Nursing Home Medication Safety: Bringing new tools to old challenges.

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Nursing Home Medication Safety Bringing new
tools to old challenges.

• Amy Vogelsmeier PhD RN
• Jill Scott-Cawiezell, Principal Investigator, PhD
  RN FAAN
• AHRQ 5 UC1 HS014281-02HRQ

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Primary Study Aim

• Evaluated the impact of technology and focused
  quality improvement efforts upon medication
  safety practices.

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Study Overview

• Five nursing homes in three states participated
  in the study
• Ranging in size from 60 to 400 beds
• Both urban and rural
• Both profit and not-for-profit
• The nursing homes implemented full EHR and then
  eMAR.
• The team observed medication administration and
  related processes for approximately 16,000
  medications.
• Nursing homes each had a focused quality
  improvement team that met monthly throughout for
  about two years.

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How Has Technology Helped the Medication
Administration Process?

• Documentation of assessment parameters correlated
  to specific medications helped link clinical data
  to medication administration.
• Elimination of monthly MAR change over reduced
  risk of medication errors and saved valuable
  staff time.

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How Has Technology Helped the Medication
Administration Process?

• Flags on eMAR are helpful the addition of
  green flags for new orders and yellow highlight
  for PRN monitoring have seen a positive response
  from staff.
• Reduced transcription from five points to two
  points with the potential to go to remote
  physician access.

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Pre eMAR Order Entry
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Post eMAR Order Entry
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Using Data to Improve Processes

• New order reports identify new orders from the
  past 24 hours
• Useful to stay current on resident condition and
  verify accuracy of new orders
• High risk medication reports, such as
  anticoagulant and psychotropic agents, identify
  specific residents that may require careful
  monitoring and identify facility-wide trends of
  medication use

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Using Data to Improve Processes

• Late medications tracked via time stamping of
  actual medication administration times
• Useful to identify trends of high volume
  medication passes and systems issues that impede
  medication administration
• 30 day look back provides a 30 day MAR for each
  resident.
• Medication exception report tracks documentation
  as to why medications were not administered
• Useful to identify systems impeding medication
  administration

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Moving from Paper to Touch Screen

• Quicker process
• Legible MAR
• Focused eMAR for current medication
  administration
• More organized medication administration
• More accessible MAR
• More accessible related health information
• Real time medication orders

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Technology Uptake CanLead to Improvement

• Maximizing success with technology requires
  diligence and creating interfaces which lead to
  updated clinical processes.
• Data, data, data can drive how to maximize
  technology to improve resident safety and guide
  more directed and focused process improvement
  strategies.
• Workarounds are a reality and occur despite good
  process improvement or instead of good process
  improvement.

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What is a Workaround?

• An informal temporary practice for handling
  exceptions to normal workflow.
• A workaround occurs as a worker perceives some
  disruption or block in the system that prevents
  the worker from completing a task as desired.

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Workarounds when the process had been improved
and integrated into technological updates.
Clinical Process Block Workaround
Medication dose limits in eMAR dictionary Unsafe dose not available in dictionary Selecting dose not matching ordered dose.
Administering medications using eMAR Time, perceived workload Administering medications via the dispensing device without checking eMAR
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Workarounds when the process had not been
improved and integrated into the technological
updates.
Clinical Process Block Workaround
Accessing EHR for clinical information. Slow wireless system Relied on handwritten notes and verbal information exchange.
Communicating new orders to pharmacy. One fax machine for 180 residents available 24 hours a day. Handwriting and calling new orders to pharmacy.
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How Facilities Defined Success

• Data from the eMAR systems results in good QI
  information.
• Increased communication, increased focus on the
  work, and a heightened awareness of the potential
  for mistakes we cannot let our guard down, we
  always need to think about the potential for
  error.
• Recognizing that systems are underlying most
  errors feel like we are becoming better problem
  solvers.

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What Have Been the Biggest Challenges?

• Working with state surveyors.
• Learning to maximize the use of data for real
  information.
• Underestimating the learning curve.
• Managing implementation with limited onsite
  resources.
• Recognizing that technology will not solve all
  the problems.