Going Beyond the Five Rights: Using Technology to Reduce Medication Errors

1
Going Beyond the Five Rights Using Technology to
Reduce Medication Errors

• Greater Baltimore Medical Center

2
Bedside Medication Verification (BMV) and the
Electronic MAR (eMAR)(current version 5.54 sr10)
3
About GBMC

• 292 Licensed Beds
• 22,000 Inpatient Admissions
• 60,000 ED Visits
• 40,000 Surgeries
• 22,200 Births in the past five years
• 1,200 Physicians
• 2,600 FTEs

4
Why is Medication Administration a Patient
Safety Issue, Consider This

• If 99.9 were good enough
• 12 babies would be given to the wrong parents
  each day
• There would be 37,000 ATM errors every hour
• There would be a major plane crash every three
  days
• Source Institute for Healthcare Improvement

5
Why GBMC Wanted to Implement eMAR

• Lack of compliance with patient identification at
  the bedside
• Nurses not taking the paper MAR to the bedside at
  time of medication administration
• Two different MARs one in Pharmacy and one on
  the unit
• Continuum of Care for the patient
• ED-gtInpatient

6
Why Bar Code Technology?

• Real-time confirmation of the patient
• Accurate medication verification at the point of
  administration
• Technology-based alert system
• Assures five rights
• Prevents faulty identification of
  look-a-like/sound-a-like medications
• Data collection for process improvement

Only 3 of U.S. Hospitals use Barcode
Technology (AJHP 2003)
7
Why Implement BMV and eMAR?

• Patient safety initiative to minimize medication
  errors
• GBMC executive leadership priority
• 34 of medication errors occur at the point of
  administration. 51 reach the patient.
• Only the nurse can detect at the point of admin
• Patient and drug information available at the
  point of care
• Physicians requested medication administration
  information to be viewable electronically

8
BMV Benefits Five Rights 1. Right Patient

• Prevents wrong patient error

9
2. Wrong Medication (Five Rights)
10
3. Wrong Dose (Five Rights)
11
Wrong Dose (Five Rights)

• Exceeding ordered dose not allowed

12
4. Wrong Time (Five Rights)
Administering against a past time
13
Wrong Time (Five Rights)

• Administering against a future time

14
Medication safety metrics prior to eMAR/BMV
15
Medication Errors due to Pharmacy interruptions

• Known problem in Pharmacy too many interruptions
  during transcription
• Missed medications needed to be dealt with now
• Stat medications
• Items on MAR needed to be D/Ced
• Constant phone calls to Pharmacy

16
PHA Orders for Nursing
17
Process For Using PHA Orders

• Nurse sends the order to Pharmacy via OE
• Prints in Pharmacy every 15 minutes
• Pharmacy completes the order in OE, or sends
  message to RN about the medication
• Medication sent to nursing unit
• Turnaround time approximately 60 min.
• QA

18
of Prevented Phone Calls to the Pharmacy from
the Nursing Floors 1st Six Months.
19
of Prevented Phone Calls to the Pharmacy from
the Nursing Floors October 07 February 08
20
Rejection Results

• First six months rejections were at 2.6 of all
  orders entered on the MAR
• Today, rejections account for less than one
  percent of all orders entered on the MAR

21
Medication Safety Metrics Results
Average Doses of Medication Administered per
Month 123,381
22
of Medications Scanned at the Bedside Today
23
Medication Safety Metrics Results
Average Doses of Medications Administered per
Month 123,381
24
Medication Safety Metrics Results
Average Doses of Medications Administered per
Month 123,381
25
Wrong Patient ArmbandOctober 07 March
08
26
Medication Safety Metrics ResultsDispensing
27
Medication Safety Metrics ResultsAdministration
28
Medication Safety Metrics Results

• Post eMAR/BMV the staff responsible for
  initiating the errors shifted from Nursing (50)
  of errors to Pharmacy (77) of errors
• Fewer errors reached the patient secondary to
  fewer administration and nurse initiated errors

29
Pain Assessment/Re-assessment

• One of our BIGGEST challenges
• Question How can MEDITECH eMAR/BMV help us
  improve our scores?
• Is there any pop-up that will help the nurse
  remember to re-assess?
• Can we force the nurse to document?
• What can we do to improve?

30
Our Scores

• December 2007
• Total of doses given on 17 inpatient units
  3014
• Pain Assessment average 57
• Lowest 32
• Highest 73
• Pain Re-assessment average 36
• Lowest 17
• Highest 42

31
Reports
32
Reports Continued
33
Nursing Follow-up

• Reporting assessment and re-assessment
• Education using Status Board to see re-assess
  time
• Education signed document for noncompliance
• Constant follow-up with nurses

34
Results

• March 2008
• Total of doses given on 17 inpatient units
  3984
• Assessment average 78 (increase 21)
• Lowest 72
• Highest 94
• Re-assessment average 72 (increase 34)
• Lowest 71
• Highest 94

35
Challenges

• Buy-in from nurses and pharmacist
• Whats in it for ME?
• Trust in the technology
• Nurses desire to print
• Nurse/Pharmacy relationship
• Usable bar codes at point of administration
• The art of scanning
• Avoiding workarounds Get it right the first time
• Equipment Scanners/COWs
• Use of reports Threatening

36
Successes

• Live on all 17 inpatient units
• 92 of all medications are scanned
• Safer patient care for patient/nurse
• Collaborative effort with improved communication
• Preventing potential errors
• Standardization of processes
• Tools for monitoring
• Very positive response from patients
• Seen as patient safety initiative, not IT project

37
End Result

• Safer patient medication administration
• Ongoing open partnership between Pharmacy and
  Nursing to reduce medication errors