Medication Delivery Administration

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Medication Delivery/Administration

• Failure Mode, Effects, Analysis (FMEA)
• September 2002

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Medication Delivery/AdministrationProject - FMEA

• A.Team Members
• B. Presentation
• C. Process Flow Chart
• D. Bibliography

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Medication Delivery/Administration Team Members

• Kristin Gibbons, RN 14th
• Traenette Williams, RN 14th
• Christie Wafford, RN 12th
• Laura Gardner, RPh
• Mary Beverley Pharmacy Technician
• Kim Williamson, RN CTD
• Facilitators
• Karen Finkel, QOM Team Lead
• Carol Miller, QOM
• Carrie Smith, QOM
• Cathey Stewart, QOM

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Medication Delivery/Administration What we
heard..

• CSC Assessment (Oct 01) found
• Inconsistent checking of 5 rights
• Inconsistent checking of MAR with batch delivery
• Delays in delivery of meds
• Inconsistent practice of 12 hour chart checks
• PCAs dont take off orders and avoid the job
• Nurses admit they dont do the batch delivery
  checks
• Nurses dont always get paged when new meds come
  up
• Nurses dont trust pharmacy blue bin for new
  orders
• Labels not always placed on yellow copy of order
  sheet
• Pharmacy feels the medication system is safe due
  to multiple checks
• Medication drawers are not consistently locked,
  locks broken

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Agenda

• Overview
• -FMEA methodology
• II. Medication delivery/administration 12th.
  and 14th. Floors
• -Strengths and Opportunities
• -Benchmark Facilities Comparison
• Wrap Up
• -Modeling TCH to Benchmark/s

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FMEA Process

• Literature review
• Identify benchmark facility/s
• Data analysis
• High level process review
• Convene team members
• Shadow personnel
• Interviews
• Use Triage questions to identify failures
• Conduct hazard analysis

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Literature Review Benchmarks

• Literature search ( 27 references)
• Reviewed sites (16 sites) - Dallas, Cincinnati,
  Seattle, Wisconsin, Virginia, Denver, Dayton,
  Minneapolis, Miami, Cook/Fort Worth, Houston
  Northwest Medical Center, Houston Driscoll,
  Corpus Christi Wesley Medical Center, Kansas
  City UTMB, Galveston Conroe Regional Medical
  Center, Conroe St. Lukes Episcopal Hospital,
  Houston
• Benchmark facility Univ. of Wisconsin _at_ Madison
  (471beds)
• Primary nursing model
• Uses McKesson bar coding system 1 ½ years
• Does not have an EMR
• Demonstrated cost savings
• Demonstrated improvement in patient safety

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Literature Review
The problem of defective medication
administration systems, although varied, is
widespread.

• Recent study (ARCH Intern Med/Vol. 162, Sept 9,
  2002)
• - 19 of the doses were in error
• - Nearly 1 in every 5 doses in error
• - 7 of errors rated potentially harmful (40/day
  in typical 300 bed facility)
• Public pressure and awareness to improve system
• Bar coding FDA mandate pending

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Data Review

• CSC Data (Oct. 01)
• TCH Data
• Wisconsin Data
• Industry Experience/RN Time McKesson
• TCH Observational Study

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CSC Data TCH July 00 June 01

• Approx 150 medication errors related to 5
  rights (though difficult to determine the exact
  cause in all cases)
• Approx 95 medication errors related to delays in
  delivery
• Data organization and utility of data unclear
  which leads to limited ability to
  identify/problem solve issues and reduce errors

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TCH Data Medication AdministrationCurrent
Error Rates

• Q3 FY01 Q2 FY02 Error Rate calculated for
• Wrong time, dose and technique
• Omissions
• Unauthorized
• Other
• CSC stated accurate data analysis is problematic
  due to
• Up to 50 of medication errors
• are not reported
• Near misses are not reported
• True error rate unknown

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TCH Data Reserves and Paid Claims
Money in reserves or paid in claims for
Medication Administration Errors for FY
99 FY 02 (current) was analyzed.
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Wisconsin DataMedication Safety Initiative

• Preparation/dispensing
• Barcodes
• Administration
• Barcodes

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Wisconsin Data Medication AdministrationInitial
450 Observations (2/01)

• Overall error rate less than most literature
• 9.1 total error rate
• 5.1 error rate without timing errors
• 29 patients not observed during administration
  (left at bedside)
• 84 did not check armbands
• 8 of doses not charted accurately

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Wisconsin Data Medication AdministrationPre
Post AcuScan Rx
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McKesson Industry Experience Proportion of RN
Time per 12h Shift

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TCH Data RN Medication Administration
Observation Sept 2002

• Study group - 12th and 14th floors
• Average scheduled doses per patient/per day
  12 to 17 doses
• Variables collected
• Order processing
• MAR check am
• MAR check pm
• Batch delivery
• Administration 5 Rights
• RNs acutely aware that data collection was
  occurring (practice was affected)

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TCH Observation Study12th 14th FloorOrders
Processing
N220

• PCA job description allocates 20 of time to
  performing clerical functions (e.g. taking orders
  off chart)

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TCH Observation Study12th 14th FloorEstimated
RN Hours for Processing Batch Delivery
Total estimated RN time range 1.24 3.30 hours
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TCH Observation Study12th 14th FloorEstimated
RN Hours for MAR checks 0700 1900

Total estimated RN time range 2.3 - 9.3 hours
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TCH Observation Study12th 14th FloorEstimated
RN Hours for Verification of 5 Rights
Total estimated RN time range 19.32 37.78
hours
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TCH Observation Study12th 14th
FloorIdentification of Patient Armband Check
by RN
N25
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Process Review
0800 New Order
0900 Med Delivery
0915 Medication Administration
1130, 1700, 2300 Batch Delivery
1900 MAR Check
0500 New MAR delivery
0700 MAR Check
Hourly MAR Checks
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FMEA Hazard Score Matrix
Severity of Effect
Catastrophic
Major
Moderate
Minor
Probability
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Medication Delivery Administration
The 12th and 14th Floors are very busy and the
physical environment is quiet and well organized.
The medication delivery administration process,
however, is very complex.
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Areas of Strength

• Nursing Pharmacy staff work hard and always
  worry about safe care
• Bedside medication storage system
• Chart at bedside
• Bedside computer terminals
• Unit dose system
• Omnicell system for narcotics

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Major Areas of Opportunity

• The current system is extremely complex.
• Policies and procedures throughout this system
  are problematic due to difficult to access
  procedure sections are very weak lack of
  nursing/pharmacy integration incomplete and
  inaccurate.
• Inconsistent training content and methods are
  used by preceptors.
• MARs are not being checked per policy.
• RNs are not checking patient armbands.
• Nurses have assumed clerical duties assigned to
  the PCAs.
• Nurses perform pharmacy delivery duties.
• Medications are not secured at the beside storage
  drawer and at Team Comm A B.

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0800 New Order Hazard Scores of gt8
0800 New Order
Data Source
Iinterview, Oobservation, PR policy review,
OR other reports
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0900 Medication DeliveryHazard Scores of gt8
0900 Med Delivery
Data Source
Iinterview, Oobservation, PR policy review,
OR other reports
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0915 Medication AdministrationHazard Scores of
gt8
0915 Med Administration
Data Source
Iinterview, Oobservation, PR policy review,
OR other reports
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0915 Medication AdministrationHazard Scores of
gt8
0915 Med Administration
Data Source
Iinterview, Oobservation, PR policy review,
OR other reports
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1130, 1700, 2300Batch Delivery Hazard Scores
of gt8
1130,1700,2300 Batch Delivery
Iinterview, Oobservation, PR policy review,
OR other reports
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1130, 1700, 2300Batch Delivery Hazard Scores
of gt8
1130,1700,2300 Batch Delivery
Iinterview, Oobservation, PR policy review,
OR other reports
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1900 MAR Check Hazard Scores of gt8
1900 Mar Check
Iinterview, Oobservation, PR policy review,
OR other reports
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0500 New MAR Delivery Hazard Scores of gt8
0500 New MAR Delivery
Iinterview, Oobservation, PR policy review,
OR other reports
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0700 MAR Check Hazard Scores of gt8
0700 MAR Check
Iinterview, Oobservation, PR policy review,
OR other reports
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Hourly MAR Checks Hazard Scores of gt8
Hourly MAR Checks
Iinterview, Oobservation, PR policy review,
OR other reports
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TCH compared to Benchmark
TCH 1. RN primarily, PCA rarely

• No specific benchmark
• Unit clerk
• Cincinnati
• 1. CPOE

0800 New Order
0900 Med Delivery
Cincinnati 1. Unit clerk delivers med to the RN.
1. RN paged to pickup med from desk.
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TCH compared to Benchmark

• TCH
• Reliance on human factors for checking of the 5
  rights.
• Manual documentation of administration.

• Wisconsin
• Bar code sweep of medication, patient armband
  RN badge.
• No documentation time.
• Flag for reminder of meds pending.
• Warning if drug or patient not correct.

0915 Med Administration

• Batch delivery 3x day.
• Delivery to med room.
• RN picks up batch from med room

1130, 1700,2300 Batch Delivery

• Cincinnati
• Batch delivery 1-2x day.
• Delivery to bedside by pharmacy.

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TCH compared to Benchmark
Wisconsin 1. No MAR check.
TCH 1. RN conducts MAR check.
1900 MAR Check
0500 New MAR Delivery

• Pharmacy tubes to floor.
• Receptionist places on counter.
• RN gathers, punches, and places in notebooks.

1. No MAR delivery.
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TCH compared to Benchmark
Wisconsin 1. No MAR check.
TCH 1. RN conducts MAR check
0700 MAR Check
Hourly MAR Checks
1. RN does hourly check at each workstation.
1. Bar code system alerts when medications are
due.
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Modeling TCH to Benchmark
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0800 New Order0900 Med Delivery(Unit clerk)
0800 New Order
0900 Med Delivery

• Develop a unit secretary role responsible for the
  clerical tasks being assumed by the RN
• Takes off physician orders
• Delivers pharmacy orders to the pharmacist
• Conducts hourly rounds for orders
• Obtains medications delivered to the unit and
  delivers to the RN
• Delivers discontinued medications to a secured
  pharmacy bin
• Determine the method for flagging orders and
  implement house-wide
• Standardize training methods and materials used
  by preceptors

Simplify/consistency
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0915 Medication Administration(Wisconsin)
0915 Med Administration

• Purchase and implement bar coding system
• Develop 1 FTE job - Bar Code Coordinator
• Develop timeline for rolling out the product with
  vendor
• Develop policies and procedures for medication
  administration
• Develop a comprehensive training program for
  pharmacy, nursing and medical staff
• Develop and implement a quality assurance program
  with defined reporting and feedback mechanisms to
  staff
• Revise EC forms to provide capture of all
  medications administered and communicated to the
  pharmacy
• Design and implement a house-wide nursing
  education program on the risk of medication
  administration and related safety issues

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Batch Deliveries(Cincinnati)
1130, 1700,2300 Batch Delivery

• Design a secured location for holding
  discontinued medications
• Decrease the number of batch deliveries to 1-2
  times per day
• Develop and implement a system in which the batch
  medications are delivered to the bedside locked
  drawer by the pharmacy technician
• Develop and implement a quality control program
  to assure all bedside storage drawers are locked
  and in good repair
• 
  
• Investigate methods to assure discontinued
  medications are returned to pharmacy and are not
  lost or stolen

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MAR Checks(Wisconsin)
1900 MAR Check
0500 New MAR Delivery
0700 MAR Check

• Purchase and implement bar coding system
• Eliminate 1900 MAR check
• Eliminate 0500 New MAR delivery
• Eliminate 0700 MAR check

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Hourly MAR Checks(Wisconsin)
Hourly MAR Checks

• Bar code system provides task list of medications
  due for the nurse

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TCH Observational Study12th 14th
FloorEstimated Annual RN Time Savings/

Range from 25,000 to 95,000
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TCH Observational StudyHouse-wide Estimated
Annual RN Time Savings/

Range from 140,000 to 560,000
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Summary

• Patient safety and performance improvement
• Implement bar coding system
• Simplify the medication process
• Financial perspective
• Limited, if any, savings in hard dollars
• Cost avoidance dollars
• (4,000/per single prevention, 100,000/per
  serious injury)

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Summary

• Lucian L. Leape, MD, the godfather of patient
  safety stated. 38 of medication errors occur
  during administration. No human safety net
  exists for nurses when administering medications.
  Only 2 percent of errors that reach the point of
  care are intercepted.
• Systems Analysis of Adverse Drug Events, JAMA.
  1995 27435-43

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Thank you
QUESTIONS?