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In 2001, McLeod Regional Medical Center, a
371-bed community hospital in Florence, South Carolina, launched a
multipronged pharmaceutical clinical and dispensing program with one purpose
in mind: To reduce medication errors. The foundation of the new program was
the acquisition of an automated drug dispensing system, with the phased-in
addition of bar coding, electronic medication administration records,
deployment of pharmacists to the nursing floors, drug reconciliation, and a
universal medication form. Aside from dramatic reductions in the hospital's
rate of harm, the system improved drug inventory control, lowered the number
of errors, and improved charge capture with drug administration.
Introduction
In the aftermath of the 1999
publication To Err is Human--the Institute of Medicine's groundbreaking
report on the high rate of medication errors in U.S. hospitals--McLeod
Regional Medical Center began to investigate new tools and approaches to
reduce the rate of harm (ROH).
At the time, McLeod's ROH (the number of doses per
thousand that cause adverse reactions) was 3.5, on the low end of the national
average (2 to 8). However, as illustrated in the Institute of Medicine report,
the status quo was no longer acceptable. A 3.5 ROH translates into harming 35
patients a day, based on the 10,000 doses dispensed daily through the
pharmacy. With the singular goal to improve medication safety by reducing the
ROH, the Medication Safety Redesign Project was launched in 2001.
Pharmacy Management Needs
McLeod's pharmacy was operating
in 2001 much the same way it had for the last 20 years, even though the
business of pharmacy management had changed significantly. The existing system
was not designed to accommodate the number of medications now available, the
entirely new types of drugs (many of which required special storing
conditions), or the often immediate need for pharmaceuticals at the bedside.
For example, the old system of drug delivery entailed 17 separate steps, each
of which represented a new opportunity to introduce errors into the system. An
automated system was the first step needed to solve this problem.
Real-time inventory monitoring and control were
functions that were badly needed. There were no clinical programs and almost
no pharmacist interventions being done. The medication delivery process was
labor-intensive and poorly designed. Instead of consulting with clinicians and
patients, the pharmacists were overbooked filling prescriptions.
The purchase of a single product was not going to
resolve all of these issues. After an extensive search, McLeod entered into a
contract with Cardinal Health Pharmacy Management. Cardinal Health was chosen
primarily because it offers technology and business solutions, including
pharmacy management, automation, and wholesaler distribution. This was not
going to be a quick fix, and McLeod needed pharmacy logistical expertise to
help find workable solutions.
McLeod's initial efforts involved a needs
assessment based on workflow trends, clinical utilization, inventory control,
and of course, the financial needs of the pharmacy. An on-site clinical
coordinator provided valuable trend data and strategies to optimize drug
utilization. This helped with operational strategies for controlling costs and
in-service training, illustrated the best practices from around the nation,
improved clinical accountability, and enabled McLeod to have access to
clinical resources and trend data that would have been difficult to acquire on
its own. Cardinal Health also helped find hidden value with current data on
reimbursement levels for pharmaceuticals to ensure the hospital was receiving
full compensation.
After choosing Cardinal Health in 2001, McLeod
began working with an interdisciplinary team to redesign the Medication Safety
Committee and forge a vision that would be instrumental in the work to follow.
The question it asks of every new system is: Does it make it easy for
caregivers to do the right thing and impossible to do the wrong thing?
Evidence-Based, Data-Driven, Physician-Led
The Medication Safety project
followed the same principles used in any work McLeod did to improve clinical
efficacy. McLeod's pharmacy decided to make changes based on proven strategies
from scientific literature. The data-driven process involved vigorous
consultation with the medical staff.
It was clear that the old system of drug delivery
had to end. The Medication Safety Committee reviewed available products and
decided on the Pyxis Profile MedStation medication administration system and
Pyxis Connect physician order management system, made by Cardinal Health. The
cost of deploying the technology was considerable, but McLeod was fortunate to
be one of five U.S. hospitals chosen to receive a Robert Wood Johnson
Foundation "Pursuing Perfection" grant, which helped underwrite part of the
technology expense.
Nurses and Pharmacists Free to Focus on
Consultation
In the first phase of the
project, the new system was installed in every unit that medications are
administered. Nurses could access drugs only for a specific patient and only
for orders that the pharmacy had verified. To prevent mix-ups between
patients, nurses could obtain drugs for just one patient at a time and only
for one dose.
Switching from a system where drugs were stored on
a centralized cart to one where drug-dispensing units were positioned
throughout the hospital but only obtained via a computer was an immense
undertaking and became an unexpected culture shock for the nursing staff. As
inefficient as the old system was, they were used to it. In fact, many nurses
were so opposed to the change that they threatened to quit. However, they
became quick fans of the ease of use of Pyxis Products and the ready supply of
medication at every unit. Many would now threaten to quit if McLeod returned
to the old system.
Automation cut the number of medication steps from
17 to five, and it freed the hospital's pharmacists to operate on the nursing
units instead of "in the basement," dispensing pills. Today, McLeod's pharmacy
staff is 100% decentralized, and pharmacists work directly with nurses,
physicians, and patients on the units and in pediatrics, the emergency
department, and operating room. The number of drug interventions has grown
from near zero in 2001 to 33,219 in 2005.
In a hospital setting, the greatest value that
pharmacists provide is consultation on complex drug regimens with physicians,
nurses, and patients. Patients generally have multiple physicians and multiple
drug priorities; the pharmacist is key in determining the safest, most
effective medication program. Enabling pharmacists to focus on consultation
has a vital role in McLeod's overall medication safety strategy.
Bar Coding: MAC and MAR
Based on McLeod's initial success
with dispensing automation, the Medication Safety Committee decided to convert
to the Medication Administration Checker (MAC)--a bar-coding system that is
now fully implemented at McLeod. Under the MAC, there are bar codes on every
nurse's badge, every patient's wristband, and every drug. The system also
includes bedside bar coding and electronic Medication Administration Record
(MAR) as part of the hospital's strategy to develop an integrated electronic
medical record that could be shared across the three-hospital system.
However, getting the right bar codes on the drugs
proved to be a challenge, as there is currently no industry standard. McLeod
uses a system from Siemens Pharmacy and Medical Packaging, Inc. that allows it
flexibility to deal with some of these challenges. Today, about 80% of the
drugs McLeod receives has a bar code it can use, and the other 20% it does
itself.
When drugs are administered, the MAR is
electronically updated. The nurse can now document everything online. In
addition, all records, plus lab results and other pertinent data, are
available on every physician's handheld wireless unit.
Drug Reconciliation
With McLeod's emphasis on
recordkeeping, its medication safety team was tasked with drug reconciliation
in the last half of 2001. The first challenge was determining what home
medications were being taken when patients were admitted.
The existing system was anything but a system.
Physicians simply noted, "Continue all home medication" as the order. However,
McLeod had no way of determining if the home medications were contributing to,
or causing, the problem that triggered the hospital visit. Therefore, it no
longer accepted blanket orders. Instead, the team created a computerized
"Admission Assessment History Form," which the nurse fills out at the initial
patient assessment. In addition to talking with the patient and family, the
nurse may also call the patient's pharmacy. The physician reviews this
medication list, either online if using a Computerized Physician Order
Management (CPOM) system or on paper. The electronic form then goes to the
pharmacist for verification, cutting transcription errors to nearly zero.
McLeod is currently rolling out a pilot CPOM system with a small group of
physicians. In addition, it has begun using a system that involves
reconciliation during patient transfers to ensure that when patients change
locations and levels of care, their medications are reconciled for accuracy
and safety.
McLeod is working through a multidisciplinary
Clinical Effectiveness team composed of physicians, pharmacists, nurses, other
health care team members, and most importantly, patients, to develop a system
where admission reconciliation will be pharmacy-driven. It is closing the loop
between admission, transfer, and discharge medication reconciliation with a
completely automated system.
Universal Medication Form
The final step of the
reconciliation process is providing each patient with complete and accurate
medication information upon discharge. For this, the team worked with the
South Carolina Hospital Association to develop a Universal Medication Form,
which has since become the statewide standard and is under investigation by
several other state associations.
To develop the form, the team consulted with focus
groups, church groups, senior citizen centers, retail pharmacies, and all 25+
physician practices that admit to McLeod. It also worked with its competitor
hospital to ensure that both hospitals would be doing the same thing. When it
comes to safety, there are no secrets.
Results
Before McLeod initiated these
changes, the hospital's ROH was 3.5, well within the national average of 2 to
8. Today, the ROH is about 0.5. Other notable accomplishments include:
• Number of steps to administer drugs was cut
from 17 to five steps
• Drug turnaround time was reduced
from one hour, 45 minutes to seven minutes
• Interventions increased from near
zero in 2001 to 33,219 in 2005
• MAC "saves" per 1,000 doses:
about three (equivalent to 30 saves/day for McLeod's dosing level of
10,000/day)
• Increased reported errors from 70
in 2000 to more than 150 average per month
• Shared results through four
seminars offered on a national level
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editor@uspharmacist.com.
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