| | Patient Safety - Medications
Purpose
Patient safety is a primary responsibility of all health care institutions. Gundersen Lutheran developed Medication Safety as a “Systems Initiative” in the fall of 2000 with the intent of performing an assessment of the level of medication safety within our system and beginning the process of improvement over a 12-18 month time period.
Background
When the book To Err is Human was first released in December 1999, the public was surprised and concerned about the low level of safety apparent in many hospitals and clinics throughout America. This served as a “wake-up” call for all health care institutions to look for ways to make care safer, as well as more efficient, equitable and more patient-centered. Gundersen Lutheran regarded itself as being basically a very safe health system, but had not performed any formal review of high risk areas of health care. Furthermore, the scientific literature suggested that there were ways to improve patient safety throughout our hospital. Medication safety was the focus of this taskforce, as we found that medication errors were the most common and most dangerous of the errors that might occur in a health care center. The taskforce was given direction to perform an assessment of medication safety, assess the culture of safety within the institution and attempt to identify measures to continually improve staff understanding and responsibility for safety. It also worked to identify processes for improvement that would have the greatest effect and could be designed to outlive the taskforce. This report provides a summary of the work completed from the fall of 2000 to spring 2002.
Aims
Learn and apply the science of safety as it applies to the medication use process within the Gundersen Lutheran System by:
- Implementing Best Practice
- Education patients/family and staff about their role in medication safety
- Supporting a culture of awareness, trust and open communication
- Developing a blameless, non-punitive system of reporting medication events and near misses
- Reducing medication events to a zero defect level.
Methods
A multidisciplinary team including nurses (the single largest membership), physicians, quality improvement personnel, pharmacists, and administrators was organized in the fall of 2000. The taskforce reviewed the mandate provided by leadership, evaluated its alternatives and began the assessment process. The taskforce utilized the interest in medication safety that was growing in medicine at that time to identify important areas in which to work. The taskforce developed 4 main areas in which to conduct its business:
1. Error reporting. We recognized that there were too many ways to report, that we had no way of identifying and utilizing the knowledge obtained from near misses, that there was some fear in reporting, and that we had no way to analyze error reports to identify weaknesses in our defenses that required improvement. It was determined early in our evaluation phase that a new reporting system was necessary. It was determined that we needed a single database that allowed for analysis by experts trained to evaluate and look for patterns in our system. It was necessary to find ways to remove the fear of reporting errors.
2. Computerized prescription order entry (CPOE). Many reports in the recent literature indicate that the ordering process is responsible for as much as 50% of the medication errors. CPOEs are expensive, cumbersome and poorly received by providers because many of them don’t fit into the flow of work for doctors, nurses and other care providers. The taskforce determined that an evaluation of system readiness for such a technological tool should be made and the movement to development of such a system in our system should be supported.
3. Best practices. Gundersen Lutheran adopted a series of Best Practices for Medication Safety from an Institute for Healthcare Improvement collaborative improvement project that identified 16 Best Practices in hospitals. The decision was made to add other improvements as we felt were indicated. The first stage was to perform an assessment of our present systems in each of these areas and then to work towards identifiable goals for improvement.
4. Patient partnering. The taskforce quickly determined that patients had responsibilities for improving their own medication safety. It would become increasingly necessary for patients and care providers to see themselves in a partnership to improve patient outcomes and reduce the rate of medication errors.
The taskforce considered education of staff and patients as an overriding consideration in all of its tasks. It was not a separate category, but a requirement of leaders for each of the above 4 projects to provide education to the staff about medication safety. Furthermore, the taskforce knew that it only had 12-18 months to begin these processes and that it needed to find owners for each of its projects, or to devise an acceptable successor that would meet goals for the institution of minimizing the number of committees and keeping the process as simple as possible.
Results
1. A new error reporting process was developed. A single, simplified form for all medication errors throughout the system was devised, utilizing NASA’s reporting form utilized in the aviation industry as a guide. This form was implemented on all nursing units and nurse liaisons were sought from each nursing staff to provide education to the nurses on the subject of utilizing the forms and to provide the taskforce with feedback. Near-miss reporting is encouraged.
Click to see the Medication Event Form.
Each reporter was guaranteed anonymity in their report. If the reporter chose to sign the form, it was at the bottom of the form. After the completeness of the report was assured, their name was cut off and sent back to them with a note of thanks from the CEO and a small bag of pretzels (like one might acquire on a commercial air-flight) as a thank-you for improving patient safety. The number of error reports increased significantly. This is not an indicator of decreasing safety, but an increase in ease and willingness to share information. The taskforce reviewed options for a new database to assist in gathering information from our reporting process and allowing for analysis. A number of databases were evaluated and one was selected. It was funded in the latest budget and will be installed during the second quarter of 2002.
2. CPOE It was determined that several significant hardware and software changes were necessary in the pharmacy computer system to allow for interfacing with a direct physician prescription order entry system. Whereas the physicians at Gundersen Lutheran were much more familiar with the use of computer systems to access patient information in their clinic practices, the development of hospital-based computer access to patient information lagged. Timing introduction of CPOE would require development of other systems to provide providers a greater purpose in utilizing computer-based supports. CPOE systems are expensive, but the cost and technological aspects of their introduction were deemed to be less important than building the systems to make CPOE a true improvement in patient care. Currently, the systems are being developed to allow for introduction of CPOE in the late fall or winter of 2002
3. Best Practices. The assessment was performed and the level of safety in the 16 Best Practices was found to be encouraging. Some areas were felt to be totally achieved (24-hour a day in-hospital availability of pharmacists, absence of concentrated Potassium Chloride (KCL) from all nursing units), whereas, there were some areas in which no work had begun (standardized protocols for high risk drugs, specifically Coumadin and Insulin).
Click to see Best Practice Grid
 
The team working in this area sought background information to better understand the requirement to be “safe” in each of these categories. They then formed work groups to perform the assessment in each of these areas. Goals were set as to when each category could be considered accomplished (turn the square from yellow to green on the grid). A requirement of each work group included determination of when and who would reassess the level of compliance for each category in the future. Several practices were included that were not part of the original IHI 16 Best Practices. This model has been extended to the ambulatory side of the Medical Center and is basis for evaluating the medication safety of the Gundersen Clinic in La Crosse and in all of its regional sites
4. Patient partnering. The approach taken to patient partnering included development of tools to improve patient safety directly at the time of discharge from the hospital. The number of medications per patient has steadily increased in America and it was felt that issues of discontinuance and poor compliance with medication regimens were high enough that significant improvement in medication safety could be achieved by improving patient understanding of their medications, especially at the time of discharge from the hospital. Many patients were confused about which medications to continue and which ones to stop. Furthermore, many patients were uncertain when to take their medications and for what duration of time. Prior to discharge, nurses and physicians were writing down the list of discharge medications in numerous locations in the medical record, which increased the chances for error. A simplified medication list that serves as the template for all medication lists at the time of discharge was developed and provided to all patients discharged from the test nursing unit (Cardiology- 6 West). The original of this form is provided to all patients at the time of discharge and a copy is kept in the chart as the master list of discharge medication for nurses and doctors. (This form will be computerized within the next several months to allow for capture on the master medication list for all patients in the GL system).
Click to see Discharge Medication List
 
Pill boxes were identified as excellent tools for patients on multiple medications to keep their medications straight. For patients who meet simple criteria, pill boxes are provided free of charge prior to discharge (over 700 pill boxes have been distributed so far). The costs were covered by Gundersen Lutheran, the Gundersen Lutheran Medical Foundation and a grant from Eli Lilly Pharmaceuticals. Click for picture of pill box.The taskforce has recommended that a patient advisory council be established to provide feedback to the institution about patient safety and to identify areas for further growth. This is planned for second quarter of 2002.
5. Education. Multiple opportunities to communicate to all staff members were identified and multiple media for such communications included Bridges (Gundersen Lutheran’s award-winning medical center newspaper), noon medical staff conferences, and nursing staff education conferences. Brochures on medication safety were reviewed and an information card to improve medication safety was developed for distribution throughout the hospital and clinic. A summary of patient safety efforts was provided the Board of Trustees of the medical center and will be the subject of an annual report to leadership and the public. Gundersen Lutheran participated and presented results at several national patient safety conferences.
6. Planning for the future. The Medication Safety Taskforce recommended that a continuously operating committee be formed with the expressed purpose of improving patient safety in all aspects of the care provided at Lutheran Hospital and Gundersen Clinic. The Patient Safety Council was formed in December, 2001 at the approval of the Executive Committee of Gundersen Lutheran. The Taskforce developed the committee description and identified key individuals for membership.Click for Committee Document Furthermore, the recommendation was made that a full-time Patient Safety Coordinator be added to the staff of the institution to make sure the work got done. Kim Weber, RN accepted this position in October, 2001. For a copy of the Patient Safety Coordinator job description please request using the patient safety
e mail address below.
Conclusion
Our assessment found that medication safety was relatively higher than most medical centers in America, but that we had substantial room for improvement. A process to lead to sustainable improvement has been developed.
Next Steps
In the first few months, the Patient Safety Council began assessing and attempting to improve non-medication safety efforts, such as decreasing the chances of wrong-site surgery and patient falls. The Council is utilizing the model previously used to assess Best Practices in the hospital to assess medication safety status in Gundersen Clinic (main clinic and all branches). The Patient Safety Council is dedicated to advance local patient safety efforts, and contribute to patient safety efforts throughout the country.
Acknowledgments
Participants in the Medication Safety Taskforce:
1. Brenda Rooney, PhD, Department of Preventive Medicine.
2. Kim Weber, RN, formerly of the Information Systems Dept, presently Patient
Safety Coordinator
3. Michelle La Fleur, RN., Quality and Performance Improvement Department
4. Cinda Bates, PharmD, Director of Clinical Pharmacy Services
5. James Lukas, RPh, Director of Pharmacy
6. Mary Stibbe, RN, Project Director, Department of Nursing
7. Thomas Taylor, JD, Vice President and General Council
8. Pat Dolan, RN, Director of Risk Management
9. Jean Frank, RN, Case manager, Cardiology
10. Charles Schauberger, M.D., Medical Director of Quality and Performance
Improvement, and Chairman of the Patient Safety Council.
For further information or copies of any of the linked documents, contact: Patientsafety@gundluth.org
1. Kim Weber RN, Patient Safety Coordinator.
2. Charles Schauberger, M.D., Chairman of Gundersen Lutheran Patient Safety
Council.
Copies of the Error Reporting Form, the Medication Discharge Sheet, the Best Practice Grid, and
the Patient Safety Coordinator job description are available upon request.
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