re-engineering medication processes to capitalize on technology jane englebright, phd, rn vice...
TRANSCRIPT
Re-Engineering Medication Processes to Capitalize on
Technology
Jane Englebright, PhD, RN
Vice President, Quality
HCA
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U.K.
Switzerland
USUS176 Hospitals176 Hospitals
92 ASC’s in92 ASC’s in22 States22 States
INTERNATIONAINTERNATIONALL
8 Hospitals8 Hospitals
Who is HCA?
• 44,000 to 98,000 deaths/year • 8th 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
Institute of Medicine Reports on Institute of Medicine Reports on Medical ErrorsMedical Errors
First Report: December 1999
• 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 Goals
Medication Safety
Initiative
HCA Patient Safety Initiatives Bring Evidence-Based Patient Safety Practices to HCA Facilities to Address Areas of
Concern for HCA
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:
Forcing Functions & Constraints
Automation & Computerization
Standardization & Protocols
Checklists & Double-Checks
Policies & Procedures
Education & Information
eMARePOM
High Risk Med Protocols
Practice Guidelines
Competencies
Awareness & Education
Rank Order of Error Reduction Strategies HCA Technologies
Errors resulting in ADEsErrors resulting in ADEs
Bates DW et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.
56%34%
6% 4%
Ordering
Administration
Transcription
Dispensing
0 % intercept
42% intercept
Electronic MAR & Bar CodingElectronic 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 Deployment172 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 AvertedErrors
eMAR Implementation• An interdisciplinary
Steering Committee was responsible for planning; implementation; staff and physician education and management of any issues.
Bar-codedPatient
Armbands
Bar-codedMedication
Doses
Bedside Verification
ElectronicSafety
Checking
ElectronicMedicationAdministrationRecord & 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
•Incident reports•Avoided errors•Stories
Completeness of MAR Chart audit
Accuracy of Charges •Chart audit
User Perception of Improved Safety
•Survey
Pharmacist and Pharmacy Tech Perception of Workload Changes
•Survey
ArmbandAudit
HCA Patient Safety Implementation Model
Process Change
Culture Change
Technology Change
PhysiciansHos
pita
l
eMAR Works in Three Ways
Policies, procedures, resource allocation
systemsBlunt End
Sharp EndDirect
caregiver
Monitored Process ERROR
Results
Process Redesign
Clinical Decision Support
Reports
Project Timeline6 – 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
0
20
40
60
80
100
120
1 2 3 4 5 6
IT&SRTNursingPharmacy
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
“Wire Tie”
Creativity
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 ImpactNew Member of the Clinical Team
• WLAN Installation and Support
• Computer Management
• Equipment Maintenance, including pharmacy equipment
• Downtime Processes
HIM ImpactSingle MAR for each admission
• Incorporate into discharge printing process
Finance ImpactMove 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
PracticeRecommendations
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
• Packaging and labeling errors in pharmacy
• Changing federal regulations
• Emerging barcode symbologies
• Invalidating bedside verification with workarounds
Project Risks
eMAR & Bar Coding Accountability Structure
IT & S S o ftw a reT e s tingS u pp o rt
D e ve lo p m e nt
P a tien t S a fe ty S p e cia listM a n isha S h ah , R R T
P a tie n t S a fe ty
IT & S Im p le m e n ta tio n T e amIm p le m en ta tio n C o o rd
E q u ip m e n t O rde ring
B u s in e ss O w n erA lic ia P e rry, P h a rm D
P a tie n t S a fe ty
e M A R A d v iso ry B o a rdF a c ility re p re sen ta tives
C o rp o ra te S M E s
V ice -P re s id e n tJa n e E n g leb rig h t, P hD , R N
P a tie n t S a fe ty
P a tien t S a fe ty T ea m L e ad e rsQ u a lity, IT & S
D & C , R isk , C o m m u n ica tio ns
E xe cu tive S p on sorF ra n k H ou se r, M D
Q u a lity
e M A R C o o rd in a torC N O a p po in ted ro le
D iv is io n C N O W o rkg ro upR e spo n sib le E xe cu tive
F a c ility C N O
C o rp o ra te C N O C o u n c il
O p era tion s S p on sorC h a rlie E va ns
E a s te rn G rou p P re s id e n t
HCA Corporate QualityHCA IT&S Organization
Advisory GroupsOperational 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 SurveyPharmacy Perception Survey
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
VerySatisfied
SomewhatSatisfied
Satisfied Dissatisfied VeryDissatisfied
I believe use of the eMAR and bar coding system is reducing medication errors in my hospital.
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
www.hcapatientsafety.com