improving the safety, efficiency & effectiveness of … the safety, efficiency &...

Improving the Safety, Efficiency & Effectiveness of the Medication

Administration ProcessNorthwest Patient Safety Conference

May 19, 2011

Joan Ching RN, MN, CPHQAdministrative Director, Hospital Quality & Safety

© 2010 Virginia Mason Medical Center

Ordering$ 26%

Transcribing$ 0%

Dispensing22%

Administering

Monitoring2%

Reported Errors in Medication Management Process

50%

CPOE

Bar Code Medication

Administration

Prepared by: Joan ChingCurrent State Date: 2/10

Value Stream Map

Medication Administration

Boundaries: From: Signal to give medication, To: Medication documentation

Wrong timeerror

Wrong formerror

No space in med room to prepare meds

Distractions/Interruptions

Discards pill packaging for crushed meds

Wrongpatient

Wrong or expired med loaded into PYXIS

Does not compare med to MAR

Doesn't check 2 forms of pt ID

Doesn't immediately document on MAR

PYXIS drawer broken

Dose not availableWithdraws meds for > one patient

Doesn't explain med 's action or indication

Doesn't label syringe or cup properly

Meds are batched, on push‐schedule

Unsecure meds on top of COW

Wrong patient error

Wrong route error

Wrong med error

Wrong dose error

Wrong technique error

Waiting in queue at PYXIS machine

Moving pt furniture, getting water

RN sees signal to give meds

Retrieves med from PYXIS Prepares med at PYXIS

- Draw up in syringe

Greets patient

Gel in with Purell"Here to give you med(s) "

Administers med Documents med given

4 4 4 4 3

"It Takes Two" ID check

- Pt states namePt states date of birth

Explains med to patient

- Medication nameMedication action

4 4

PYXIS Supplies

0:01:00 0:00:000:00:000:00:45 0:02:390:00:00 0:02:00

- Label with med name/strength- Put into med cup

"Here to give you med(s)."

RN RN RN RN RN

- Pt states date of birth - Medication action

RN RN

Median of 4 timings Median of 4 timings

0:01:00 h:m:sVA 0:01:00 h:m:s

CT

0:00:00 h:m:s

h:m:s

NVA

% VA

0:00:00

100 00%

h:m:s

0:01:00 h:m:s

CT 0:01:00 h:m:s

h:m:s % VA

h:m:s NVA

100 00% h:m:s0 00% h:m:s

VA

NVA

CT 0:00:20VA 0:00:20

NVA

% VA 100 00%

0:00:48 h:m:s 0:00:00

0 00%

h:m:sNVA

% VA

CT

VA

% VA 0 00%

NVA

0:00:11

0:00:00

0:00:00

0:00:11

0:00:00

CT

0:00:00

h:m:s % VA

h:m:s

h:m:s

0:00:00

0:00:13

0:00:13

h:m:s

% VA

VA 0:00:00 h:m:sNVA 0:00:50

h:m:s

h:m:s

h:m:s

CT

VA

NVA

0:00:48

h:m:s0:01:14 h:m:s

h:m:s

0:00:20 0:01:00

h:m:s VAh:m:s

0 00%

h:m:s

0:01:14 0:00:13

h:m:s

h:m:s

0:01:00

CT 0:00:48 h:m:sVA 0:00:00

0:00:50

CT 0:00:50 h:m:s

% VA 0 00% h:m:s

Takt Time = Time Available =

h:m:s100.00%h:m:s 100.00% h:m:s0.00% h:m:s

11.4 min

100.00%0.00%

h:m:sNon Value Added (NVA) Tim

0:12:00

0:04:16

0:02:20

h:m:s

Current State 2/10

Value Added (VA) Time

Lead Time

Cycle Time

h:m:s

0.00%

0:08:15

h:m:s

1245 min

109 meds

h:m:s h:m:s0.00% h:m:s 0.00% h:m:s

Demand (max washer output)

Operators Needed

%

%69%

0.37

% VA

% NVA

19%


CALNOC Medication Administration Accuracy Survey

• Systematic assessment, targeted improvement

• Barker & Pepper’s research§ 1 of 5 doses in error§ Wrong time 43%§ Wrong dose 17%§ 7% error rate (>40/day in

300-bed facility)Betty Irene Moore

Comparing Error Detection Methods

456

373

24 1

050

100150200250300350400450500

Errors detected on 2,557 doses

PharmTech

RN Chartreview

Incidentreports

Error = a dose administered differently than ordered on the patient’s medical record

Flynn, Barker, Pepper, Bates, Mikeal, AJHP, 2002.

© 2010 Virginia Mason Medical Center© 2010 Virginia Mason Medical Center

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


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.


Baseline MeasuresJan-Feb 2010 N=898 doses

57%

14% 13%

6% 5% 4%

0

10

20

30

40

50

60

70

80

90

100

0

10

20

30

40

50

60

CUMULATIVE

%

DEFECT

Safe Practices Defects

% Defects Cumulative %


Baseline MeasuresJan-Feb 2010 N=898 doses

55%

24%

7% 6% 5%3%

0

10

20

30

40

50

60

70

80

90

100

0

10

20

30

40

50

60

Wrong time Wrong technique

Unauthorized drug

Drug not available

Wrong route Wrong dose

CUMULATIVE

%

ERROR

Type of Errors

% Error Cumulative %

Improperly administered so as to alter drug’s effect

Given more than 1-hr before or after scheduled dose


Reducing Waste in the RN’s Day

DefectsProcessing

MotionInventory.

Time

Waste

Transportation.

Overproduction

The 9 AM Line-up


Vertical Inspection

• Inspecting the workflow

Control upstream processes

• Conditions that create defects

SWAMP

• Medication schedule

Horizontal Source

Inspection

Within the process MOSQUITOES

Approaches to Mistake Proofing

InterruptionsRoom Layout

Horizontal Inspection

Within the process MOSQUITOES


Interruptions

• “Expected, natural component of RN work”• 89% of interruptions ð negatively impact

patient safety-- Hall, et al., JONA, 40(4), April 2010

• 12% # in procedural failures• 13% # in clinical errors• # interruption frequency ð # error severity

-- Westbrook, et al., Arch Intern Med, 170(8), April 26, 2010

Visual Control & Mistake Proofing

Medication Room


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

i Walkingi Wasted motion$ Hunt-and-find$ Forgotten supplies

Point-of-use

Carry & go

Self-Check

Visual Control

BEFOREAFTER


Medication Administration Schedule

0

50

100

150

200

250

300

350

400

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Doses Dispensed by Day of Week & Hour

FRI

MON

SAT

SUN

THU

TUE

WED

LEVELING PRODUCTION


Unit DashboardMEDICATION ADMINISTRATION DASHBOARDNEUROLOGY-UROLOGY-NEUROSURGERY Level 17

Legend: Better than CALNOC Worse than CALNOC

% M

ed C

ompa

red

wit

h M

AR

% M

ed E

xpla

ined

to

Pat

ient

% M

ed L

abel

edTh

roug

hout

% M

ed C

hart

edIm

med

iate

ly

% 2

For

ms

IDCh

ecke

d

% M

ed P

ass

Dis

trac

ted/

Inte

rrup

ted

98100 99 100

96

95

97

9290

95

100

Q1 10 Q2 10 Q3 10 Q4 10

NUN Mean CALNOC Mean

92

86

100 10096 95

94 91

80

85

90

95

100

Q1 10 Q2 10 Q3 10 Q4 10


99

94

10097

93

88

92

84

80

85

90

95

100

Q1 10 Q2 10 Q3 10 Q4 10


100 100 99100

89 91 89

92

85

90

95

100

Q1 10 Q2 10 Q3 10 Q4 10


47

24

87

28

27

22

33

01020304050

Q1 10 Q2 10 Q3 10 Q4 10NUN Mean CALNOC Mean

100 100 100 100

98

95

96

99

94

96

98

100

Q1 10 Q2 10 Q3 10 Q4 10NUN Mean CALNOC Mean

48%46% 42%

29%

0%

10%

20%

30%

40%

50%

60%

Q1 Q2 Q3 Q4

Distractions/Interruptions

1.4%

1.6%

0.9%

0.6%

0%

1%

2%

Q1 Q2 Q3 Q4

Wrong Technique

8.6%

2.1%3.9% 3.5%

0%

2%

4%

6%

8%

10%

Q1 Q2 Q3 Q4

Wrong Time2010 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 control @ automated dispensing cabinet•Reducing interruptions in patient room


Overall Risk & Defect Reduction

N=5,125 observed medication doses in 2010

65%71%

46%52% 53% 51% 50%

56%

47%

31%40%

35%

0%

20%

40%

60%

80%

100%

Percent Defect Rate

In 2010, we reduced the # of unsafe practices & med errors by 52%!