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Reduce medication errors through following metrics
Pharmacy targets workflow issues
Hospital pharmacists should learn how to develop metrics for charting a variety of processes, including switching to new technology, following medication error reduction programs, and tracking best practices at multiple sites, an expert says.For example, MedCentral Health System in Mansfield, OH, has a goal of having 92% or greater of all medications scanned without an override, says Brian F. George, PharmD, assistant director of pharmacy services.
By using metrics to track progress on safety and other goals, hospital pharmacists can keep track of how well staff are adhering to policies and procedures and note areas that need improvement.
The pharmacy department tracks its success with meeting the goal through metrics that were developed over a six-month period, George says.
Here are some examples of their metrics and how they tracked and improved progress in those areas:
• Metric: Are 92% or greater of all medications scanned?
"Every medication that leaves our pharmacy has a barcode on it, and they're checked when they come in," he adds. "So we hit that goal in the first few months of being live on this process."
"We saw early on that we were hitting that 92% benchmark," George says.
There always will be some unavoidable overrides, but for the most part the process has been successful, George says.
The hospital pharmacy also tracks workflow and process, making sure the barcode is in place and scans well.
"So when the drug comes into the pharmacy, we verify that the barcode reads correctly," George says. "If we bring a drug into the pharmacy and don't check it, then when it doesn't scan right for the nurse, the nurse will override it."
Nursing overrides is a big workflow issue, so the pharmacy improves its metric in this area by checking all product orders and verifying that they can be scanned, he adds.
Another way to improve workflow is to focus on nursing education and compliance enforcement.
"We talked with nurses about the whole process, and we had great support from the nursing administration," George says.
The nursing administration made barcode scanning overrides a disciplinary issue.
"If nurses knowingly bypassed the barcoding system just because they wanted to bypass it, then it would be a disciplinary issue," George says. "That might sound like a hard line, but that's what you have to do."
Also, nurses were told that if supervisors found extra barcode armbands on patients or on medical carts then they'd be subject to disciplinary action, he adds.
"I've heard of sites where you would see an armband taped to the wall and things like that," George notes. "That was never an issue here."
• Metric: What is overall error rate?
One of the convenient aspects of metrics is that these can be grouped however one likes. So for this metric, there were a number of items included, such as omissions, scheduled medications that were not charted, etc.
"We also looked at early PRNs," George says.
For instance, if a physician ordered pain medication to be administered every six hours, as needed, for a patient, then it would be a mistake for a nurse to administer the medication after three hours, he explains.
"We would need to stop that from happening," he says. "If someone needs the pain medication that much earlier, then someone needs to evaluate the order."
Other errors would be if the wrong patient's armband is being scanned.
"The scanner would give a beep, and it would be a near miss," George says. "But we count that as an error."
George examines the errors that were caught by the barcode scanning system to see what type of mistakes might have occurred if the technology had not been in place to stop the nurse from administering medication incorrectly.
"While we prevented these and they're counted as saves, these are errors because without our barcoding system these medications would have been given incorrectly," George adds.
The metric calls for a less than 2% error rate of these near misses.
Whenever a pharmacy uses metrics to measure success, it's also necessary to have tools that help with measurement.
At MedCentral Health System, there is a medication error form that assesses severity of errors.
It has a score of 1 through 9, with 9 being equal to a patient's death, George says.
The lowest score of an error goes to a near miss.
"So when you implement a system like this, you hope any medication-related errors of higher severity would decrease and medication errors of low severity would increase — like near misses," George says.
"These are things that weren't reported before, and you wouldn't have had a good way of capturing them because they were self-reported," he adds. "So the near misses weren't captured really well before barcode scanning."
This is why the hospital anticipated these low severity numbers to rise once the barcode scanning technology was put in place.
"That number goes really high, and you want it to do this because it shows the effect and benefit of the system," George explains. "So we know the system is helping us prevent mistakes."
The barcode scanning system decreases the number of errors that impact patients, and the metrics proved this point: "We saw a reduction from the year prior to implementation to the year of implementation, and we've seen a reduction that has been maintained every year since," he adds.
For instance, the medication error metrics showed that the rate of errors was 0.37 per 1,000 doses prior to the implementation of barcode scanning, George says.
After the implementation, the rate decreased to 0.29 per 1,000 doses, showing that the new technology prevented 140-150 events, George adds.
• Metric: How well is pain reassessed?
"We also look at pain reassessment and have it set up in the system where 30 minutes after the administration of pain medication they have to reassess," George says.
"The system prompts them for that, and if they fail to do it, we re-evaluate," he adds. "We want greater than 90% of all pain medications administered re-assessed, whatever the dose."
By following this metric, George knows that the hospital achieves this goal.
"We're above 90%," he says.
"I have a philosophy that if you want something improved, you have to measure it," George adds. "By measuring it, it will be improved because people know it's being measured and they start to do better."
When metrics show that employees are not doing as well as expected, then the results can be used to coach people to do a better job, he says.
"This is a tool to better evaluate that processes are done in a timely fashion and well documented," George says.
The metrics have been a successful tool for the hospital pharmacy, George notes.
"It's helped us stay more involved in the process," he says.
Tracking and documenting success data about the technology change will have a long-term positive impact on the hospital pharmacy, he says.
"It's put our department in a good position for when we ask to do other projects," George says. "It allows us to utilize our staff to do stuff, and it allows us to say, 'Here is a project we did very successfully, and here's another project I'd like to do.'"
Hospital leaders are more likely to let the pharmacy implement new processes and technology if they are given data demonstrating patient safety and success, George adds.
"We want to provide medication in the safest fashion possible," he says. "That was our whole goal with the project, and I think we showed them we could do that."