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Improving the Safety, Efficiency & Effectiveness of the Medication
Administration ProcessNorthwest Patient Safety Conference
May 19, 2011
Joan Ching RN, MN, CPHQAdministrative Director, Hospital Quality & Safety
© 2010 Virginia Mason Medical Center
Ordering$ 26%
Transcribing$ 0%
Dispensing22%
Administering
Monitoring2%
Reported Errors in Medication Management Process
50%
CPOE
Bar Code Medication
Administration
Prepared by: Joan ChingCurrent State Date: 2/10
Value Stream Map
Medication Administration
Boundaries: From: Signal to give medication, To: Medication documentation
Wrong timeerror
Wrong formerror
No space in med room to prepare meds
Distractions/Interruptions
Discards pill packaging for crushed meds
Wrongpatient
Wrong or expired med loaded into PYXIS
Does not compare med to MAR
Doesn't check 2 forms of pt ID
Doesn't immediately document on MAR
PYXIS drawer broken
Dose not availableWithdraws meds for > one patient
Doesn't explain med 's action or indication
Doesn't label syringe or cup properly
Meds are batched, on push‐schedule
Unsecure meds on top of COW
Wrong patient error
Wrong route error
Wrong med error
Wrong dose error
Wrong technique error
Waiting in queue at PYXIS machine
Moving pt furniture, getting water
RN sees signal to give meds
Retrieves med from PYXIS Prepares med at PYXIS
- Draw up in syringe
Greets patient
Gel in with Purell"Here to give you med(s) "
Administers med Documents med given
4 4 4 4 3
"It Takes Two" ID check
- Pt states namePt states date of birth
Explains med to patient
- Medication nameMedication action
4 4
PYXIS Supplies
0:01:00 0:00:000:00:000:00:45 0:02:390:00:00 0:02:00
- Label with med name/strength- Put into med cup
"Here to give you med(s)."
RN RN RN RN RN
- Pt states date of birth - Medication action
RN RN
Median of 4 timings Median of 4 timings
0:01:00 h:m:sVA 0:01:00 h:m:s
CT
0:00:00 h:m:s
h:m:s
NVA
% VA
0:00:00
100 00%
h:m:s
0:01:00 h:m:s
CT 0:01:00 h:m:s
h:m:s % VA
h:m:s NVA
100 00% h:m:s0 00% h:m:s
VA
NVA
CT 0:00:20VA 0:00:20
NVA
% VA 100 00%
0:00:48 h:m:s 0:00:00
0 00%
h:m:sNVA
% VA
CT
VA
% VA 0 00%
NVA
0:00:11
0:00:00
0:00:00
0:00:11
0:00:00
CT
0:00:00
h:m:s % VA
h:m:s
h:m:s
0:00:00
0:00:13
0:00:13
h:m:s
% VA
VA 0:00:00 h:m:sNVA 0:00:50
h:m:s
h:m:s
h:m:s
CT
VA
NVA
0:00:48
h:m:s0:01:14 h:m:s
h:m:s
0:00:20 0:01:00
h:m:s VAh:m:s
0 00%
h:m:s
0:01:14 0:00:13
h:m:s
h:m:s
0:01:00
CT 0:00:48 h:m:sVA 0:00:00
0:00:50
CT 0:00:50 h:m:s
% VA 0 00% h:m:s
Takt Time = Time Available =
h:m:s100.00%h:m:s 100.00% h:m:s0.00% h:m:s
11.4 min
100.00%0.00%
h:m:sNon Value Added (NVA) Tim
0:12:00
0:04:16
0:02:20
h:m:s
Current State 2/10
Value Added (VA) Time
Lead Time
Cycle Time
h:m:s
0.00%
0:08:15
h:m:s
1245 min
109 meds
h:m:s h:m:s0.00% h:m:s 0.00% h:m:s
Demand (max washer output)
Operators Needed
%
%69%
0.37
% VA
% NVA
19%
© 2010 Virginia Mason Medical Center
CALNOC Medication Administration Accuracy Survey
• Systematic assessment, targeted improvement
• Barker & Pepper’s research§ 1 of 5 doses in error§ Wrong time 43%§ Wrong dose 17%§ 7% error rate (>40/day in
300-bed facility)Betty Irene Moore
Comparing Error Detection Methods
456
373
24 1
050
100150200250300350400450500
Errors detected on 2,557 doses
PharmTech
RN Chartreview
Incidentreports
Error = a dose administered differently than ordered on the patient’s medical record
Flynn, Barker, Pepper, Bates, Mikeal, AJHP, 2002.
© 2010 Virginia Mason Medical Center© 2010 Virginia Mason Medical Center
The Six Safe Practices
• Compares med w/ MAR• Med labeled throughout• Checks 2 forms of pt ID• Explains med to pt• Charts med
immediately• No distractions or
interruptions
© 2010 Virginia Mason Medical Center
Our Study Methods: Observation & Error Review
Naïve observation is a process whereby the observers do not know the actual medication order but observe the entire preparation and administration process.
Comparative record review is performed later to determine number, type of errors, and frequency of each type of medication error.
© 2010 Virginia Mason Medical Center
Baseline MeasuresJan-Feb 2010 N=898 doses
57%
14% 13%
6% 5% 4%
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
CUMULATIVE
%
DEFECT
Safe Practices Defects
% Defects Cumulative %
© 2010 Virginia Mason Medical Center
Baseline MeasuresJan-Feb 2010 N=898 doses
55%
24%
7% 6% 5%3%
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
Wrong time Wrong technique
Unauthorized drug
Drug not available
Wrong route Wrong dose
CUMULATIVE
%
ERROR
Type of Errors
% Error Cumulative %
Improperly administered so as to alter drug’s effect
Given more than 1-hr before or after scheduled dose
© 2010 Virginia Mason Medical Center
Reducing Waste in the RN’s Day
DefectsProcessing
MotionInventory.
Time
Waste
Transportation.
Overproduction
The 9 AM Line-up
© 2010 Virginia Mason Medical Center© 2010 Virginia Mason Medical Center
Vertical Inspection
• Inspecting the workflow
Control upstream processes
• Conditions that create defects
SWAMP
• Medication schedule
Horizontal Source
Inspection
Within the process MOSQUITOES
Approaches to Mistake Proofing
InterruptionsRoom Layout
Horizontal Inspection
Within the process MOSQUITOES
© 2010 Virginia Mason Medical Center© 2010 Virginia Mason Medical Center
Interruptions
• “Expected, natural component of RN work”• 89% of interruptions ð negatively impact
patient safety-- Hall, et al., JONA, 40(4), April 2010
• 12% # in procedural failures• 13% # in clinical errors• # interruption frequency ð # error severity
-- Westbrook, et al., Arch Intern Med, 170(8), April 26, 2010
© 2010 Virginia Mason Medical Center
Visual Control & Mistake Proofing
• Flashing bike light mounted to WOW pinnacle
• Widespread campaign• A protected hour to
exclusively focus on medications§ Redirect telephone calls§ Reschedule supply
restocking
i Walkingi Wasted motion$ Hunt-and-find$ Forgotten supplies
Point-of-use
Carry & go
Self-Check
Visual Control
© 2010 Virginia Mason Medical Center
Medication Administration Schedule
0
50
100
150
200
250
300
350
400
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Doses Dispensed by Day of Week & Hour
FRI
MON
SAT
SUN
THU
TUE
WED
LEVELING PRODUCTION
© 2010 Virginia Mason Medical Center© 2010 Virginia Mason Medical Center
Unit DashboardMEDICATION ADMINISTRATION DASHBOARDNEUROLOGY-UROLOGY-NEUROSURGERY Level 17
Legend: Better than CALNOC Worse than CALNOC
% M
ed C
ompa
red
wit
h M
AR
% M
ed E
xpla
ined
to
Pat
ient
% M
ed L
abel
edTh
roug
hout
% M
ed C
hart
edIm
med
iate
ly
% 2
For
ms
IDCh
ecke
d
% M
ed P
ass
Dis
trac
ted/
Inte
rrup
ted
98100 99 100
96
95
97
9290
95
100
Q1 10 Q2 10 Q3 10 Q4 10
NUN Mean CALNOC Mean
92
86
100 10096 95
94 91
80
85
90
95
100
Q1 10 Q2 10 Q3 10 Q4 10
NUN Mean CALNOC Mean
99
94
10097
93
88
92
84
80
85
90
95
100
Q1 10 Q2 10 Q3 10 Q4 10
NUN Mean CALNOC Mean
100 100 99100
89 91 89
92
85
90
95
100
Q1 10 Q2 10 Q3 10 Q4 10
NUN Mean CALNOC Mean
47
24
87
28
27
22
33
01020304050
Q1 10 Q2 10 Q3 10 Q4 10NUN Mean CALNOC Mean
100 100 100 100
98
95
96
99
94
96
98
100
Q1 10 Q2 10 Q3 10 Q4 10NUN Mean CALNOC Mean
48%46% 42%
29%
0%
10%
20%
30%
40%
50%
60%
Q1 Q2 Q3 Q4
Distractions/Interruptions
1.4%
1.6%
0.9%
0.6%
0%
1%
2%
Q1 Q2 Q3 Q4
Wrong Technique
8.6%
2.1%3.9% 3.5%
0%
2%
4%
6%
8%
10%
Q1 Q2 Q3 Q4
Wrong Time2010 KAIZEN ACTIVITY
Rapid Process Improvemt Wksps:•Improving med room layout•Medication preparation•Medication administration•Insulin administration•Bar code medication packaging•Bar code wrist band printing
Kaizen Events:•Bar code medication supply•Crushed enteral medications•Reducing telephone interruptions•ED medication preparation•Standardized visual control @ automated dispensing cabinet•Reducing interruptions in patient room