Improving the Safety, Efficiency & Effectiveness of the Medication Administration Process
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1 Improving the Safety, Efficiency & Effectiveness of the Medication Administration Process Northwest Patient Safety Conference May 19, 2011 Joan Ching RN, MN, CPHQ Administrative Director, Hospital Quality & Safety
2 Reported Errors in Medication Management Process Monitoring 2% Ordering $ 26% CPOE Administering 50% Transcribing $ 0% Bar Code Medication Administration Dispensing 22%
3 Prepared by: Joan Ching Current State Wrong or expired med loaded into PYXIS Date: 2/10 Value Stream Map Discards pill No space in med packagingfor Medication Administration room to prepare crushed meds meds Boundaries: From: Signal to give medication, To: Medication documentation Distractions/Interruptions Meds are batched, on push schedule Waiting in queue at PYXIS machine Does not compare med to MAR Dose not available PYXIS drawer broken Withdraws meds for > one patient Doesn't label syringe or cup properly Unsecure meds on top of COW Moving pt furniture, getting water Doesn't check 2 forms of pt ID Doesn't explain med 's action or indication Wrong patient error Wrong route error Wrong form error Wrong med error Wrong dose error Wrong time error Wrong technique error Doesn't immediately document on MAR PYXIS Supplies RN sees signal to give meds Retrieves med from PYXIS Prepares med at PYXIS Greets patient "It Takes Two" ID check Explains med to patient Administers med Documents med given Draw up in syringe 4 Gel in with Purell 4 - Pt states name 4 - Medication name 4 3 -Label with med "Heretogiveyoumed(s)" med(s)." - Pt states date of birth - Medication action name/strength - Put into med cup RN RN RN RN RN RN RN 0:00:45 0:00:00 0:02:39 0:01:00 0:00:00 0:02:00 0:00:00 0:00:11 0:01:14 0:00:13 0:00:48 0:00:20 0:01:00 0:01:00 0:00:50 Median of 4 timings Median of 4 timings CT VA NVA % VA 0:00:11 h:m:s 0:00:00 h:m:s 0:00:00 h:m:s 0.00% 00% h:m:s CT VA NVA % VA 0:01:14 h:m:s CT 0:00:13 h:m:s 0:00:00 h:m:s VA 0:00:00 h:m:s 0:00:00 h:m:s NVA 0:00:13 h:m:s CT 0:00:48 h:m:s VA 0:00:00 h:m:s CT VA 0:00:20 h:m:s CT 0:01:00 h:m:s CT 0:01:00 h:m:s 0:00:20 h:m:s VA 0:01:00 h:m:s VA 0:01:00 h:m:s CT 0:00:50 h:m:s VA 0:00:00 h:m:s NVA NVA NVA NVA NVA 0:00:48 h:m:s 0:00:00 h:m:s 0:00:00 h:m:s 0:00:00 h:m:s 0:00:50 h:m:s % VA % VA % VA % VA % VA 000%h:m:s 00% % VA 0.00% 00% h:m:s 000% 0.00% h:m:s 0.00%.00% h:m:s.00% 00% h:m:s.00% 00% h:m:s 0.00% 00% h:m:s Lead Time Cycle Time Current State 2/10 0:12:00 h:m:s 0:04:16 h:m:s Takt Time = Time Available 1245 min = 11.4 min Demand (max washer output) 109 meds Value Added (VA) Time Non Value Added (NVA) Tim % VA % NVA Operators Needed 0:02:20 h:m:s 0:08:15 h:m:s 19% % 69% % 0.37
4 CALNOC Medication Administration Accuracy Survey Systematic assessment, targeted improvement Barker & Pepper s research Betty Irene Moore 1 of 5 doses in error Wrong time 43% Wrong dose 17% 7% error rate (>40/day in 300-bed facility)
5 Comparing Error Detection Methods Errors detected on 2,557 doses Pharm Tech RN 373 Error = a dose administered differently than ordered on the patient s medical record Chart review 24 1 Incident reports Flynn, Barker, Pepper, Bates, Mikeal, AJHP, 2002.
6 The Six Safe Practices Compares med w/ MAR Med labeled throughout Checks 2 forms of pt ID Explains med to pt Charts med immediately No distractions or interruptions
7 Our Study Methods: Observation & Error Review Naïve observation is a process whereby the observers do not know the actual medication order but observe the entire preparation and administration process. Comparative record review is performed later to determine number, type of errors, and frequency of each type of medication error.
8 Baseline Measures Jan-Feb 2010 N=898 doses Safe Practices Defects % D E F E C T % 14% 13% 6% 5% 4% C U M U L A T I V E % Defects Cumulative %
9 Baseline Measures Jan-Feb 2010 N=898 doses Type of Errors % E R R O R % 24% Improperly administered so as to alter drug s effect 7% 6% 5% 3% C U M U L A T I V E 0 Wrong time Wrong technique Unauthorized drug Drug not available Wrong route Wrong dose 0 % Error Cumulative % Given more than 1-hr before or after scheduled dose
10 Reducing Waste in the RN s Day Time Processing Defects Inventory. Waste Motion The 9 AM Line-up Overproduction Transportation.
11 Approaches to Mistake Proofing Vertical Inspection Inspecting the workflow Control upstream processes Conditions that create defects SWAMP Medication schedule Horizontal Horizontal Source Inspection Inspection Within the process MOSQUITOES Interruptions Room Layout
12 Interruptions Expected, natural component of RN work 89% of interruptions negatively impact patient safety -- Hall, et al., JONA, 40(4), April % # in procedural failures 13% # in clinical errors # interruption frequency # error severity -- Westbrook, et al., Arch Intern Med, 170(8), April 26, 2010
13 Visual Control & Mistake Proofing Medication Room
14 Visual Control & Mistake Proofing Flashing bike light mounted to WOW pinnacle Widespread campaign A protected hour to exclusively focus on medications Redirect telephone calls Reschedule supply restocking
15 Visual Control Carry & go i Walking i Wasted motion $ Hunt-and-find $ Forgotten supplies Self-Check Point-of-use
16 BEFORE AFTER
17 Medication Administration Schedule 400 Doses Dispensed by Day of Week & Hour LEVELING PRODUCTION FRI MON SAT SUN THU TUE WED
18 Unit Dashboard MEDICATION ADMINISTRATION DASHBOARD NEUROLOGY-UROLOGY-NEUROSURGERY Level 17 Legend: Better than CALNOC Worse than CALNOC % Med Compared with MAR Q1 10 Q2 10 Q3 10 Q4 10 NUN Mean CALNOC Mean 99 % Med Explained to Patient Q1 10 Q2 10 Q3 10 Q4 10 NUN Mean CALNOC Mean % Med Labeled Throughout Q1 10 Q2 10 Q3 10 Q4 10 % Med Charted Immediately Q1 10 Q2 10 Q3 10 Q4 10 NUN Mean CALNOC Mean NUN Mean CALNOC Mean % 2 Forms ID Checked Q1 10 Q2 10 Q3 10 Q4 10 NUN Mean CALNOC Mean % Med Pass Distracted/Interrupted Q1 10 Q2 10 Q3 10 Q4 10 NUN Mean 8 CALNOC Mean 33 7
19 2010 KAIZEN ACTIVITY Rapid Process Improvemt Wksps: Improving med room layout Medication preparation Medication administration Insulin administration Bar code medication packaging Bar code wrist band printing Kaizen Events: Bar code medication supply Crushed enteral medications Reducing telephone interruptions ED medication preparation Standardized visual automated dispensing cabinet Reducing interruptions in patient room Wrong Time 10% 8% 8.6% 6% 4% 3.9% 3.5% 2% 2.1% 0% Q1 Q2 Q3 Q4 Wrong Technique 2% 1.6% 1.4% 1% 0.9% 0.6% 0% Q1 Q2 Q3 Q4 Distractions/Interruptions 60% 48% 50% 40% 46% 42% 30% 20% 29% 10% 0% Q1 Q2 Q3 Q4
20 Overall Risk & Defect Reduction In 2010, we reduced the # of unsafe practices & med errors by 52%! Percent Defect Rate % 80% 60% 40% 65% 71% 46% 52% 53% 51% 50% 56% 47% 31% 40% 35% 20% 0% N=5,125 observed medication doses in 2010
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