How one community hospital addressed potential patient safety risks with a multidisciplinary quality improvement program
As many CIOs can attest, we never forget the date of a “big-bang” go-live. On St. Patrick’s Day 2014, Western Reserve Hospital went from a paper-based system to a comprehensive electronic health record (EHR). Initially, this was a substantial change for the organization, but our approach supports more effective organizational improvements in the long run. With a solid governance structure as our foundation, we’ve re-engineered key workflows, such as medication dispensing and delivery, and use technology to continuously evaluate patterns and improve delivery of care.
Going paperless with medication administration
Prior to our EHR launch, we did not have barcoded medication administration at the bedside. We enhanced our technologies, policies and procedures to help our clinicians ensure the “five rights” of medication administration: right patient, right drug, right time, right dose and right route. Our teams felt a lot of pressure when automating medication dispensing and delivery, because the patient safety aspect is critical.
“Patients are at the center of everything we do at Western Reserve Hospital,” Director of Medical-Surgical Services Abi Morrison, MSN, BSN, RN, said. “It’s part of our culture and mission to know that we’re doing what’s best for the patient.”
Automating our medication dispensing and delivery started in the pharmacy. We purchased robot dispensing technology at the same time we went live with the EHR. With oversight from a dedicated pharmacist, this machine (nicknamed “Phil”) puts bulk medication into unit doses and labels it with the correct barcode. We lowered our chances of introducing risk by purchasing a product that fully integrated with our EHR system.
We invested in mobile workstations and hand-held scanners that nurses could take to the bedside. Now they scan the order, the drug and the patient – if something doesn’t match, a notification appears at the point of delivery. As with any other workflow and alert, we monitored the new automated system for effectiveness and efficiency.
Taking a closer look at overrides
Once we got past the go-live learning curve, it wasn’t long before our pharmacy noticed a trend in the medication administration reports: nurses were overriding about 2% of all alerts.
“Two percent might not seem like a big number, but when you consider that it might represent hundreds of medications given across the entire hospital during a given timeframe, we took a closer look,” Clinical Manager Erin Onder said. “We wanted to understand the reasons behind the overrides.”
Our goal was not to reach zero, because there are legitimate and necessary reasons for nurses to override an alert at the bedside. For example, if the patient is nauseated and cannot take a pill, or if it is an emergent situation, a nurse should override the alert. But we needed to understand the reasons behind the trend to identify opportunities to improve.
“We didn’t set a specific goal in mind for an override rate, because there are times when it is appropriate, such as emergencies,” Morrison said. “But we do want documentation to support the reason for the override, as well as notification of the occurrence, so we can work to prevent overrides in the future.”
We went back to the data and realized that we needed more specific information about why nurses were overriding alerts before we could design a program to improve. With input from our clinicians, we expanded the list of reason codes to capture more complete information. Multidisciplinary teams met regularly to review the findings.
“Pharmacy and nursing met frequently to look at these reports and the pathways of everything that had been happening,” Onder said. “Better documentation helps us know that the drugs we’re delivering are safe.”
Changing what we can control
With more specificity, we discovered a few areas for improvement, including:
Scanner recalibration – Hand-held scanners require periodic recalibration to work properly. We held education sessions to help nurses understand how to recalibrate their equipment when needed, reducing frustration and overrides due to equipment.
Bad barcode – If the same drug is consistently un-scannable, there may be an issue with that specific barcode, which can be corrected at the source.
Damaged labels – Sometimes a barcode cannot be scanned if the label is mis-applied and includes a bubble, or if it is torn when a single pill is removed from a multi-pack. Identifying these trends can help improve label placement.
We examine data by provider and unit, too. Each manager can pull override reports for their team and monitor trends.
“In the medical and surgical unit, when staff has to override an alert, they email me with the patient name, medication, reason and steps they took to prevent the override,” Morrison said. “I’m on their side to get everything fixed, and this level of detail tells me whether it’s a barcode issue, or a scanner issue, or something else we need to fix in the nurse’s workflow.”
As with any organization improvement, patient safety initiative, it’s important to articulate what we’re trying to achieve. We developed a plan in accordance with guidance for process improvements from the Institute for Healthcare Improvement (IHI). The clinical quality committee continues to track our progress and report to the quality council and board of managers who have oversight for patient safety issues.
We looked at best practices across the country and found that some organizations were attempting to reach unrealistic goals for reducing the number of overrides. We gathered research articles and worked with our vendor (now Allscripts) to learn about how other hospitals measured success. While we didn’t enter with a specific number for overrides, we stayed focused on patient safety and developing better processes to support that mission.
“Our staff is dedicated to doing what’s best for patients, and sometimes in the moment they will create a ‘work around’ to overcome challenges within a workflow…soon everyone is doing work arounds and it can defeat the purpose of the process in the first place,” Director of Quality Improvement and Accreditation Beth F. Rohrer, MSN, BSN, RN, CPHQ, said. “When we take the time to do some digging into the reasons for the work arounds, we can fix the root cause – either by changing the process or re-educating staff about best practices.”
While we cannot point to a specific reduction in the rate of overrides, staff report positive results.
“Operationally, there are some benefits that we can’t quantify exactly, such as decreased phone calls and less stress in the pharmacy,” Director of Pharmacy Tom Bauer, RPh, said. “Cleaning up the process and getting things working smoothly has made it easier for the nurse and pharmacist.
Perhaps most satisfying is the anecdotal evidence that several patients and family members have commented on the use of barcoding at the bedside. There is a degree of confidence and assurance that comes from knowing a highly reliable technology is helping their clinicians deliver medications safely.
Because of our confidence in the medication barcode technology, we are expanding a similar quality and safety effort for blood and mobile specimen collection. Automation through our Paragon EHR will help ensure right patient, right draw at the right time and reduce human error associated with paper-based collection efforts.
There’s not much I would change about our approach to medication barcode safety. I cannot overestimate the importance of testing, particularly integrated testing, and staff education. Simulating the new workflow within the new technology and performing daily tasks can help identify potential issues ahead of time.
It’s also critical to assess the hardware and infrastructure needs: Do you have enough scanners? Is the Wi-Fi sufficient? We quickly overcame an initial shortage of equipment, but an early assessment could have helped us avoid that issue.
Western Reserve’s improvements in medication safety is just one example of how we have used comprehensive technology solutions and the quality improvement process to govern our efforts. When patient safety is at stake, we must be vigilant and proactive. We continue to use our tools to identify and address potential risks and improve the patient experience.