Med Errors Compared to RN Turnover 30 25 20 15 10 5 0 1992 1993 1994 1995 1996 1997 1998 Med Errors/100 Admits 1999 2000 2001 2002
% RN Turnover 10% 0% MEMBER 20 MEMBER 13 MEMBER 7 37% MEMBER 1 42% MEMBER 8
46% 46%45% MEMBER 3 MEMBER 5 MEMBER 19 50% 49%49% MEMBER 12 MEMBER 11 MEMBER 10
65% 60% 56% 56% 55% 55% 54% 53%52% MEMBER 14 MEMBER 9 MEMBER 4 MEMBER 18 MEMBER 16 MEMBER 6
MEMBER 2 MEMBER 15 50% 40% MEMBER 21 70% 60% MEMBER 17 ISMP Survey Results December 2000
100% 90% 80% 34% 30% 20% ISMP Survey Results 2003 Compared to 2000 Concord Hospital - At a Glance (photo by Rixon Photography) Concord Hospital - At a Glance
295 bed not-for-profit regional medical center Located in the capital city of Concord, NH 2nd busiest acute care hospital in New Hampshire Serving approximately 150,000 patients
Regional referral center for: Orthopaedic Services Cardiac Services Womens Health Comprehensive Cancer Services Clinical Technology Development & Medication Safety as Organizational Priorities
2001: One of 10 Most Improved HHN Most Wired Hospitals & Health Care Systems 2001: VIP Award for Clinical Achievement Awarded for reduction of medication errors McKesson Corporation 2002: One of 100 Most Wired HHN Most Wired Hospitals & Health Care Systems 2002: Cheers Award for Safe Medication Practice Institute for Safe Medication Practices 2003: One of 100 Most Wired Small & Rural HHN Most Wired Hospitals & Health Care Systems
Making Medication Administration Safe at Concord Hospital STAR Pharmacy System Decentralized Pharmacist Role Bar-Coding of Medications at Bedside Medication Administration Process PI VHA Collaborative ISMP Survey IHI Quantum Leaps in Patient Safety MEDICATION ADMINISTRATION PROCESS Right Patient, Right Medication, Right Time, Right Dose, Right Route 1
2 Purchasing & Inventory Unit Dose Prep 4 Pharmacy Order Entry 7 RN Prepares To Administer 3
MD Order 5 6 Medication Preparation Medication Dispensed 8 Medication Administered To Patient
9 Monitoring & Follow Up Components of Medication BarCoding System Bar-Code Label affixed to all individual med doses Online Medication Administration Record as part of Clinical Documentation System Laptop computers with bar-code scanners COWS Proxim 2mb/sec Wireless Network Bar-Coding at the Bedside
Bar-Coding at the Bedside The Nurse Scans Bar-Code on ID badge to log on and as signature Selects patient online Selects and reviews medication order online Scans Bar-Code on medication Bar-Coding at the Bedside The Computer Matches Bar-Code to medication order Checks 5 rights of medication administration
& notifies nurse of any discrepancies Documents medication administration Charges patient for medication Reminds the nurse of missed and late medications The Final Line of Defense in a Complex Process 1 2 Purchasing & Inventory Unit Dose Prep
3 MD Order 4 5 6 Pharmacy Order Entry Medication Preparation
Medication Dispensed 7 8 9 RN Prepares To Administer Medication Administered To Patient Monitoring &
Follow Up Hidden Benefits of Medication Bar-Coding Enhanced Reporting Capabilities Support PI & education activities Recruitment & Retention Appeal of high tech environment Recognition of patient safety/safe work environment as important retention factors Implementation Process 6-8 month planning process Extensive Staff Involvement & Champions Pilot Unit Developed standard procedures Implemented Meds & IVPBs only on first
unit Resolved bugs & glitches Intense 24 x 7support by expert resources Timely roll out to other units Formal evaluation at 3-months & 6-months Early Challenges Redesign of med administration process Uncovers practice issues Belief systems & assumptions Need to differentiate from computer issues Lack of commercially prepared individual
med doses with bar-code labeling What Have We Done Lately? Increased utilization of Bar-Coding Decreased work arounds and shadow system Upgraded scanners to newer more effective technology
Improved quality of Bar-Coding labels Reinforcement of importance of Bar-Coding Implemented Bar-Coding on Maternity and AM Admit Unit What Have We Done Lately? Executive Walk Arounds Blameless Culture and Anonymous reporting Focus on Near Misses as Opportunities to prevent errors Balance with accountability Birthdate as 2nd identifier for med admin and other key processes Standardized Abbreviations
Where are We Going? Bring med carts closer to patients & Bar-Code scanning equipment Educate & involve patients in the process Implement bar-coding in PACU, Cardiac Cath Lab & Outpatient Units Implement hand-held devices for scanning patient ID bands Implement CPOE Why Does It Really Matter? The Victims of a Medication Error 1.) The Patient 2.) The Nurse
Lessons Learned Dont underestimate the magnitude of the implementation Recognize that technology solves some problems but creates others A strong Pharmacy-Nursing relationship is essential Dont pilot on a specialty unit Standardization of med times across all units is essential Lessons Learned EVERYONE needs to understand The WHY Accept you are never done
We are better than we were yesterday but not as good as we will be tomorrow!
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