Re-Engineering Medication Processes to Capitalize on Technology Jane Englebright, PhD, RN Vice President, Quality HCA
Who is HCA? % % % % U.K. % % % Switzerland % %% % % % % % %% % % % % % % % %% % % % % % % % %% % % %%% % % % % % % % % % % %%% % % % % % %% % % % %% % % %% %% % %% % % % % % %% % % % % % % %% % % % %% % % % % % %% % %% %% % % % % %% US 176 Hospitals 92 ASC s in 22 States INTERNATIONAL 8 Hospitals
Institute of Medicine Reports on Medical Errors First Report: December 1999 44,000 to 98,000 deaths/year 8 th leading cause of death in US Provocative Statements: Most errors are caused by system failures rather than human error All manual processes are subject to error Many error reduction efforts do not take advantage of information systems Conclusions Status quo is not acceptable 50% reduction of error over next 5 years
HCA Patient Safety Goals Establish patient safety as a visible commitment to putting patients first philosophy Move from blaming people to improving processes Improve use of technology to prevent and detect error Use data to identify and measure improvements
HCA Patient Safety Initiatives Bring Evidence-Based Patient Safety Practices to HCA Facilities to Address Areas of Concern for HCA Medication Safety Initiative Evidence- Based Patient Safety Practices: IOM Report ISMP Bates Areas of Concern for HCA: IOM Report Each HCA Facility Implements Evidence- Based Patient Safety Practices in Areas of Concern for HCA
The Medication Safety Initiative Included: Rank Order of Error Reduction Strategies Forcing Functions & Constraints Automation & Computerization Standardization & Protocols Checklists & Double-Checks Policies & Procedures Education & Information HCA Technologies emar epom High Risk Med Protocols Practice Guidelines Competencies Awareness & Education
Errors resulting in ADEs 0 % intercept 34% 6% 4% 56% 42% intercept Ordering Administration Transcription Dispensing Bates DW et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.
Electronic MAR & Bar Coding
emar Safety Features Validates Five Rights of Medication Administration Requires patient specific clinical data for certain medications (i.e, pulse rate prior to administration Lanoxin, review of potassium level before giving Lasix). Sends a warning to alert nurse when the dose is to much or to little, or if the dose is being given to early or to late. Single source of truth for patient medication status.
HCA Clinical Information Systems
emar & Bar Coding Deployment 172 Sites in 5 years
emar & Bar Coding: (Company-wide Results-Year 2005) 115,933,163 Doses administered in 171 hospitals 2,913,018 Error warnings 2,121,315 Doses not given after warning Averted Errors
emar Implementation An interdisciplinary Steering Committee was responsible for planning; implementation; staff and physician education and management of any issues. Bar-coded Patient Armbands Bar-coded Medication Doses Bedside Verification Electronic Safety Checking Electronic Medication Administration Record & Charging
Expected Outcomes Fewer medication administration errors More complete documentation Staff perception of improved safety Patient perception of improved safety Improved accuracy of billing
Measurement Plan: Understanding the Impact Medication Administration Errors Completeness of MAR Accuracy of Charges User Perception of Improved Safety Pharmacist and Pharmacy Tech Perception of Workload Changes Incident reports Avoided errors Stories Chart audit Chart audit Survey Survey Armband Audit
Hospital Technology Change Process Change Physicians Culture Change HCA Patient Safety Implementation Model
emar Works in Three Ways Blunt End Policies, procedures, resource allocation systems Process Redesign Sharp End Monitored Process Direct caregiver ERROR Clinical Decision Support Reports Results
Project Timeline 6 7 months per hospital Pre- Assessment Barcoding Meds, Hardware, Dictionary Changes, Testing End User Training Post Implement Support Kick Off Go Live
Project Workload: Fluctuations over 6 months 120 100 80 60 40 IT&S RT Nursing Pharmacy 20 0 1 2 3 4 5 6
Implementation Activities: Culture Executive Walk-Arounds Do No Harm video Verification not Scanning Patient Safety Principles: Double-Check
Implementation Activities: Process Functions Most Impacted.... Nursing Pharmacy Respiratory Care IT&S HIM Finance Quality & Risk
Process Re-Design Develop a workflow study of the actual steps in the medication preparation and delivery process at your facility Start at the patient and work backwards Include Nursing, Respiratory Therapy, and Pharmacy
Nursing Impact Model of care delivery Who do you want to give medications? Medication distribution system How do medications get from the pharmacy to the bedside?
Pharmacy Impact Accuracy and timeliness of order entry and turn around Bar Coding ALL medications Medication acquisition philosophy Override policy adherence
Creativity Wire Tie
Respiratory Care Impact Workflow: Sequential vs Concurrent Therapy Scheduling of medication administration Medication storage and distribution Clear accountability for medication administration Non-standard medication preparations Order acknowledgement processes
IT&S Impact New Member of the Clinical Team WLAN Installation and Support Computer Management Equipment Maintenance, including pharmacy equipment Downtime Processes
HIM Impact Single MAR for each admission Incorporate into discharge printing process
Finance Impact Move to billing on Administration instead of billing as Dispensed Improved Audit accuracy Improved Charge capture Decreased paybacks from insurance audits
Quality & Risk Impact Explaining it all to the Surveyor Averted errors = Near misses Areas with 100% utilization rates can have zero medication administration errors Preserving Quality Control Activities Order Acknowledgement Chart Checks
Practice Recommendations
Infection Control Recommendations Carts should be cleaned at least daily with hospital approved disinfectant Carts may be used in isolation rooms Carts should be cleaned before leaving the room if contaminated and when used in isolation Patient Safety equipment can be safely used in all patient care areas exception: Known SARS or Small Pox
Pediatric/NICU Recommendations Identify armband solution Newborn Pre-registration Processes Unit dose medications Bar code identification of Breast Milk and documentation of feeding
Psychiatric Recommendations Don t take the scanner into seclusion Consider alternative form factors for scanners Unit dose medications Special armband needs
Implementing emar Roll out in waves Bring up first 1 or 2 units First unit that mostly discharges patients Maintain for 1-2 weeks Troubleshoot and resolve issues as they arise Roll out remaining units quickly in related waves Turn on Admin Billing
Project Risks Packaging and labeling errors in pharmacy Changing federal regulations Emerging barcode symbologies Invalidating bedside verification with workarounds
emar & Bar Coding Accountability Structure Executive Sponsor Frank Houser, MD Quality Operations Sponsor Charlie Evans Eastern Group President Vice-President Jane Englebright, PhD, RN Patient Safety Patient Safety Team Leaders Quality, IT&S D&C, Risk, Communications Corporate CNO Council Business Owner Alicia Perry, PharmD Patient Safety emar Advisory Board Facility representatives Corporate SMEs Division CNO Workgroup Responsible Executive Facility CNO IT&S Software Testing Support Development Patient Safety Specialist Manisha Shah, RRT Patient Safety IT&S Implementation Team Implementation Coord Equipment Ordering emar Coordinator CNO appointed role HCA Corporate Quality HCA IT&S Organization Advisory Groups Operational Accountability Structure
Getting Staff to Use the Technology How is this going to help me do my job better? Why is this necessary? I didn t go to school to become a computer genius! I guess this keeps somebody employed! Just when I thought I had myself organized, they come up with something new!
Answering the Why? Keep the team engaged. Be patient as many do not adapt to change readily Communication e-mar benefits vs. expectations Focus on patient knowledge and patient safety Ongoing involvement of core team Keep the team focused on Patient Safety as a priority goal
Get it Right Equipment Analysis Pilot FIRST!!!! Communication Training/Education Troubleshooting Plan Competency Ongoing unit based resources
Leadership Strategies Staff Meetings PATIENT SAFETY STRESSED Expectations clearly communicated again Non-compliance outcomes discussed Accountability Mandatory Education & Competency Assessment Regular monitoring of usage reports Prompt follow-up on negative usage patterns
Leadership Makes a Difference Results from pilot hospital: Usage STATS improved within one week of implementing accountability plan. No formal disciplinary measures were required. Satisfaction scores improved!!! Goal 90 100%
Results Averted Errors Usage Staff Perception
First & Second quarter summary reports Malpractice claims related to medication administration have decreased by 16%
Pharmacy Perception Survey 50% 45% I believe use of the emar and bar coding system is reducing medication errors in my hospital. 40% 35% 30% 25% 20% 15% 10% 5% 0% Very Satisfied Somewhat Satisfied Satisfied Dissatisfied Very Dissatisfied
Novice Staff Rely on e-mar! Pt. history - allergies etc Lab link Reminder to document BP/HR/Pain Scale Checks and balances Look alike sound alike drugs Unusual doses flagged Realistic expectations
emar Maintenance Work Software Equipment Culture transformation Process change
emar & Bar Coding The Way We Do Meds at HCA Single point of accountability within each hospital to assure optimal ongoing operation Corporate emar Advisory Committee to address Culture-Process-Technology issues Regular division meetings Monthly conference calls/quarterly web casts for sharing best practices and enhancements
the way we do things
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