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

1. 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

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

3. 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.

5. 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.

6. 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.

7. Pre eMAR Order Entry

8. Post eMAR Order Entry

9. 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

10. 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

11. 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

12. 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.

13. 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.

14. Workarounds when the process had been improved and integrated into technological updates.

15. Workarounds when the process had not been improved and integrated into the technological updates.

16. 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.”

17. 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.