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

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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