Accreditation Field Report

Medication safety gets a close look during survey

Processes for storage, error reporting examined

At recent JCAHO surveys at two hospitals in the Wisconsin-based Aurora Healthcare System, all components of medication management were a major focus.

During the April and May 2006 surveys at West Allis Memorial Hospital and Aurora Medical Center, surveyors looked closely at the storage and security of medications, specifically whether the hospitals were complying with the CMS Conditions of Participation (COP) requirements regarding who has legal access to medications.

At West Allis Memorial, surveyors noticed that an unlocked anesthesia cart was in a Cesarean section room while housekeepers were cleaning the room for the next patient, without direct supervision of licensed personnel.

"If medications are in an unlocked area where unlicensed personnel can access them, compliance with the COP is compromised," says Mary Kannenberg, director of quality management for both hospitals. "JCAHO is surveying us against both what our hospital policy requires, and what laws or regulations stipulate."

Surveyors were comfortable with the organization's medication reconciliation process and use of a "Home Medication Profile," which is completed for all patients. "They wanted to see that all the elements of a medication order were documented, such as route, dose, and frequency. They were really focused on that," says Kannenberg.

Surveyors looked to see an indication or symptom was documented for medications ordered "as needed" or "PRN."

The surveyors will assess compliance with this based on hospital policy, says Kannenberg. "At the time of the survey, our policy stated that indications need to be in the order. However, the physicians were documenting the indications for PRN anywhere, which theoretically is fine, but our policy didn't say that," she says. "The policy was changed immediately to reflect our current practice."

Surveyors asked about how medication errors are tracked and what is done with the information. "There are a number of facets to the process for medication error reporting, depending on the severity of the error and the cause, such as prescription, transcription, dispensing, administration, or monitoring," says Kannenberg.

The data are reported to the pharmacy and therapeutics committee and the performance improvement committee, an analysis is conducted, and appropriate actions are taken to reduce the risk for reoccurrence, she says.

Surveyors also looked at the following:

Handoff communication. The surveyor asked staff what information they were provided about the patient, and whether they got it in writing or verbally. "They were interested in the hand-off communications between the OR staff and the staff on the receiving inpatient unit," says Kannenberg. "In all of the cases, the staff were able to articulate what they do, and met the intent."

Patient flow. "They were interested in our patient flow initiatives from a leadership standpoint," says Kannenberg. At West Allis Memorial, a data dashboard is used to display key indicators related to patient flow and is reported to hospital leadership.

Surveyors were impressed with a process implemented a year ago called "Access Alert," used when the ED has reached capacity and is getting close to diversion. "The Access Alert page results in staff from the lab, radiology, nursing, and other department representatives reporting to the ED to help fast track anything that needs to get done," says Kannenberg. "Sometimes it's just a matter of getting the patient transported to the floor. It's been very successful in facilitating patient flow and reducing our rate of diversions."

The diversion rate previously was 5.31%, but since the Access Alert process was implemented, that has decreased to 3.56%. "We are able to safely and efficiently move patients through the ED with the assistance of extra hands from other disciplines," says Kannenberg. "We had a number of Access Alerts while the surveyors were here. They were impressed with the level of work we had done to address patient flow activities, and that our scope of assessment and actions were hospitalwide as opposed to just the ED."

Patient safety. Surveyors asked unit staff what projects the hospitals were engaged in and how a culture of safety was assessed. "We were able to articulate about how we participate in the Leapfrog Group survey, the Institute for Healthcare Improvement's 100,000 Lives campaign, and a number of other projects," says Kannenberg. "Surveyors were impressed when front-line staff brought them into their lounge to show the data posted on their performance improvement activities, and how they were applying the PDSA model to their PI activities."

Anesthesia safety. The physician surveyor asked staff in the OR about the process for patients who have a reaction to anesthesia. "What they were looking for is that we had a malignant hyperthermia kit to administer to the patient should they have signs and symptoms of malignant hyperthermia, and that education has been provided to the staff," says Kannenberg.

Physician involvement. When surveyors asked how physicians and leadership collaborate, staff reported that a physician chairs the hospital's multidisciplinary quality council and clinical safety committees.

"We also have good participation from the additional physician members on those committees. We utilize physician champions to help spread the word and provide a better understanding of why things are important for patients," says Kannenberg.