UMHS Program and Operations Department. Mott Children s Hospital Medication Turnaround Time Analysis

Transcription

1 UMHS Program and Operations Department Mott Children s Hospital Medication Turnaround Time Analysis Final Report December 15, 2006 Client: Brian Callahan, Pharm.D., Manager, Inpatient Operations Denise Glenn, R.Ph., Supervisor Mott Pharmacy Stephanie Newland, Pharm.D., Manager, Orders Management Project Bruce Chaffee, Pharm.D., Team Lead, Medication Management Coordinator: Mary Duck, Senior Management Consultant Programs & Operations Analysis Prepared by: Bridgette Kapets, IOE 481 Student, Project Team Nick Martin, IOE 481 Student, Project Team

2 Table of Contents Executive Summary...3 Introduction...6 Background and Environment...6 Goals...7 Project Scope...8 Methodology...8 Conducted Literature Search...8 Collected Data for Manual Tasks...8 Collected Data for Computerized Tasks...9 Conduced Interviews...9 Analysis...9 Results...9 Medication Order Turnaround Time...9 Long Pre & Post-Pharmacy Wait Times...10 Lower Turnaround Time for STAT, NOW, & ASAP...10 Data Highly Variable within Intervals...10 Specialty Orders Not Statistically Different from Others...11 Current State Value Stream Map...13 Interviews...14 Conclusions and Recommendations...14 Majority of Turnaround is Wait Time...14 Faster Overall Turnaround for Omnicell Medication...14 Faster STAT/NOW/ASAP Turnaround for Non-Omnicell Medication...15 No Difference Between Specialty and Other Medication Turnarounds...15 Confusion Around the Terms STAT, NOW, and ASAP...15 Appendix A: Literature Search...16 Appendix B: Interval Times by Medication Category...17 Appendix C: Raw Data

3 Executive Summary Mott Children s Hospital is in the process of implementing UM-CareLink, an online prescription order system. This system is expected to significantly reduce the total turnaround time (time from when a physician writes a prescription order until the medication is administered to the patient) for prescription orders; however, there is little data available on the current system to measure UM- CareLink s performance against. Management believes that there are long wait times in the turnaround process both before arriving to and after being dispensed from the pharmacy. Additionally, previous studies indicate that there is little difference between the Omnicell and non- Omnicell medication turnaround times. Goals To address these issues, the project team was asked to perform an analysis of the turnaround time for inpatient prescription orders of medications requiring quick turnaround (STAT, NOW, ASAP, cardiac drips, antibiotics, antiemetics, and pain medication). The purpose of the analysis was to: Create a benchmark to measure the performance of UM-CareLink, once it is operational. Determine the times for each high level task within the turnaround process. Measure the difference between Omnicell medication and non-omnicell medication turnaround times. Measure the difference between specialty medication and other medication turnaround times. Methodology In order to achieve these goals, the turnaround process was divided into high level tasks. The project team worked with Mott Pharmacy to collect both manual and computerized data for each task of 225 prescription orders. In addition to quantitative data collection, the project team also conducted informal interviews with eight individuals from the pharmacy and nursing staff in order to clarify the definition of the terms STAT, NOW, and ASAP. After analyzing the data and compiling the results, the project team developed recommendations based on conclusions drawn from the results. Key Findings The key findings from the study follow: Overall, the average turnaround time for a prescription order was 4 hours, 21 minutes. Average turnaround time for STAT, NOW, and ASAP orders was 1 hour, 44 minutes. On average, 11% of the total turnaround time is spent in the pharmacy. Overall, Omnicell medication turnaround times are 1 hour, 22 minutes less than non- Omnicell medication turnaround times. STAT, NOW, and ASAP Omnicell medication turnaround times are an average of 13 minutes greater than non-omnicell STAT, NOW, and ASAP medication turnaround times. Confusion exists regarding the definitions of the terms STAT, NOW, and ASAP as well as how each type of order is treated. 3

4 Majority of Turnaround is Wait Time The data indicates that the majority of a medication s turnaround time is wait time, both before arriving to and after being dispensed from the pharmacy. The implementation of UM-CareLink is expected to eliminate most if not all of the pre-pharmacy wait time. The data also suggests that much of the post-pharmacy wait time results from large variation in administration times, possibly due to differences in administration procedures on the units. The project team recommends that follow-up studies be conducted to address the following: Evaluate the performance of UM-CareLink and its impact on both the pre-pharmacy and total medication turnaround time. Identify opportunities for reducing the post-pharmacy wait time. Evaluate the post-pharmacy process on each unit, specifically the use of standard administration times. Faster Turnaround for Omnicell Medication Overall, medication stored in the Omnicell machines had faster turnaround times than those that needed to be filled to order by the pharmacy. This is partially due to the lack of fill and travel time between the unit and the pharmacy and partially due to the nature of the medication stored in the Omnicell. Generally, a medication is chosen to be stored in the Omnicell because of the urgency associated with its administration, so faster turnaround times are expected. A substantial portion of the Omnicell turnaround time is wait time between when the medication is available in the Omnicell and when it is pulled. One possible explanation for this is that the only way for a nurse to know if a medication is available is try to pull it from the machine. Therefore, follow-up studies are recommended to: Verify that the current medication mix available in the Omnicell machines is appropriate. Evaluate the feasibility of methods for communicating with nurses about when Omnicell medications are available to be pulled from the Omnicell (e.g. pagers, text messages). Faster STAT/NOW/ASAP Turnaround for Non-Omnicell Medication In the case of STAT, NOW, and ASAP orders Omnicell medication had a turnaround time slightly longer than non-omnicell medication. This result is probably due to the small sample size of Omnicell STAT, NOW, and ASAP orders. However, as discussed above, the lack of communication about when a medication is available to be pulled could also be a contributing factor. Therefore, it is recommended that follow-up studies be conducted to: Verify that low sample size is the driver behind the longer turnaround time found for the Omnicell STAT, NOW, and ASAP medication. No Difference Between Specialty and Other Medication Turnarounds There is no statistically significant difference between specialty medication (i.e. those in categories studied) and other types of medication. The only statistically significant differences found were between Omnicell and non-omnicell medications. 4

5 Confusion Around the Terms STAT, NOW, & ASAP Responses from informal interviews indicated that there is confusion among nursing and pharmacy staff regarding the definitions of the terms STAT, NOW, and ASAP. STAT is generally understood to be the most urgent of the three. However, the perception among the nurses questioned was that all three terms are treated in the same manner. Additionally, no one interviewed was able to define ASAP and it seems to be used interchangeably with NOW. Based on these results, the project team recommends the following steps be taken: Eliminate the use of the term ASAP. Define the terms STAT and NOW in writing. Communicate these definitions to all units, physicians, and pharmacy staff. 5

6 Introduction Mott Children s Hospital is in the process of implementing UM-CareLink, a new online prescription order system that will allow physicians to enter medication orders directly into a computer. UM-CareLink transfers the orders immediately to the pharmacy to be filled manually or dispensed via an Omnicell machine (a machine the nursing staff can access to obtain prepackaged, frequently prescribed medication). Management believes using UM-CareLink will eliminate a significant amount of wait time from the current order process. However, very little data exists about the current manual process. Therefore, the project team was asked to study the manual process to compile and organize data measuring the major steps in the medication turnaround process for high priority orders including STAT, NOW, and ASAP orders, as well as orders for cardiac drips, antibiotics, antiemetics, and pain medications. This measurement will provide a benchmark against which to measure the future process with UM-CareLink. Additionally, the team was asked to determine if a significant difference exists between the turnaround time for a medication that is dispensed via an Omnicell machine and a medication that must be prepared and dispensed from the pharmacy. These measurements will provide an overall picture of the complete turnaround process from when a physician writes an order until the medication is administered to the patient. The purpose of this report is to present the methodology used to collect and analyze data, the results obtained from the analysis, and the conclusions and recommendations drawn from these results. Background and Environment Currently Mott Children s Hospital has a manual system in which physicians write prescriptions for patients on pink paper slips. As can be seen in Figure 1, these slips are transferred to the Mott Pharmacy where the orders are either made available to nurses via an Omnicell machine or prepared and dispensed from the pharmacy to the units. The nurses then administer the medication to patients and enter the administered time in the patient s MAR. Figure 1. Current medication order process Physician writes order Pulled from Omnicell Arrives at pharmacy Entered in WORx Filled by pharmacy & delivered to unit Administered to patient The project team has measured the turnaround time for prescriptions in the following groups: STAT, NOW, ASAP, cardiac drips, antibiotics, antiemetics, other, and pain medication. This information will provide management with the necessary data to evaluate UM-CareLink once it is fully operational. We have also compared wait times for medication that are stored in Omnicell machines and those that are not. Additionally, we have developed recommendations based on the results from this analysis and our observations of the medication turnaround process. 6

7 The driving factors behind this project request are as follow: Benchmarks are needed to measure the effectiveness of UM-CareLink once it is operational. Specifically, a benchmark of the front-end wait time, which is the time between when the order is written and when it reaches the pharmacy, is necessary. Management believes there are long wait times between when a physician writes a prescription order and when it reaches the pharmacy, as well as between when an order is dispensed and when it is administered to the patient. The process should have a significantly lower turnaround time when medications stored in the Omnicell machines are used, since these do not need to be prepared by the pharmacy. Also, the medication is stored on the unit so there is no travel time between the unit and the pharmacy for these orders. However, based on the results of previous studies, management believes that the turnaround times for the process using Omnicell medication and the process using pharmacy prepared medication are fairly similar. Parties affected by this project are physicians, nurses, and pharmacists assigned to the Mott Inpatient Units and Mott Pharmacy. Several similar studies have been conducted in the University Hospital, both by students and the Orders Management Project (OMP) Committee. These studies have provided background information and have been used as a guide in conducting this medication turnaround time study. Goals To provide a complete and accurate overview of the medication turnaround process, the project team has timed the major steps in the medication order process. We have completed the following tasks: Measured the wait time between when the physician writes an order until it is entered into WORx, the pharmacy s current computer system Determined the difference between the wait time from when the medication is dispensed and when it is administered to the patient for both the Omnicell and non-omnicell medications Determined the difference between specialty medication (i.e. medication in categories discussed in the Project Scope section) and other medication orders Developed recommendations based on results and project team observations 7

8 Project Scope The scope of this project included the process of ordering a prescription within the inpatient units at Mott Children s Hospital. This process begins when a physician writes an order for a prescription and ends when that medication is administered to the patient. It has been broken down into the following steps: 1) Physician writes order order arrives at pharmacy 2) Order arrives at pharmacy - entered into WORx 3) Order entered into WORx - delivered to a unit OR pulled from Omnicell machine 4) Order delivered to unit OR pulled from Omnicell machine administered to patient The project team collected data for medication that require quick turnaround times (i.e. those listed previously). We collected time samples for medication ordered from the following units: PICU, NICU, PCTU, 7 Mott, 6 Mott, 5 East Mott, and 5 West Mott. The medications studied in this project were: STAT, NOW, ASAP, Antibiotics, Antiemetics, Pain, Cardiac Drips, and Other Medications. However, results are medication category, not unit, specific. Any tasks that are unrelated to the flow of the prescription from the physician to the patient were not included in the scope of this project. Specifically, we did not look at medication ordered on one day to be administered on a future date; updated orders (e.g. an ongoing prescription with a dose change); or orders placed for outpatient units, maternity units, or units from other hospitals. Additionally, tasks within those outlined above (e.g. steps to fill an order within the pharmacy) have not been broken out and measured individually. Methodology The methodology for conducting this study included conducting a literature search to obtain background information about previous studies; collecting data for both the manual and computerized portions of the order process; conducting informal interviews regarding the definitions of the terms STAT, NOW, and ASAP; and analyzing and compiling that data. Data was collected on the day shift only. The project team has also developed recommendations based on the results of this analysis. Each of these steps is detailed below. Conducted Literature Search The project team began by conducting a literature search including previous studies conducted at University and Mott Children s Hospitals pertaining to medication turnaround time. A list of these studies can be found in Appendix A. Collected Data for Manual Tasks Most of the data collection for the manual tasks was done in the Mott Pharmacy where project team members worked with pharmacists to record arrival and dispensing times of relevant orders (i.e. those in the categories listed previously). Pharmacists sorted relevant orders as the pink order slips were delivered to the pharmacy. A project team member tagged the slips with a sticker indicating the order s arrival time to the pharmacy. 8

9 The dispensing time of the order associated with each slip was also recorded on the sticker as the order left the pharmacy. All tagged slips were saved until the end of the data collection period. Team members then looked up each order in the patient MAR to record the time the medication was administered. These steps provided the following time stamps for the process: 1) Physician writes order (recorded by physician on pink order slip) 2) Order arrives at pharmacy 3) Order delivered to unit 4) Order is administered to patient Collected Data for Computerized Tasks After a pink slip s order was dispensed to a unit, a project team member looked up the order in WORx and recorded the following time stamp: 5) Order entered into WORx Additionally, a pharmacy staff member pulled Omnicell reports for the hours around and including the data collection period in the pharmacy. Team members matched the tagged order slips to the report and recorded the time stamp for: 6) Order is pulled from Omnicell Conducted Interviews After the preliminary data analysis, the project team found it necessary to clarify the terms STAT, NOW, and ASAP since perceptions of these terms seemed to vary among staff. Therefore, the project team conducted informal interviews with eight individuals from the pharmacy and nursing personnel. Each was asked to define the terms STAT, NOW, and ASAP. Analysis The project team used statistical software to analyze the collected data. We determined, on average, how long each task of the process takes and how much that average varies. Data was broken down by medication to compare results by medication type in addition to comparing medication that is pre-packaged in Omnicell machines and those that have to be prepared in the pharmacy. Results The study results have been broken down into two major sections, medication order turnaround time and interviews. Turnaround time results have been broken down further by medication category, Omnicell vs. non-omnicell, and specialty vs. other. Medication Order Turnaround Time The data indicates that overall, a non-omnicell medication has a total turnaround time of 5 hours, 2 minutes while an Omnicell medication s total turnaround time is 3 hours, 40 minutes. Table 1 summarizes the data collected for each interval in the turnaround process. 9

10 Table 1. Data Summary Mean (HR:MM) StDev (HR:MM) STAT/NOW/ASAP Mean (HR:MM) STAT/NOW/ASAP StDev (HR:MM) Interval COV Written to Arrival (N/O) 1:01 0:46 75% 0:39 0:24 Arrival to Entry (N/O) 0:16 0:12 75% 0:07 0:09 Entry to Exit (N) 0:26 0:15 58% 0:12 0:10 Entry to Omnicell Pull (O) 2:06 2:23 113% 0:58 1:30 Exit to Administered (N) 3:19 3:24 103% 0:40 0:36 Omnicell Pull to Administered (O) 0:17 0:33 194% 0:07 0:02 Total Turnaround (Non-Omnicell): 5: :38 - Total Turnaround (Omnicell): 3: :51 - *225 samples, collected 10/9/06-11/10/06 Long Pre & Post-Pharmacy Wait Times. Table 1 s summary shows that the bulk of a medication s turnaround time is made up of waiting and travel time to get from a unit to the pharmacy and then getting to the patient once dispensed from the pharmacy. The time spent in the pharmacy accounts for an average of 11% of the total turnaround time. As shown in the table, on average an order is waiting in the pharmacy to be entered into WORx for 16 minutes. This is the only time an Omnicell medication order spends in the pharmacy, roughly 7% of the total turnaround time. On average, a non-omnicell medication spends an additional 26 minutes in the pharmacy being filled, making time in the pharmacy about 14% of the total turnaround time. Lower Turnaround Time for STAT, NOW, & ASAP. The mean turnaround time for an order classified as STAT, NOW, or ASAP is significantly lower than that of medication in the remaining categories. This is to be expected given the nature of the medication and the time in which they are supposed to be administered to the patient. By definition, STAT orders are to be administered to a patient no more than 15 minutes after the order is written while NOW orders are 90 minutes after written (a quantitative definition of ASAP was not available). However, the table indicates that the average turnaround time for a non-omnicell medication is 1 hour, 38 minutes while an Omnicell medication s is 1 hour, 51 minutes. Again, most of this time occurs between when the order is written and when it arrives to the pharmacy as well as between when the order is dispensed and when it is administered. (Time in the pharmacy accounts for roughly 19% of total turnaround time for non-omnicell medication in this category and roughly 6% for Omnicell medications.) Data Highly Variable within Intervals. Table 1 indicates that the data for each interval is highly variable. The lowest variation is for the interval between when the order is entered into WORx and when it is dispensed from the pharmacy with a coefficient of variation (COV) of 58%. The greatest variability is seen in the time after an order leaves the pharmacy with COVs ranging from 103% to 194%. To evaluate the increased variability in these intervals, the project team removed all orders that were marked PRN, meaning the medication was to be administered to the patient as needed. 10

11 Figure 2, compares the PRN to non-prn orders for each of the post-pharmacy intervals. These charts indicate that the PRN and non-prn orders are statistically the same, so the variability noted above is not skewed by PRN orders. Figure 2. PRN vs. non-prn Orders for Post-Pharmacy Intervals a) Order entered into WORx Pulled from Omnicell b) Pulled from Omnicell Administered to patient c) Exit pharmacy Administered to patient Specialty Orders Not Statistically Different from Others. Figure 3 displays the data broken out further by interval and medication category. (This data can found in tabular form in Appendix B.) Figures 3a, 3b, and 3c indicate that the STAT, NOW, and ASAP orders have a lower mean than other categories, however the difference between categories is not statistically significant. Figure 3d shows that for the interval between when an order is entered into WORx and when it is pulled from an Omnicell, the Other category has the lowest mean followed by the STAT/NOW/ASAP category. Note that there are no outliers skewing the data for the STAT/NOW/ASAP category. This figure also shows a statistically significant difference between antiemetics and the STAT/ NOW/ASAP and Other categories in this interval. Nothing can be said about the mean or statistical significance of the antibiotic or cardiac categories in this interval due to their low sample size. 11

12 Figure 3. Data Broken Out by Interval & Medication Category (time units H:MM) a) Physician writes order Arrives to pharmacy b) Arrives to pharmacy Entered into WORx c) Entered into WORx Dispensed from pharmacy d) Entered into WORx Pulled from Omnicell e) Dispensed from pharmacy Administered to patient f) Pulled from Omnicell Administered to patient Figure 3e indicates that the STAT/NOW/ASAP category has a lower mean time between when an order is dispensed from the pharmacy and when it is administered to the patient. Although there are no statistically significant differences between categories, the figure also shows that the data for this category is highly variable, as discussed above with the coefficient of variation. Finally, 12

13 Figure 3f indicates that again, the STAT/NOW/ASAP category has the lowest mean time between when a medication is pulled from an Omnicell and when it is administered to the patient. Also, there are no statistically significant differences between the categories in this interval (excluding the antibiotic, aniemetic, and cardiac categories due to low sample size). Current State Value Stream Map. Based on this data the project team has developed the Current State Value Stream Map pictured in Figure 4. The process times and first time quality (FTQ) measures were taken from the existing VSM of the medication turnaround process at University Hospitals. Note that more than half of the total turnaround time is wait time between when the order is dispensed and when it is administered to the patient. Also, roughly ¼ of the total turnaround time is spent getting the order from the physician into WORx. This time is expected to be eliminated with the implementation of UM-CareLink. Figure 4. Medication Turnaround Current State Value Stream Map 13

14 Interviews The project team interviewed eight individuals from the pharmacy and nursing staff, asking each to define the terms STAT, NOW, and ASAP. The results of these interviews are summarized in the Table 2 below. The table indicates that generally STAT is understood to be the most urgent of the three terms, however, more than 1/3 of those interviewed believe that all are treated the same. Also, none of the individuals interviewed gave a quantitative definition of ASAP; most said that it was either less urgent or the same as an order marked NOW. Table 2. Interview Summary 62.5% said STAT is most urgent 37.5% said all three treated the same 37.5% defined STAT as <15 min. and now as <90 min. (written to administered time) 50% said there are no defined times 0% gave a quantitative definition for ASAP * 8 interviews, collected 10/26/06 11/10/06 Conclusions and Recommendations Based on the results discussed above, the project team has drawn the following conclusions and developed the recommendations corresponding to each: Majority of Turnaround is Wait Time The majority of a medication order s turnaround time is wait time. This wait time occurs in two large sections, both before arriving to and after being dispensed from the pharmacy. The data indicates that on average 11% of the total turnaround time is spent inside the pharmacy while about 24% is time spent getting from the physician to the pharmacy and about 65% is time spent getting to the patient once dispensed from the pharmacy. Since the implementation of UM-CareLink is expected to eliminate the 24% of pre-pharmacy turnaround time it is recommended that a follow-up study be conducted to verify the performance improvement. It is also recommended that another study be conducted with a focus on identifying opportunities to reduce the post-pharmacy wait time, especially for STAT, NOW, and ASAP orders. Orders in other categories may still see long wait times since nurses may need to wait until the scheduled administration time to administer the medication to the patient. However, opportunities for wait time reductions should be evaluated for these orders as well. For example, refresher courses on administration standards could reduce the mean and the variation of this interval by standardizing administration methods across units and among nurses. Faster Overall Turnaround for Omnicell Medication Overall, Omnicell medication s turnaround time is 1 hour, 22 minutes faster than non-omnicell medications. This is understandable since the medication is readily available on the unit, eliminating filling time in the pharmacy and travel time between the pharmacy to the unit. Also, medication stored in the Omnicells are generally chosen for the urgency associated with their administration to the patient so, a faster turnaround is expected. However, about 2 hours of the 3 hour, 40 minute turnaround time is the time between when the order is entered into WORx (i.e. 14

15 available in the Omnicell) and when it is pulled from the Omnicell. One possible explanation for this delay is that the nurses do not know the medication is available until they try to pull the order from the Omnicell. It is recommended that a follow-up study be conducted to verify that the current medication mix available in the Omnicells is appropriate. In addition, methods of communication between the pharmacy and the nurses (e.g. pages or text messages when an order has been approved and is available) be evaluated to reduce the wait time in this interval. Faster STAT/NOW/ASAP Turnaround for Non-Omnicell Medication Omnicell medication orders in the STAT, NOW, and ASAP category take, on average, 13 minutes longer to turnaround than non-omnicell medications. It is likely that this is due in part to the small samples size of Omnicesll STAT/NOW/ASAP orders. Another possible explanation is that the nurses are not aware when a medication becomes available in the Omnicell. It is recommended that a follow-up study be conducted to verify that low sample size was the driver behind the increase. No Difference Between Specialty and Other Medication Turnarounds There is no statistically significant difference between specialty medication (i.e. those in categories studied) and non specialty medications. The only statistically significant differences found were between Omnicell and non-omnicell medications. Confusion Around the Terms STAT, NOW, and ASAP There is confusion about the definitions of the terms STAT, NOW, and ASAP. Although STAT is generally understood to be the most urgent, the perception of the nurses interviewed was that all three categories are treated the same while in the pharmacy, those interviewed cited a definite difference between STAT and NOW. Overall, only 50% of those interviewed knew that defined times exist and only 37.5% accurately defined STAT and NOW. None of the individuals interviewed gave a quantitative definition for an order marked ASAP. It is recommended that the term ASAP be eliminated since it is perceived to mean the same thing as a NOW. In addition, it is recommended that the terms STAT and NOW be defined in writing and that this definition be communicated to all units, pharmacy personnel, and physicians. 15

16 Appendix A: Literature Search UMHHC Pharmacy. Medication Turnaround Times. December 30, 2004 Chang, Paul, Kevin Liu, and John McMahon. Medication Flow and Processes: Turnaround Times and Related System Metrics. Mensah, L Rai Arthur, Johathan Garrett, Vanessa Hudson, and Veronica Lucas. Orders Management Project (OMP): Recommendations for Implementing Computer Workstations at University of Michigan Hospital and C.S. Mott Children s Hospital. October 24, 2005 Duck, Mary and Chad Wiegand. Mott Pharmacy. June 8,

17 Appendix B: Interval Times by Medication Category Interval Written To Arrival Arrival To Entry Entry To Exit Entry To Omni Pull Exit To Administered Omni Pull To Administered Medication Category Mean (HR:MM) Standard Deviation (HR:MM) Coefficient of Variance (%) All 1:01 0:46 75% STAT/NOW/ASAP 0:39 0:24 62% Cardiac 1:30 1:24 93% Antibiotic 1:03 0:42 67% Antiemedic 0:41 0:23 56% Pain 0:46 0:22 48% Other 1:09 0:37 54% All 0:16 0:12 75% STAT/NOW/ASAP 0:07 0:09 129% Cardiac 0:13 0:09 69% Antibiotic 0:17 0:11 65% Antiemedic 0:25 0:13 52% Pain 0:18 0:11 61% Other 0:20 0:13 65% All 0:26 0:15 58% STAT/NOW/ASAP 0:12 0:10 83% Cardiac 0:28 0:14 50% Antibiotic 0:30 0:14 47% Antiemedic 0:31 0:20 65% Pain 0:19 0:13 68% Other 0:30 0:13 43% All 2:06 2:23 113% STAT/NOW/ASAP 0:58 1:30 155% Cardiac 0:03 - Antibiotic 5:22 - Antiemedic 4:34 1:24 31% Pain 2:15 2:32 113% Other 0:44 1:12 164% All 3:19 3:24 103% STAT/NOW/ASAP 0:40 0:36 90% Cardiac 3:56 3:12 81% Antibiotic 3:19 3:28 105% Antiemedic 3:53 3:16 84% Pain 3:14 2:45 85% Other 4:05 4:00 98% All 0:17 0:33 194% STAT/NOW/ASAP 0:07 0:02 29% Cardiac 0:10 - Antibiotic 2:41 - Antiemedic 0:17 - Pain 0:09 0:09 100% Other 0:13 0:09 69% 17

18 Appendix C: Raw Data Date Medication Name Medication Category Omni Written Time Arrive Time Order Entry Time Exit Time Omni Time Administered Time PRN 10/9/06 Vancomycin Antibiotic 10:10 11:07 11:39 12:05 10/9/06 Erythromycin Antibiotic 10:14 10:24 11:00 12:00 10/9/06 Penicillin Antibiotic 10:14 10:26 11:00 15:00 10/9/06 Cefepime Antibiotic 10:10 11:07 11:38 12:05 10/9/06 Vancomycin Antibiotic 11:07 11:35 12:05 10/9/06 Nafcillin Antibiotic 11:08 11:16 12:05 10/9/06 Gentamicin Antibiotic x 12:20 12:57 10/9/06 Vancomycin Antibiotic x 10:00 11:07 11:35 10/9/06 Erythromycin Antibiotic 10:14 10:25 11:00 10/9/06 Cefepime Antibiotic 10:10 12:20 12:39 13:05 13:00 10/9/06 Fluconazole Antibiotic 11:55 12:20 12:36 13:05 17:00 10/9/06 Neomycin Antibiotic 13:00 13:15 13:28 13:59 15:00 10/9/06 Clindamycin Antibiotic 13:15 13:31 13:59 14:25 10/9/06 Sulfamethoxazole/tmp Antibiotic 13:15 13:26 13:59 10/9/06 Cefotaxime Antibiotic 12:15 13:15 13:24 13:59 10/9/06 Erythromycin Antibiotic 13:00 13:15 13:27 13:59 15:00 10/9/06 Azithromycin Antibiotic 11:15 12:20 13:07 13:59 14:30 10/9/06 Metoclopramide Antiemedic 10:14 10:26 11:00 15:00 10/9/06 Diphenhydranine Antiemedic x 11:40 12:20 12:57 18:31 PRN 10/9/06 Diphenhydranine Antiemedic x 11:30 12:20 13:09 16:43 17:00 PRN 10/9/06 Sodium Citrate (Bicitra) Antiemedic 11:15 12:20 12:56 13:05 10/9/06 Propranolol Cardiac 11:02 11:04 11:11 11:14 10/9/06 KCL Cardiac x 9:20 10:05 10:09 10/9/06 KCL Cardiac 10:14 10:24 10:29 10/9/06 Mag Sulfate Cardiac 9:20 10:05 11:00 10/9/06 Captopril Cardiac 10:14 10:25 11:00 16:00 10/9/06 KCL Cardiac x 13:15 13:30 10/9/06 Adenosine Cardiac x 11:07 11:19 10/9/06 Furosemide Cardiac x 10:05 10:10 10/9/06 Furosemide Cardiac 10:14 10:21 11:00 16:00 10/9/06 Aminophylline Cardiac 12:22 12:28 13:05 10/9/06 KCL Cardiac 13:00 13:15 13:30 13:59 10/9/06 Dexamethasome Cardiac 13:15 13:31 13:59 10/9/06 Caffeine Citrate Other 10:29 10:34 10/9/06 Cyanocobalamin Other 10:30 11:07 11:28 12:05 10/9/06 Sod. Polystyrene Sulf Other x 12:20 12:58 13:01 10/9/06 Methylypred (Solumedrol) Other 11:07 11:30 12:05 13:00 10/9/06 Caffeine Citrate Other 12:20 12:52 13:05 10/9/06 Caffeine Citrate Other 11:05 12:20 12:42 13:05 10/9/06 Hydrocortisone Other 12:20 12:53 13:05 10/9/06 Chloral Hydrate Pain X 10:05 10:16 16:11 10/9/06 Morphine Pain x 10:19 10:23 10/9/06 Oxycodone (PRN) Pain x 10:12 11:08 11:23 13:28 PRN 10/9/06 Oxycodone (PRN) Pain x 11:09 11:19 18:58 PRN 10/9/06 Fentanyl Pain x 10:00 11:07 11:26 10/9/06 Ketorolac (toractol) Pain x 9:58 11:07 11:25 12:25 12:30 10/9/06 Acetaminophen Pain x 11:08 11:34 14:00 PRN 10/9/06 Acetaminophen Pain x 10:30 11:07 11:41 PRN 10/9/06 Oxycodone Pain 10:14 10:21 10:26 10/9/06 Motrin (Ibuprofen) Pain 9:15 10:14 10:22 10:26 PRN 10/9/06 Clonazepam Pain 9:30 10:14 10:26 12:30 10/9/06 Lorazepam Pain x 10:30 11:09 11:34 10/9/06 Methodone Pain x 11:10 12:20 13:08 12:57 13:00 10/9/06 Acetaminophen Pain 10:00 11:08 11:24 12:05 10/9/06 Acetaminophen Pain x 12:20 12:54 5:00 PRN 10/9/06 Morphine Pain x 13:15 13:34 15:59 16:00 PRN 10/9/06 Acetaminophen Pain x 13:15 13:30 PRN 10/9/06 Morphine Pain x 13:15 13:39 10/9/06 Morphine Pain x 13:15 13:40 10/9/06 Diazepam (Valium) Pain x 13:15 13:38 PRN 10/9/06 Diazepam (Valium) Pain x 11:08 11:31 12:01 10/9/06 Lorazepam Pain 10:14 10:22 10:26 10/9/06 Caffeine STAT/NOW/ASAP 10:19 10:34 10:55 10/9/06 Calcium Chloride STAT/NOW/ASAP 11:45 11:54 12:05 10/9/06 Albumin STAT/NOW/ASAP 11:15 11:21 11:28 10/9/06 Fosphenytoin STAT/NOW/ASAP 10:10 10:25 10:28 10:33 11:10 10/9/06 Vancomycin STAT/NOW/ASAP 11:19 11:21 11:27 10/9/06 Cyclosporin STAT/NOW/ASAP 12:05 12:20 12:21 12:26 12:30 PRN 10/9/06 Penicillin STAT/NOW/ASAP 10:00 10:11 10:13 10:20 10/9/06 Vancomycin STAT/NOW/ASAP 10:30 10:58 11:08 10/9/06 Morphine STAT/NOW/ASAP 12:45 12:46 12:59 10/9/06 Midazolam STAT/NOW/ASAP 12:45 12:46 12:59 10/9/06 Dexmedetomidine STAT/NOW/ASAP 12:45 12:45 12:59 10/9/06 Capital w/ Codeine STAT/NOW/ASAP x 12:28 13:06 13:05 10/9/06 Aminophylline STAT/NOW/ASAP 12:22 12:28 13:05 18

19 Date Medication Name Medication Category Omni Written Time Arrive Time Order Entry Time Exit Time Omni Time Administered Time PRN 10/20/06 Valganciclovir Antibiotic 12:14 12:24 12:44 13:02 10/20/06 Clindamycin Antibiotic x 12:10 12:24 12:32 15:00 10/20/06 Metronidazole Antibiotic 11:07 12:24 12:34 13:54 21:00 10/20/06 Vancomycin Antibiotic 13:38 13:41 13:54 18:40 10/20/06 Gentamicin Antibiotic 13:38 13:40 13:54 14:25 10/20/06 Metronidazole Antibiotic 12:24 12:27 12:39 13:00 10/20/06 Gentamicin Antibiotic 11:15 12:24 12:30 13:02 13:00 10/20/06 Vancomycin Antibiotic 12:24 13:02 10/20/06 Dolasetron Antiemedic x 11:58 12:24 12:59 10/20/06 Dolasetron Antiemedic 11:15 12:24 12:49 13:54 21:00 PRN 10/20/06 Spironolactone Cardiac 11:25 12:24 12:42 13:02 10/20/06 Hydralaxine Cardiac 11:17 12:24 12:48 13:02 17:00 PRN 10/20/06 Furosemide Cardiac 11:17 12:24 12:45 13:02 15:20 10/20/06 Spironolactone Cardiac 13:21 13:29 13:54 10/20/06 Furosemide Cardiac 12:00 13:21 13:31 13:54 10/20/06 Baclofen Other 11:57 12:24 12:56 13:02 15:30 PRN 10/20/06 Acetaminophen Pain 11:10 12:24 12:33 13:02 21:10 PRN 10/20/06 Clonazepam Pain x 11:56 12:24 12:57 21:55 22:00 10/20/06 Acetaminophen Pain x 11:58 12:24 12:59 15:08 PRN 10/20/06 Diazepam (Valium) Pain x 11:57 12:24 13:06 15:07 15:30 PRN 10/20/06 Acetaminophen w/ codeine Pain x 12:24 13:02 15:19 15:30 PRN 10/20/06 Lorazepam Pain x 10:55 12:24 12:33 PRN 10/20/06 Morphine Pain 12:00 12:24 12:30 13:02 10/20/06 Lorazepam Pain x 12:24 13:16 12:40 PRN 10/20/06 Sodium Phosphate STAT/NOW/ASAP 11:27 12:24 12:36 12:42 13:00 10/20/06 Lorazepam STAT/NOW/ASAP 12:34 12:34 12:43 14:00 10/20/06 Oxycodone STAT/NOW/ASAP x 11:21 12:36 12:39 15:21 PRN 10/20/06 Morphine STAT/NOW/ASAP x 12:24 12:30 12:36 12:45 10/20/06 Sodium Phosphate STAT/NOW/ASAP 12:24 12:30 12:34 14:30 10/26/06 Sulfamethoxazole/tmp Antibiotic 11:15 12:17 12:46 12:57 21:15 10/26/06 Azithromycin Antibiotic 12:17 12:31 12:57 10/26/06 Azithromycin Antibiotic 11:00 12:17 12:32 12:57 14:00 10/26/06 Azithromycin Antibiotic 11:00 12:17 12:31 12:57 10/26/06 Gentamicin Antibiotic 12:17 12:25 12:57 14:10 10/26/06 Azithromycin Antibiotic 11:00 12:02 12:06 12:57 10/26/06 Dolasetron Antiemedic x 10:40 10:59 11:25 PRN 10/26/06 Diphenhydranine Antiemedic 12:10 12:17 12:35 12:57 13:30 PRN 10/26/06 Metoclopramide Antiemedic 11:50 12:17 12:30 12:57 PRN 10/26/06 KCL Cardiac x 10:40 10:59 11:24 10/26/06 Calcium Gluconate Cardiac 10:00 12:17 12:29 12:57 13:30 10/26/06 Furosemide Cardiac 10:59 11:12 12:00 13:00 10/26/06 Spironolactone Cardiac 10:59 11:09 12:00 13:00 10/26/06 Furosemide Cardiac 10:59 11:08 12:00 10/26/06 Milrinone Cardiac 12:10 12:11 12:57 13:00 10/26/06 Prednisone Other 10:30 12:17 12:35 12:57 21:35 10/26/06 Sodium Chloride Other 11:30 12:17 12:31 12:57 10/26/06 Influenza Vaccine Other 10:50 12:17 12:23 12:57 16:00 10/26/06 Hepatitis B Vaccine Other 10:50 12:17 12:24 12:57 16:00 10/26/06 Hydroxyzine HCL Other 12:17 12:23 12:57 14:45 10/26/06 Docusate SOD Other x 11:20 12:17 12:34 12:00 10/26/06 Docusate SOD Other x 11:00 12:17 12:25 12:45 13:00 10/26/06 Ranitidine Other 11:40 12:17 12:39 12:57 15:00 10/26/06 Miralax Other 11:00 12:17 12:22 12:57 13:00 PRN 10/26/06 Sodium Chloride Other 10:00 12:17 12:28 12:57 14:00 10/26/06 Insulin Aspart Other 10:15 12:17 12:30 12:57 15:00 10/26/06 Omeprazole Other 10:59 11:10 12:00 13:00 10/26/06 Glycerin Other x 12:02 12:09 PRN 10/26/06 Hydrocortisone Other 12:00 12:02 12:10 12:57 13:30 10/26/06 Hepatitis B Vaccine Other x 9:45 12:17 12:24 5:00 10/26/06 Rash Cream - UMH Other 11:25 12:17 12:25 12:57 PRN 10/26/06 Oxycodone Pain x 10:10 10:59 11:07 13:00 13:00 PRN 10/26/06 Morphine Pain x 10:40 10:59 11:10 PRN 10/26/06 Acetaminophen Pain x 10:40 10:59 11:24 PRN 10/26/06 Morphine Pain x 11:00 12:17 12:32 12:39 12:40 10/26/06 Acetaminophen Pain x 11:00 12:17 12:26 PRN 10/26/06 Acetaminophen Pain x 12:02 12:09 12:30 PRN 10/26/06 Midazolam Pain x 12:02 12:09 PRN 10/26/06 Morphine Pain x 12:02 12:09 PRN 10/26/06 Ibuprofen Pain x 12:02 12:09 PRN 10/26/06 Citrulline STAT/NOW/ASAP 10:06 11:13 11:17 11:40 13:00 10/26/06 Sodium Phenybutrate STAT/NOW/ASAP 10:06 11:13 11:23 11:40 10/26/06 Tobramycin STAT/NOW/ASAP 11:35 11:50 11:52 11:56 12:10 10/26/06 Ibuprofen STAT/NOW/ASAP x 11:00 12:17 12:18 16:20 10/31/06 Vancomycin Antibiotic 10:00 11:10 11:17 11:58 12:35 10/31/06 Metronidazole Antibiotic 12:15 12:30 13:03 19

20 Date Medication Name Medication Category Omni Written Time Arrive Time Order Entry Time Exit Time Omni Time Administered Time PRN 10/31/06 Amoxicillin Antibiotic 8:00 11:10 11:20 11:58 13:00 10/31/06 Fluconazole Antibiotic 11:45 12:15 12:18 13:03 10/31/06 Vancomycin Antibiotic 10:10 12:15 12:26 13:03 17:00 10/31/06 Ampicillin Antibiotic 10:15 11:10 11:55 13:03 23:05 10/31/06 Gentamicin Antibiotic x 10:15 11:10 11:56 22:50 10/31/06 Ampicillin Antibiotic 12:15 12:46 13:03 20:10 10/31/06 Erythromycin Antibiotic 12:15 12:47 13:03 22:30 10/31/06 Gentamicin Antibiotic 12:15 12:47 13:03 23:30 10/31/06 Metoclopramide Antiemedic x 10:00 11:10 11:18 PRN 10/31/06 Aminophylline Cardiac 11:05 11:25 11:34 11:38 12:45 10/31/06 Digoxin Cardiac 11:15 12:15 13:03 14:00 10/31/06 Furosemide Cardiac x 12:15 12:22 12:30 10/31/06 Isradipine Cardiac 10:50 12:15 12:21 13:03 22:40 PRN 10/31/06 Furosemide Cardiac x 10:05 12:15 12:27 12:30 12:40 10/31/06 Furosemide Cardiac 6:30 12:15 12:36 13:03 15:00 10/31/06 Warfarin (Coumadin) Other 11:30 12:15 12:24 13:03 22:00 10/31/06 Nystatin Other 11:05 12:15 12:26 13:03 10/31/06 Lisinopril Other 11:15 12:15 13:10 14:00 10/31/06 Montelukast Other 11:15 12:15 13:10 14:00 10/31/06 Pantoprazole Other 11:15 12:15 13:10 14:00 10/31/06 Lactulose Other 10:30 11:10 11:16 11:58 20:30 10/31/06 Albumin Other 12:00 12:15 12:23 13:03 14:00 10/31/06 Foscarnet Other x 8:40 11:10 11:29 10/31/06 Metoprolol Other 10:30 11:10 11:23 11:58 21:15 10/31/06 Methylprednisolone Other 10:30 11:10 11:22 11:58 10/31/06 Sumatriptan Other 9:00 11:10 11:26 11:58 22:30 PRN 10/31/06 Glycerin Other x 11:10 11:15 PRN 10/31/06 Hydrocortisone Other 11:10 11:23 11:58 12:00 10/31/06 Dextrose Other 10:15 11:10 11:57 13:03 10/31/06 Phytonadione Other 12:15 12:47 13:03 23:30 10/31/06 Dextrose Other 12:15 12:44 13:03 20:22 10/31/06 NaCl Heparin Flush Other 12:15 12:44 13:03 23:30 10/31/06 Methadone Pain x 10:05 11:10 11:19 13:01 10/31/06 Methadone Pain x 11:59 12:15 12:29 12:45 12:50 10/31/06 Oxycodone Pain x 12:00 12:15 12:19 12:31 12:40 10/31/06 Morphine Pain x 11:10 11:23 11:46 12:00 10/31/06 Morphine Pain x 11:10 11:23 15:38 10/31/06 Morphine Pain 12:15 12:45 13:03 15:25 10/31/06 Lorazepam Pain 12:15 12:45 13:03 10/31/06 Ampicillin STAT/NOW/ASAP 12:39 12:48 12:49 13:45 10/31/06 Gentamicin STAT/NOW/ASAP 12:39 12:48 12:49 13:00 10/31/06 Pulmozyme STAT/NOW/ASAP 11:06 11:07 11:08 11/10/06 Ampicillin Antibiotic 12:30 12:46 13:05 16:00 11/10/06 Cefoxitin Antibiotic x 13:22 13:32 18:54 21:35 11/10/06 Azithromycin Antibiotic 11:50 12:30 12:46 13:05 13:30 11/10/06 Fluconazole Antibiotic 11:30 12:30 12:45 13:05 11/10/06 Acyclovir Antibiotic 11:33 12:30 12:49 13:05 15:30 11/10/06 Mupirocin Antibiotic 9:55 12:30 12:43 13:05 21:45 11/10/06 Piperacillin Antibiotic 13:10 13:22 13:30 14:12 14:45 11/10/06 Furosemide Cardiac 11:10 12:18 12:49 13:05 11/10/06 KCL Cardiac 8:45 13:22 13:32 14:04 19:00 11/10/06 Propranolol Cardiac 13:22 13:33 14:04 21:25 11/10/06 KCL Cardiac 12:30 13:22 13:48 14:04 21:25 11/10/06 Chlorothiazole Cardiac 11:20 12:30 12:44 13:05 21:00 11/10/06 Spironolactone Cardiac 11:20 12:30 12:43 13:05 21:00 11/10/06 Albuterol Other x 12:30 13:06 15:39 16:00 11/10/06 Prednisone Other 11:40 12:18 12:41 13:05 11/10/06 Hydroxyzine HCL Other x 12:11 13:22 13:33 PRN 11/10/06 Calamine Lotion Other 12:11 13:22 13:33 14:04 PRN 11/10/06 Aveeno Bath Packet Other 13:22 14:02 14:04 14:05 PRN 11/10/06 Insulin Aspart Other x 11:30 12:30 12:48 11/10/06 Albuterol Other x 10:25 12:30 12:48 11/10/06 Nystatin Other 11:10 12:18 12:54 13:05 14:00 11/10/06 Ranitidine Other x 12:30 12:42 11/10/06 Dextrose Other x 12:30 13:05 13:07 13:10 11/10/06 Dextrose Other 12:40 13:22 13:48 14:04 11/10/06 Morphine Pain x 13:22 13:32 13:35 13:45 PRN 11/10/06 Acetaminophen Pain 13:22 13:31 14:04 15:30 11/10/06 Hydromorphone Pain x 11:45 12:30 12:41 15:58 16:05 11/10/06 Morphine Pain x 12:00 12:30 12:53 11:51 12:25 PRN 11/10/06 Morphine Pain 12:00 12:30 12:53 13:05 15:15 11/10/06 Potassium Phosphate STAT/NOW/ASAP 11:43 12:18 12:42 13:05 13:30 11/10/06 Prednisone STAT/NOW/ASAP 11:45 12:18 12:33 13:05 11/10/06 Miralax STAT/NOW/ASAP 12:40 13:22 13:31 13:50 14:00 11/10/06 Bisacodyl STAT/NOW/ASAP x 12:40 13:22 13:48 13:54 14:00 20

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