Re-Engineering Medication Processes to Capitalize on Technology

1. Re-Engineering Medication Processes to Capitalize on Technology Jane Englebright, PhD, RN Vice President, Quality HCA

2. % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % U.K. % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % Switzerland % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % Who is HCA? US 176 Hospitals 92 ASC’s in 22 States INTERNATIONAL 8 Hospitals

3. 44,000 to 98,000 deaths/year 8th leading cause of death in US Provocative Statements: Most errors are caused by system failures rather than human error All manual processes are subject to error Many error reduction efforts do not take advantage of information systems Conclusions Status quo is not acceptable 50% reduction of error over next 5 years Institute of Medicine Reports on Medical Errors First Report: December 1999

4. HCA Patient Safety Goals • Establish patient safety as a visible commitment to putting patients first philosophy • Move from blaming people to improving processes • Improve use of technology to prevent and detect error • Use data to identify and measure improvements

5. HCA Patient Safety Initiatives Bring Evidence-Based Patient Safety Practices to HCA Facilities to Address Areas of Concern for HCA Each HCA Facility Implements Evidence-Based Patient Safety Practices in Areas of Concern for HCA Evidence-Based Patient Safety Practices: IOM Report ISMP Bates Areas of Concern for HCA: IOM Report Medication Safety Initiative

6. The Medication Safety Initiative Included: Rank Order of Error Reduction Strategies HCA Technologies Forcing Functions & Constraints Automation & Computerization Standardization & Protocols Checklists & Double-Checks Policies & Procedures Education & Information eMAR ePOM High Risk Med Protocols Practice Guidelines Competencies Awareness & Education

7. 42% intercept 0 % intercept Errors resulting in ADEs 4% 6% Ordering Administration 34% Transcription 56% Dispensing Bates DW et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.

8. Electronic MAR & Bar Coding

9. Validates “Five Rights” of Medication Administration Requires patient specific clinical data for certain medications (i.e, pulse rate prior to administration Lanoxin, review of potassium level before giving Lasix). Sends a warning to alert nurse when the dose is to much or to little, or if the dose is being given to early or to late. Single “source of truth” for patient medication status. eMAR Safety Features

10. HCA Clinical Information Systems

11. eMAR & Bar Coding Deployment172 Sites in 5 years

12. 115,933,163 Doses administered in 171 hospitals 2,913,018 Error warnings 2,121,315 Doses not given after warning eMAR & Bar Coding:(Company-wide Results-Year 2005) Averted Errors

13. An interdisciplinary Steering Committee was responsible for planning; implementation; staff and physician education and management of any issues. eMAR Implementation Bar-coded Patient Armbands Electronic Safety Checking Bedside Verification Bar-coded Medication Doses Electronic Medication Administration Record & Charging

14. Fewer medication administration errors More complete documentation Staff perception of improved safety Patient perception of improved safety Improved accuracy of billing Expected Outcomes

15. Measurement Plan: Understanding the Impact Armband Audit

16. Physicians HCA Patient Safety Implementation Model Technology Change Hospital Process Change Culture Change

17. eMAR Works in Three Ways Policies, procedures, resource allocation systems Blunt End Process Redesign Direct caregiver Clinical Decision Support Sharp End ERROR Monitored Process Reports Results

18. Project Timeline6 – 7 months per hospital Post Implement Support Pre-Assessment Barcoding Meds, Hardware, Dictionary Changes, Testing End User Training Go Live Kick Off

19. Project Workload:Fluctuations over 6 months

20. Executive Walk-Arounds “Do No Harm” video “Verification” not “Scanning” Patient Safety Principles: Double-Check Implementation Activities: Culture

21. Functions Most Impacted . . . . Nursing Pharmacy Respiratory Care IT&S HIM Finance Quality & Risk Implementation Activities: Process

22. Process Re-Design • Develop a workflow study of the actual steps in the medication preparation and delivery process at your facility • Start at the patient and work backwards • Include Nursing, Respiratory Therapy, and Pharmacy

23. Model of care delivery Who do you want to give medications? Medication distribution system How do medications get from the pharmacy to the bedside? Nursing Impact

24. Accuracy and timeliness of order entry and turn around Bar Coding ALL medications Medication acquisition philosophy Override policy adherence Pharmacy Impact

25. “Wire Tie” Creativity

26. Workflow: Sequential vs Concurrent Therapy Scheduling of medication administration Medication storage and distribution Clear accountability for medication administration Non-standard medication preparations Order acknowledgement processes Respiratory Care Impact

27. New Member of the Clinical Team WLAN Installation and Support Computer Management Equipment Maintenance, including pharmacy equipment Downtime Processes IT&S Impact

28. Single MAR for each admission Incorporate into discharge printing process HIM Impact

29. Move to billing on Administration instead of billing as Dispensed Improved Audit accuracy Improved Charge capture Decreased paybacks from insurance audits Finance Impact

30. Explaining it all to the Surveyor Averted errors = Near misses Areas with 100% utilization rates can have zero medication administration errors Preserving Quality Control Activities Order Acknowledgement Chart Checks Quality & Risk Impact

31. Practice Recommendations

32. Carts should be cleaned at least daily with hospital approved disinfectant Carts may be used in isolation rooms Carts should be cleaned before leaving the room if contaminated and when used in isolation Patient Safety equipment can be safely used in all patient care areas – exception: Known SARS or Small Pox Infection Control Recommendations

33. Identify armband solution Newborn Pre-registration Processes Unit dose medications Bar code identification of Breast Milk and documentation of feeding Pediatric/NICU Recommendations

34. Don’t take the scanner into seclusion Consider alternative form factors for scanners Unit dose medications Special armband needs Psychiatric Recommendations

35. Implementing eMAR • Roll out in waves • Bring up first 1 or 2 units • First unit that mostly discharges patients • Maintain for 1-2 weeks • Troubleshoot and resolve issues as they arise • Roll out remaining units quickly in related waves • Turn on Admin Billing

36. Packaging and labeling errors in pharmacy Changing federal regulations Emerging barcode symbologies Invalidating bedside verification with workarounds Project Risks

37. eMAR & Bar Coding Accountability Structure HCA Corporate Quality HCA IT&S Organization Advisory Groups Operational Accountability Structure

38. Getting Staff to Use the Technology • “How is this going to help me do my job better?” • “Why is this necessary?” • “I didn’t go to school to become a computer genius!” • “I guess this keeps somebody employed!” • “Just when I thought I had myself organized, they come up with something new!”

39. Answering the “Why?” • Keep the team engaged. Be patient as many do not adapt to change readily • Communication…e-MAR benefits vs. expectations • Focus on patient knowledge and patient safety • Ongoing involvement of core team • Keep the team focused on Patient Safety as a priority goal

40. “Get it Right” • Equipment Analysis • Pilot FIRST!!!! • Communication • Training/Education • Troubleshooting Plan • Competency • Ongoing unit based resources

41. Staff Meetings PATIENT SAFETY STRESSED Expectations clearly communicated again Non-compliance outcomes discussed Accountability Mandatory Education & Competency Assessment Regular monitoring of usage reports Prompt follow-up on negative usage patterns Leadership Strategies

42. Leadership Makes a Difference Results from pilot hospital: • Usage STATS improved within one week of implementing accountability plan. • No formal disciplinary measures were required. • Satisfaction scores improved!!! Goal 90 – 100%

43. Results • Averted Errors • Usage • Staff Perception

44. First & Second quarter summary reports Malpractice claims related to medication administration have decreased by 16%

45. Pharmacy Perception Survey I believe use of the eMAR and bar coding system is reducing medication errors in my hospital.

46. Pt. history - allergies etc… Lab link Reminder to document BP/HR/Pain Scale Checks and balances Look alike sound alike drugs… Unusual doses flagged Realistic expectations Novice Staff Rely on e-MAR!

47. eMAR Maintenance Work • Software • Equipment • Culture transformation • Process change

48. The Way We Do Meds at HCA Single point of accountability within each hospital to assure optimal ongoing operation Corporate eMAR Advisory Committee to address Culture-Process-Technology issues Regular division meetings Monthly conference calls/Quarterly web casts for sharing best practices and enhancements eMAR & Bar Coding

49. … the way we do things

50. www.hcapatientsafety.com