamsburg Community Hospital, Williamsburg, Virginia. Julie Joyner, RN, is Director of Critical Care and Emergency Services. Please address requests for reprints to Terri A. Sim, RPh, Chief Operating Officer, Williamsburg Community Hospital, 301 Monticello Ave, Box 8700, Williamsburg, VA 23187-8700; phone 757/259-6280; fax 757/259-6473; e-mail [email protected]. Copyright © 2002 by the Joint Commission on Accreditation of Healthcare Organizations
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The Medication Safety Team The Medication Safety Team at the hospital was formed in March 2000 to analyze data related to medication variance reports and develop strategies to reduce the incidence of medication variances. A medication variance is defined as an event that occurs, or may occur, that is a deviation from the expected practice of prescribing, administering, or dispensing medications. The team is composed of representatives from nursing, pharmacy, performance improvement, and administration. The team’s original philosophy was to develop educational strategies to address the variance and to develop a corrective action plan for the involved staff members. The team joined the (VHA; Dallas, Tex) Clinical Advantage Patient Safety Initiative in May 2001. The VHA process allowed the team to become more focused and goal oriented, as well as to move along a quicker time line. With the VHA’s involvement, the team quickly changed direction regarding how to address medication variances. The team began to focus on the processes that led to the variance, as opposed to the individual involved, and sought to build safety nets around those processes. The primary objectives of the team were to ■ promote a nonpunitive reporting environment; ■ develop a comprehensive collaborative medication administration policy; and
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THE JOINT COMMISSION Article-at-a-Glance Background: In March 2000 a multidisciplinary team was formed at Williamsburg Community Hospital (Williamsburg, Virginia) to address medication-related patient safety initiatives. Medication Safety Team: The team focused on promoting a nonpunitive reporting environment, developing a collaborative medication administration policy, and designing an education and communication plan that promoted safe medication practices. In creating a nonpunitive environment, the first step was to revise the medication variance reporting policy. The team focused on process improvement and removed all references to corrective action from the policy. It launched an extensive educational effort throughout the hospital to raise awareness of the change in policy and to increase the focus on patient safety initiatives. The team also oversaw development of a comprehensive medication administration policy, which consolidated nursing, physician, and pharmacy practices. The
■ design an education and communication plan that promotes safe medication practices.
Revising the Medication Variance Policy In creating a nonpunitive environment, the first step was to revise the medication variance reporting policy. The team focused on process improvement and removed all references to corrective action from the policy. It launched an extensive educational effort throughout the hospital to raise awareness of the change in policy and to increase the focus on patient safety initiatives. Posters were developed and displayed throughout the hospital. An educational brochure for staff members and patients was created, and a booth on medication safety was developed for the hospital safety fair. A survey of the clinical staff revealed a need to simplify the reporting system. A phone line was installed in the performance improvement office to provide an easy method for staff members and physicians to report medication variances. The team also focused on the need to report medication variances that were identified prior to medication administration. (An example would be a transcription error by the pharmacy that is caught on review of the medication administration record by the nursing staff.) Reporting and trending the transcription errors resulted in improvements in the organization of med-
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team implemented a number of quick fixes that generated momentum and provided some immediate successes. Results: Within a 9-month period (May 2001— January 2002), the number of reports doubled. As the number of variance reports increased, a subcommittee formed, with the specific responsibility of reviewing the reports on a weekly basis. Discussion: The team sought to change the environment and attitudes related to medication variances and reporting. This was an organizationwide change that required employees to change their perceptions regarding the purpose of reporting. Implementing the changes in small bites to realize immediate successes helped provide the impetus to keep the team focused and energized in tackling this huge endeavor. The team provided the ability to solve problems and recommend changes quickly and effectively from a variety of perspectives.
ication orders on the medication administration record. By focusing on these near misses, we have been able to expand our efforts in reviewing processes. A benchmark for success was to actually see an increase in reporting of medication variances. This goal was realized as we recorded a twofold increase in reporting between the May 2001 baseline measurement and January 2002. The Medication Safety Team also sought to develop a comprehensive medication administration policy.* Before 2001, there were a number of nursing, pharmacy and medical staff policies that addressed medication administration. The team consolidated the policies into one comprehensive medication administration and safety policy that combines the policies and procedures. The policy addresses the use of abbreviations, hard-to-read orders, incomplete orders, and specific guidelines regarding certain high-risk medications. The policy has been extensively reviewed and modified throughout the initiative and has been approved by the medical executive committee. The medication administration policy was tackled a piece at a time and presented for approval in small sections. Introducing the practices embedded in the new policy and getting approval in small bites allowed the team to implement changes quickly and provided an additional communication tool to intro-
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duce activities of the team. Support was required from the medical staff leadership on major issues, such as the elimination of the “resume home medications” order, the guidelines regarding the use of abbreviations, and standards related to handwriting legibility. Since implementation of the policy, the credentials committee has required one physician to dictate all progress notes because of ongoing issues with his handwriting. Education and communication were and continue to be major initiatives. A nursing practice survey (Appendix 1, p 407) was conducted in September 2000 to focus on actual practices related to medication administration and to provide feedback regarding the process for reporting medication variances. The form for reporting medication variances (Appendix 2, p 408) was revised in November 2000 to include more information related to causes, outcomes, process issues, and follow-up. Nursing staff members identified medications used on their unit that were considered high risk or problem prone, or were used infrequently. From this assessment, a unit-specific self-learning packet including educational competency assessments was developed. For example, an annual competency for the administration of dobutamine is required for nurses working on the medical–surgical units but not for nurses in the critical care areas, where the medication is used more frequently.
Process Improvements The team completed the Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment™1 and the VHA Patient Safety Organizational Assessment. These two evaluation tools allowed the team to focus on specific processes and helped identify some relatively easy improvements that could be implemented quickly. Examples of these quick fixes and process safety nets can be found in Table 1 (right). The team’s experience of success had a positive impact on its momentum and focus. The quick fixes provided immediate feedback in terms of measurable improvements in patient safety measures. The ISMP survey also provided much-needed objective data on other changes, such as the elimination of vials of potassium chloride from nursing units and the importance of limiting access to medications via the Pyxis® (Pyxis Corp, San Diego) dispensing system.
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Table 1. Quick Fixes and Process Safety Nets* ■
■
■ ■
■
■
■
■
A dedicated phone line in the pharmacy was installed for faxing time-sensitive orders, including those for stat medications, heparin, and antibiotics. A list of antibiotics was distributed to all nursing units to assist the unit secretaries in identifying orders that needed to be started in a timely manner. Verbal orders for chemotherapy are not allowed. All pediatric medications require a patient weight before they may be dispensed. On the night shift, when the pharmacy is closed, the oncall pharmacist is called, and pediatric medication orders are checked by the pharmacist before dispensing. Neuromuscular blocking agents are stocked only in the ICU, OR, and ECC. They are stored separately from other medications and packaged in neon-green sealed bags that have external labels and warnings. The “Resume Medications from Home” order is prohibited. All medication orders must be completely written. The same is true for orders to resume medications postoperatively and/or on transfer to or from the ICU. Medications available on an emergency basis through Pyxis without requiring entry of the order into the pharmacy information system by a pharmacist, were reviewed for appropriateness of that classification, and a number of changes were made to reduce availability. Two nurses must verify any IV administration rate changes for insulin and heparin.
* stat, immediate; ICU, intensive care unit; OR, operating room; ECC, emergency care center; IV, intravenous.
When Pyxis was implemented, the knowledge that the drugs were “right there” on the nursing unit gave rise to the expectation that there would be immediate access. The focus on control, the importance of maintaining existing safeguards through pharmacist review of orders, and the more widespread distribution and discussion of serious medication errors has helped reinforce the need to limit access to medications. The belief that the pharmacy does not trust nurses to correctly withdraw medications from Pyxis on an emergency basis before pharmacy review of the medication order has been corrected through the educational process related to the reasons for the controls. The medical staff has also been supportive of the changes.
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THE JOINT COMMISSION Results An initial increase in the reporting of medication variances was expected—and it did occur. Within a 9month period (May 2001–January 2002), the number of reports doubled. The Medication Safety Team was overwhelmed with the volume, and it formed a subcommittee to review the variances on a weekly basis, focusing on process issues and potential improvement opportunities. The subcommittee is composed of the Medication Safety Team leader, the chief operating officer [T.A.S.], a clinical director, the pharmacy director, and the education director. These different perspectives provide the format for a comprehensive and objective review of all the issues, and recommendations for improvement can be implemented quickly. The data related to the variances are summarized and reviewed by the Medication Safety Team and by the pharmacy and therapeutics committee. With process changes, the number of reports has leveled off and is expected to continue at a stable rate. There has been a decline in the number of variances in certain areas, such as transcription errors and dose omissions, as process changes have been made.
the hospital was invited to participate in the Clinical Advantage Patient Safety Initiative. The Medication Safety Team at Williamsburg Community Hospital joined several other hospitals in the region to implement changes to improve patient safety. Although the teams operated independently to facilitate changes within their specific institutions, the opportunity to network and share ideas contributed to the success of the team. With the help of the VHA initiative, nine key aspects within six domains were identified as objective measures of the team’s success (Table 2, below). At the end of the formal VHA initiative in May 2001, Williamsburg Community Hospital’s performance ranked it in the top quintile for three of the measures, in the second quintile for five measures, and in the third quintile for the remaining measure. The team was able to show improvement in eight of the nine measures, with the greatest improvements noted in assessment of risk of error, evaluation of a competitive/collaborative environment, and promotion of a nonpunitive culture. Opportunities for improvement remain in all areas but are greatest in evaluating the competitive/collaborative environment and in establishing rewards and recognition for reporting errors.
Discussion Continued education of the staff and the physicians is critical to success. It needs to be an ongoing process, and it needs to stay interesting and applicable. The Medication Safety Team continues to provide information related to medication safety at the hospital safety fairs and shares its progress at department leader, quality board, patient safety, and medical staff meetings. Team composition is also critical to success. The multidisciplinary team provides the ability to solve problems and recommend changes quickly and effectively from a variety of perspectives. Through its VHA membership, in May 2001
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Table 2. Key Aspects and Domains of Patient Safety Domain
Key Aspect of Safety
Leadership
Demonstrate patient safety as a top leadership priority Promote a nonpunitive culture for sharing information and lessons learned
Strategic Planning
Routinely conduct an organizationwide assessment of the risk of error and adverse events in care delivery processes Actively evaluate the competitive/collaborative environment and identify partners with whom to learn and share best practices in clinical care
Information and Analysis
Analyze adverse events and identify themes across events
Human Resources
Establish rewards and recognition for reporting errors and safety-driven decision making Foster effective teamwork, regardless of a team member’s position of authority
Process Management
Implement care delivery process improvements that avoid reliance on memory and vigilance
Patient and Family Involvement
Engage patients and their families in care delivery workflow process design and feedback
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QUALITY IMPROVEMENT and updates are given to the board of directors and the medical executive committee on a monthly basis. Further plans include repeating both the ISMP survey and the VHA Patient Safety Organizational Assessment in 2002 to further demonstrate the far-reaching impact of the team and to continue to identify areas for improvement. A full disclosure policy is in the draft stage of development and will be one of the next major projects. The Medication Safety Team continues to flourish, reflecting the positive outcomes from the changes that it has overseen. J
The major roadblocks for the team include the lack of a physician order entry system and the integration of patient-centric information, including an electronic medical record and a rules-based system to increase safety nets. Implementing these improvements is on information, technology’s strategic plan, and the team will be participating in the selection of products that will be implemented in the future. Although the team has been able to accomplish many goals and has maintained focus and momentum, finding time for meetings and for implementing the changes continues to challenge team members. A tremendous amount of work has been accomplished. The medication administration policy was a huge undertaking that took months to complete but is truly a comprehensive product that achieved a number of goals. The education and communication plan raised the level of awareness throughout the organization. The team reports regularly to the quality board,
* Copies of the document are available (for a printing and mailing charge) from Terri Sim.
Reference 1. Institute for Safe Medication Practices: ISMP Medication Safety Self-Assessment™. Hunt-
ingdon, PA. www.ismp.org/ Survey.Survey_instructions.html (last accessed May 1, 2002).
Appendix 1. The Medication Adminstration Practice Survey: September 2001 Anonymous
In an effort to understand the current medication practices, this survey is being circulated to all patient care units and departments in the hospital. Please take the time to complete this survey and return it to the Quality Department. 1. Do you check the patient’s armband 100% prior to administering medications?
q yes
q no
2. Do you prepare and carry more than 2 patient medications with you?
q yes
q no
3. Do you label the medication cup with the patient’s name and room number?
q yes
q no
4. Do you open the single-dose medications at the patient’s bedside?
q yes
q no
5. Do you label syringes with the medication, name, patient name, and room number?
q yes
q no
6. Do you ever administer medications that another nurse has prepared?
q yes
q no
7. Do you consistently have insulin and heparin doses double-checked by another nurse?
q yes
q no
PLEASE MARK THE DEPARTMENT WHERE YOU WORK: q ECC q FMC
q GCC q ICU
q PCU q Surgical Services
q M/S q WCC q HHC
A nursing practice survey was conducted in September 2001, to focus on actual practices related to medication administration and to provide feedback regarding the process for reporting medication variances. ECC, emergency care center; FMC, family maternity center; GCC, Gloucester Convenient Care; ICU, intensive care unit; PCU, progressive care unit; WCC, Williamsburg Convenient Care; M/S, medical–surgical; HHC, home health care.
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THE JOINT COMMISSION Appendix 2. Williamsburg Community Hospital Medication Variance Reporting Form Williamsburg Community Hospital
q Med variance call-in report
Patient: _______________________________ Age: _______ MR #: _____________ Patient’s Room: Unit(s) involved ________________________________ Event time: ___________ Day: _________ Date: Variance reported by: ________________________________________________________ Date: Dr. _____________________________________________ notified on ____________________________ at q Medication Variance
q ADR (Adverse Drug Reaction)
Drug(s): _____________________________________________ Staff involved _____________________________________________ Causes of variance:
q Did not receive drugs Family notified: q yes
q no
Brief description & clinical action taken:
Prescribing q legibility q incorrect order q confusing order/instructions q other Processing q computer entry error q transcription error q error checking MAR q no order to/received by pharmacy q other Dispensing q filled incorrectly q mislabeled q delay in receipt q unavailable q names of meds look alike q labels of meds look alike q other Administering q performance issue related q procedure/policy not followed q knowledge deficit q distractions q miscalculation q code blue situation Monitoring q IV infiltration q IV clotted/dislodged Other q count discrepancy q other
The form for reporting medication variances was revised to include more information related to causes, outcomes, process issues, and follow-up. MR, medical record; MAR, medication administration record; IV, intravenous; TJ [T.A.S., J.J.], the subcommittee formed to review medication variances weekly; IM, intramuscular; SC, subcutaneous; PO, by mouth.
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Appendix 2. Williamsburg Community Hospital Medication Variance Reporting Form (continued) Proposed action plan if necessary (to be completed by Clinical Director) Manager follow up: q Team coordinator reviewed q 2nd manager reviewed q TJ reviewed q Director
q Discussed with staff involved q Refer to the Medication Safety Team
Variances
Point Assignments
Omission Wrong time Incorrect solution rate or hour infused Drug incompatibility Transcription Errors not identified: inadequate 24 hour chart check Wrong dose Extra dose Med given when there are indicators for withholding it Mechanical error (ie: wrong tubing) Wrong medication or IV solution Wrong patient Medication given without a physician order Wrong route score given:
1 for each dose 1 each 1 for each hour infused 1 each 1 each 1 each 2 each 2 each dose 2 each 3 each 4 each 4 each 4 each IV (4 each) IM/SC (3 each) PO/SC (2 each)
totals
PATIENT OUTCOME q 0 No injury; Variance discovered prior to medication administration, thus drug not given q 1 Variance resulted in no harm to patient q 2 Temporary injury; Additional patient monitoring required q 3 Temporary injury; Variance resulted in a change in vital signs or the need of additional laboratory tests q 4 Serious; Variance that requires treatment and results in an increased length of stay q 5 Severe; Variance that requires intensive medical care or cause permanent harm to the patient POINT
CLASSIFICATION OF DRUGS
1 point
Topical dermatological agents, pediculicide, antiemetic, anti-dandruff shampoo, acne preparations, local anesthetics, vitamins/minerals, antipyretics, unmedicated IVs, expectorants, antitussives, oral contraceptives, cathartics, laxatives, antidiarrheal agents, antacids Eye drops, anti-inflammatories, antidepressants, antihistamines, estrogens, progestins, muscle relaxants, non-narcotic analgesics, complex IVs, non-barbiturate sedatives, hypnotics, anti-Parkinson’s agents, alcohol abuse deterents, vaccines, immune serum, lactation suppressants Antibiotics, anti-infectives, anticonvulsants, barbiturates, diuretics, oral antidiabetic agents, narcotic antagonists, steroids, glucose 50%, glucagon Bronchodilators, cardiovascular drugs, narcotic analgesics, electrolytes, calcium metabolism regulators, oxytocics Anticoagulants, thrombolytics, chemotherapeutic drugs, antineoplastic agents, blood/blood components, hyperalimentation, hypolipidemic agents, insulin, medication given to children less than 12 years or under 80 pounds
2 points
3 points 4 points 6 points
Score: variance + classification X outcome = Points q After completion of medication variance report, forward to Pharmacy Coordinator q Pharmacy to forward report to Patient Care Quality Counsel Coordinator
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Assigned by
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The medication safety team worked toward promoting a nonpunitive reporting environment, developing a collaborative medication administration policy, and designing an education and communication plan that promoted safe medication practices.
A Multidisciplinary Team Approach to Reducing Medication Variance TERRI A. SIM, RPH JULIE JOYNER, RN
A
t Williamsburg Community Hospital, for everyone from the board of directors to the clinician, patient safety has been identified as a top priority. This article describes the hospital’s initiative to improve medication safety, with a focus on work undertaken to reduce medication variance.
Establishing the Initiative to Improve Medication Safety Setting Williamsburg Community Hospital is a 139-bed acute care hospital located in Williamsburg, Virginia. The hospital employs approximately 900 full-time equivalents (FTEs), including 28 employed physicians, and has a medical staff of approximately 150 physicians. The hospital provides a wide variety of acute care, critical care, emergency care, and surgical and diagnostic services. Terri A. Sim, RPh, is Chief Operating Officer, Williamsburg Community Hospital, Williamsburg, Virginia. Julie Joyner, RN, is Director of Critical Care and Emergency Services. Please address requests for reprints to Terri A. Sim, RPh, Chief Operating Officer, Williamsburg Community Hospital, 301 Monticello Ave, Box 8700, Williamsburg, VA 23187-8700; phone 757/259-6280; fax 757/259-6473; e-mail [email protected]. Copyright © 2002 by the Joint Commission on Accreditation of Healthcare Organizations
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The Medication Safety Team The Medication Safety Team at the hospital was formed in March 2000 to analyze data related to medication variance reports and develop strategies to reduce the incidence of medication variances. A medication variance is defined as an event that occurs, or may occur, that is a deviation from the expected practice of prescribing, administering, or dispensing medications. The team is composed of representatives from nursing, pharmacy, performance improvement, and administration. The team’s original philosophy was to develop educational strategies to address the variance and to develop a corrective action plan for the involved staff members. The team joined the (VHA; Dallas, Tex) Clinical Advantage Patient Safety Initiative in May 2001. The VHA process allowed the team to become more focused and goal oriented, as well as to move along a quicker time line. With the VHA’s involvement, the team quickly changed direction regarding how to address medication variances. The team began to focus on the processes that led to the variance, as opposed to the individual involved, and sought to build safety nets around those processes. The primary objectives of the team were to ■ promote a nonpunitive reporting environment; ■ develop a comprehensive collaborative medication administration policy; and
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THE JOINT COMMISSION Article-at-a-Glance Background: In March 2000 a multidisciplinary team was formed at Williamsburg Community Hospital (Williamsburg, Virginia) to address medication-related patient safety initiatives. Medication Safety Team: The team focused on promoting a nonpunitive reporting environment, developing a collaborative medication administration policy, and designing an education and communication plan that promoted safe medication practices. In creating a nonpunitive environment, the first step was to revise the medication variance reporting policy. The team focused on process improvement and removed all references to corrective action from the policy. It launched an extensive educational effort throughout the hospital to raise awareness of the change in policy and to increase the focus on patient safety initiatives. The team also oversaw development of a comprehensive medication administration policy, which consolidated nursing, physician, and pharmacy practices. The
■ design an education and communication plan that promotes safe medication practices.
Revising the Medication Variance Policy In creating a nonpunitive environment, the first step was to revise the medication variance reporting policy. The team focused on process improvement and removed all references to corrective action from the policy. It launched an extensive educational effort throughout the hospital to raise awareness of the change in policy and to increase the focus on patient safety initiatives. Posters were developed and displayed throughout the hospital. An educational brochure for staff members and patients was created, and a booth on medication safety was developed for the hospital safety fair. A survey of the clinical staff revealed a need to simplify the reporting system. A phone line was installed in the performance improvement office to provide an easy method for staff members and physicians to report medication variances. The team also focused on the need to report medication variances that were identified prior to medication administration. (An example would be a transcription error by the pharmacy that is caught on review of the medication administration record by the nursing staff.) Reporting and trending the transcription errors resulted in improvements in the organization of med-
404
team implemented a number of quick fixes that generated momentum and provided some immediate successes. Results: Within a 9-month period (May 2001— January 2002), the number of reports doubled. As the number of variance reports increased, a subcommittee formed, with the specific responsibility of reviewing the reports on a weekly basis. Discussion: The team sought to change the environment and attitudes related to medication variances and reporting. This was an organizationwide change that required employees to change their perceptions regarding the purpose of reporting. Implementing the changes in small bites to realize immediate successes helped provide the impetus to keep the team focused and energized in tackling this huge endeavor. The team provided the ability to solve problems and recommend changes quickly and effectively from a variety of perspectives.
ication orders on the medication administration record. By focusing on these near misses, we have been able to expand our efforts in reviewing processes. A benchmark for success was to actually see an increase in reporting of medication variances. This goal was realized as we recorded a twofold increase in reporting between the May 2001 baseline measurement and January 2002. The Medication Safety Team also sought to develop a comprehensive medication administration policy.* Before 2001, there were a number of nursing, pharmacy and medical staff policies that addressed medication administration. The team consolidated the policies into one comprehensive medication administration and safety policy that combines the policies and procedures. The policy addresses the use of abbreviations, hard-to-read orders, incomplete orders, and specific guidelines regarding certain high-risk medications. The policy has been extensively reviewed and modified throughout the initiative and has been approved by the medical executive committee. The medication administration policy was tackled a piece at a time and presented for approval in small sections. Introducing the practices embedded in the new policy and getting approval in small bites allowed the team to implement changes quickly and provided an additional communication tool to intro-
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duce activities of the team. Support was required from the medical staff leadership on major issues, such as the elimination of the “resume home medications” order, the guidelines regarding the use of abbreviations, and standards related to handwriting legibility. Since implementation of the policy, the credentials committee has required one physician to dictate all progress notes because of ongoing issues with his handwriting. Education and communication were and continue to be major initiatives. A nursing practice survey (Appendix 1, p 407) was conducted in September 2000 to focus on actual practices related to medication administration and to provide feedback regarding the process for reporting medication variances. The form for reporting medication variances (Appendix 2, p 408) was revised in November 2000 to include more information related to causes, outcomes, process issues, and follow-up. Nursing staff members identified medications used on their unit that were considered high risk or problem prone, or were used infrequently. From this assessment, a unit-specific self-learning packet including educational competency assessments was developed. For example, an annual competency for the administration of dobutamine is required for nurses working on the medical–surgical units but not for nurses in the critical care areas, where the medication is used more frequently.
Process Improvements The team completed the Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment™1 and the VHA Patient Safety Organizational Assessment. These two evaluation tools allowed the team to focus on specific processes and helped identify some relatively easy improvements that could be implemented quickly. Examples of these quick fixes and process safety nets can be found in Table 1 (right). The team’s experience of success had a positive impact on its momentum and focus. The quick fixes provided immediate feedback in terms of measurable improvements in patient safety measures. The ISMP survey also provided much-needed objective data on other changes, such as the elimination of vials of potassium chloride from nursing units and the importance of limiting access to medications via the Pyxis® (Pyxis Corp, San Diego) dispensing system.
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Table 1. Quick Fixes and Process Safety Nets* ■
■
■ ■
■
■
■
■
A dedicated phone line in the pharmacy was installed for faxing time-sensitive orders, including those for stat medications, heparin, and antibiotics. A list of antibiotics was distributed to all nursing units to assist the unit secretaries in identifying orders that needed to be started in a timely manner. Verbal orders for chemotherapy are not allowed. All pediatric medications require a patient weight before they may be dispensed. On the night shift, when the pharmacy is closed, the oncall pharmacist is called, and pediatric medication orders are checked by the pharmacist before dispensing. Neuromuscular blocking agents are stocked only in the ICU, OR, and ECC. They are stored separately from other medications and packaged in neon-green sealed bags that have external labels and warnings. The “Resume Medications from Home” order is prohibited. All medication orders must be completely written. The same is true for orders to resume medications postoperatively and/or on transfer to or from the ICU. Medications available on an emergency basis through Pyxis without requiring entry of the order into the pharmacy information system by a pharmacist, were reviewed for appropriateness of that classification, and a number of changes were made to reduce availability. Two nurses must verify any IV administration rate changes for insulin and heparin.
* stat, immediate; ICU, intensive care unit; OR, operating room; ECC, emergency care center; IV, intravenous.
When Pyxis was implemented, the knowledge that the drugs were “right there” on the nursing unit gave rise to the expectation that there would be immediate access. The focus on control, the importance of maintaining existing safeguards through pharmacist review of orders, and the more widespread distribution and discussion of serious medication errors has helped reinforce the need to limit access to medications. The belief that the pharmacy does not trust nurses to correctly withdraw medications from Pyxis on an emergency basis before pharmacy review of the medication order has been corrected through the educational process related to the reasons for the controls. The medical staff has also been supportive of the changes.
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THE JOINT COMMISSION Results An initial increase in the reporting of medication variances was expected—and it did occur. Within a 9month period (May 2001–January 2002), the number of reports doubled. The Medication Safety Team was overwhelmed with the volume, and it formed a subcommittee to review the variances on a weekly basis, focusing on process issues and potential improvement opportunities. The subcommittee is composed of the Medication Safety Team leader, the chief operating officer [T.A.S.], a clinical director, the pharmacy director, and the education director. These different perspectives provide the format for a comprehensive and objective review of all the issues, and recommendations for improvement can be implemented quickly. The data related to the variances are summarized and reviewed by the Medication Safety Team and by the pharmacy and therapeutics committee. With process changes, the number of reports has leveled off and is expected to continue at a stable rate. There has been a decline in the number of variances in certain areas, such as transcription errors and dose omissions, as process changes have been made.
the hospital was invited to participate in the Clinical Advantage Patient Safety Initiative. The Medication Safety Team at Williamsburg Community Hospital joined several other hospitals in the region to implement changes to improve patient safety. Although the teams operated independently to facilitate changes within their specific institutions, the opportunity to network and share ideas contributed to the success of the team. With the help of the VHA initiative, nine key aspects within six domains were identified as objective measures of the team’s success (Table 2, below). At the end of the formal VHA initiative in May 2001, Williamsburg Community Hospital’s performance ranked it in the top quintile for three of the measures, in the second quintile for five measures, and in the third quintile for the remaining measure. The team was able to show improvement in eight of the nine measures, with the greatest improvements noted in assessment of risk of error, evaluation of a competitive/collaborative environment, and promotion of a nonpunitive culture. Opportunities for improvement remain in all areas but are greatest in evaluating the competitive/collaborative environment and in establishing rewards and recognition for reporting errors.
Discussion Continued education of the staff and the physicians is critical to success. It needs to be an ongoing process, and it needs to stay interesting and applicable. The Medication Safety Team continues to provide information related to medication safety at the hospital safety fairs and shares its progress at department leader, quality board, patient safety, and medical staff meetings. Team composition is also critical to success. The multidisciplinary team provides the ability to solve problems and recommend changes quickly and effectively from a variety of perspectives. Through its VHA membership, in May 2001
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Table 2. Key Aspects and Domains of Patient Safety Domain
Key Aspect of Safety
Leadership
Demonstrate patient safety as a top leadership priority Promote a nonpunitive culture for sharing information and lessons learned
Strategic Planning
Routinely conduct an organizationwide assessment of the risk of error and adverse events in care delivery processes Actively evaluate the competitive/collaborative environment and identify partners with whom to learn and share best practices in clinical care
Information and Analysis
Analyze adverse events and identify themes across events
Human Resources
Establish rewards and recognition for reporting errors and safety-driven decision making Foster effective teamwork, regardless of a team member’s position of authority
Process Management
Implement care delivery process improvements that avoid reliance on memory and vigilance
Patient and Family Involvement
Engage patients and their families in care delivery workflow process design and feedback
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QUALITY IMPROVEMENT and updates are given to the board of directors and the medical executive committee on a monthly basis. Further plans include repeating both the ISMP survey and the VHA Patient Safety Organizational Assessment in 2002 to further demonstrate the far-reaching impact of the team and to continue to identify areas for improvement. A full disclosure policy is in the draft stage of development and will be one of the next major projects. The Medication Safety Team continues to flourish, reflecting the positive outcomes from the changes that it has overseen. J
The major roadblocks for the team include the lack of a physician order entry system and the integration of patient-centric information, including an electronic medical record and a rules-based system to increase safety nets. Implementing these improvements is on information, technology’s strategic plan, and the team will be participating in the selection of products that will be implemented in the future. Although the team has been able to accomplish many goals and has maintained focus and momentum, finding time for meetings and for implementing the changes continues to challenge team members. A tremendous amount of work has been accomplished. The medication administration policy was a huge undertaking that took months to complete but is truly a comprehensive product that achieved a number of goals. The education and communication plan raised the level of awareness throughout the organization. The team reports regularly to the quality board,
* Copies of the document are available (for a printing and mailing charge) from Terri Sim.
Reference 1. Institute for Safe Medication Practices: ISMP Medication Safety Self-Assessment™. Hunt-
ingdon, PA. www.ismp.org/ Survey.Survey_instructions.html (last accessed May 1, 2002).
Appendix 1. The Medication Adminstration Practice Survey: September 2001 Anonymous
In an effort to understand the current medication practices, this survey is being circulated to all patient care units and departments in the hospital. Please take the time to complete this survey and return it to the Quality Department. 1. Do you check the patient’s armband 100% prior to administering medications?
q yes
q no
2. Do you prepare and carry more than 2 patient medications with you?
q yes
q no
3. Do you label the medication cup with the patient’s name and room number?
q yes
q no
4. Do you open the single-dose medications at the patient’s bedside?
q yes
q no
5. Do you label syringes with the medication, name, patient name, and room number?
q yes
q no
6. Do you ever administer medications that another nurse has prepared?
q yes
q no
7. Do you consistently have insulin and heparin doses double-checked by another nurse?
q yes
q no
PLEASE MARK THE DEPARTMENT WHERE YOU WORK: q ECC q FMC
q GCC q ICU
q PCU q Surgical Services
q M/S q WCC q HHC
A nursing practice survey was conducted in September 2001, to focus on actual practices related to medication administration and to provide feedback regarding the process for reporting medication variances. ECC, emergency care center; FMC, family maternity center; GCC, Gloucester Convenient Care; ICU, intensive care unit; PCU, progressive care unit; WCC, Williamsburg Convenient Care; M/S, medical–surgical; HHC, home health care.
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THE JOINT COMMISSION Appendix 2. Williamsburg Community Hospital Medication Variance Reporting Form Williamsburg Community Hospital
q Med variance call-in report
Patient: _______________________________ Age: _______ MR #: _____________ Patient’s Room: Unit(s) involved ________________________________ Event time: ___________ Day: _________ Date: Variance reported by: ________________________________________________________ Date: Dr. _____________________________________________ notified on ____________________________ at q Medication Variance
q ADR (Adverse Drug Reaction)
Drug(s): _____________________________________________ Staff involved _____________________________________________ Causes of variance:
q Did not receive drugs Family notified: q yes
q no
Brief description & clinical action taken:
Prescribing q legibility q incorrect order q confusing order/instructions q other Processing q computer entry error q transcription error q error checking MAR q no order to/received by pharmacy q other Dispensing q filled incorrectly q mislabeled q delay in receipt q unavailable q names of meds look alike q labels of meds look alike q other Administering q performance issue related q procedure/policy not followed q knowledge deficit q distractions q miscalculation q code blue situation Monitoring q IV infiltration q IV clotted/dislodged Other q count discrepancy q other
The form for reporting medication variances was revised to include more information related to causes, outcomes, process issues, and follow-up. MR, medical record; MAR, medication administration record; IV, intravenous; TJ [T.A.S., J.J.], the subcommittee formed to review medication variances weekly; IM, intramuscular; SC, subcutaneous; PO, by mouth.
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Appendix 2. Williamsburg Community Hospital Medication Variance Reporting Form (continued) Proposed action plan if necessary (to be completed by Clinical Director) Manager follow up: q Team coordinator reviewed q 2nd manager reviewed q TJ reviewed q Director
q Discussed with staff involved q Refer to the Medication Safety Team
Variances
Point Assignments
Omission Wrong time Incorrect solution rate or hour infused Drug incompatibility Transcription Errors not identified: inadequate 24 hour chart check Wrong dose Extra dose Med given when there are indicators for withholding it Mechanical error (ie: wrong tubing) Wrong medication or IV solution Wrong patient Medication given without a physician order Wrong route score given:
1 for each dose 1 each 1 for each hour infused 1 each 1 each 1 each 2 each 2 each dose 2 each 3 each 4 each 4 each 4 each IV (4 each) IM/SC (3 each) PO/SC (2 each)
totals
PATIENT OUTCOME q 0 No injury; Variance discovered prior to medication administration, thus drug not given q 1 Variance resulted in no harm to patient q 2 Temporary injury; Additional patient monitoring required q 3 Temporary injury; Variance resulted in a change in vital signs or the need of additional laboratory tests q 4 Serious; Variance that requires treatment and results in an increased length of stay q 5 Severe; Variance that requires intensive medical care or cause permanent harm to the patient POINT
CLASSIFICATION OF DRUGS
1 point
Topical dermatological agents, pediculicide, antiemetic, anti-dandruff shampoo, acne preparations, local anesthetics, vitamins/minerals, antipyretics, unmedicated IVs, expectorants, antitussives, oral contraceptives, cathartics, laxatives, antidiarrheal agents, antacids Eye drops, anti-inflammatories, antidepressants, antihistamines, estrogens, progestins, muscle relaxants, non-narcotic analgesics, complex IVs, non-barbiturate sedatives, hypnotics, anti-Parkinson’s agents, alcohol abuse deterents, vaccines, immune serum, lactation suppressants Antibiotics, anti-infectives, anticonvulsants, barbiturates, diuretics, oral antidiabetic agents, narcotic antagonists, steroids, glucose 50%, glucagon Bronchodilators, cardiovascular drugs, narcotic analgesics, electrolytes, calcium metabolism regulators, oxytocics Anticoagulants, thrombolytics, chemotherapeutic drugs, antineoplastic agents, blood/blood components, hyperalimentation, hypolipidemic agents, insulin, medication given to children less than 12 years or under 80 pounds
2 points
3 points 4 points 6 points
Score: variance + classification X outcome = Points q After completion of medication variance report, forward to Pharmacy Coordinator q Pharmacy to forward report to Patient Care Quality Counsel Coordinator
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