Magnet Recognition Program® Request for Additional Documentation
Homestead Hospital
Homestead, FL
MGN20140102
EP19EO Nurses are involved in the facility- or system-wide approach focused on proactive risk assessment and error management.
Provide one example, with supporting evidence, of an improvement in patient safety that resulted from nurses’ involvement in facility- or system-wide proactive risk assessment or error management. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
The MAK override data represented the work done/intervention on the part of the interprofessional team; however, pre- and post-initiative data were not provided to demonstrate an improvement (outcome of the work done) in patient safety as a result of the initiative to reduce MAK overrides.
Provide one example, with supporting evidence, of an improvement in patient safety that resulted from nurses’ involvement in facility- or system-wide proactive risk assessment or error management.
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A new example is presented below.
NAME OF INITIATIVE
Medication Safety: Medication Administration Check (MAK) Product Overrides
BACKGROUND/PROBLEM
In 1999, the Institute of Medicine published the report “To Err is Human” which revealed that as many as 98,000 people die each year within U.S. hospitals as a result of adverse events due to medical errors. The most recent estimates indicate that as many as 400,000 preventable adverse events contributed to the deaths of patients within the U.S. between 2002-2012 (James, 2013). Medication errors are the most prevalent type of medical error; some estimates indicate that as many as 50% of patients admitted to hospitals suffer at least one medication error during their hospital stay (de Vries, E.N., Ramrattan, M.A., Smorenburg, 2008; Lewis, Dornan, Taylor, Tully, Wass & Ashcroft, 2009). The use of bar-coded medication dispensing and administration systems has demonstrated efficacy in cutting the rate of medication administration errors by 50% in some hospitals (Hassinck, van-Essenberg, & van den Bemt, 2013). Despite agreement that such systems allow for safer administration of medications, nurses report that workarounds, allowing them to bypass some of the safety processes associated with bar-coding systems, occur frequently in hospitals (Rack, Dudjak & Wolf, 2012).
Facility-Wide Proactive Risk Assessment
At Homestead Hospital, the pharmacy tracks the number of overrides to the checks and balances that are embedded into the medication bar-code verification processes via routinely-generated monthly exception reports. In January 2013, Pharmacy Director Marie-Elsie Ade, RPh noticed a large number of overrides (N=172) to the MAK system across all nursing units. Upon further investigation, she noted that a large portion of the overrides were actually workarounds in an attempt to bypass safety protocols embedded within the system. Even though no medication errors could be directly linked to the use of overrides thus far, she determined that the lack of adherence to safety protocols must be addressed urgently in order to avoid potential problems in the future. Ade, together with Clinical Staff Pharmacist Sarah Amofah, RPh, presented the information to the nurse leaders during the Nursing Leadership and Operations meetings chaired by Chief Nursing Officer and Vice President Gail Gordon, RN. Addressing MAK product overrides would potentially reduce medication errors in the administration phase. The team reviewed reported medication administration errors in calendar year 2012 and noted an average of 1 medication administration error per 100,000 doses dispensed. The group then developed an action plan to address the use of workarounds; encourage adherence to proper procedure; and avoid the potential for medication errors.
GOAL STATEMENT(S)
The goal was to reduce the medication administration error rate. This was calculated by:
Number of reported medication administration error X 100,000
Number of doses dispensed
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Nurses’ Involvement
During the period of March to May 2013, pharmacy staff continued to track override data. Ade presented it on a weekly basis at the Operations meeting (at the request of Gordon) and on a monthly basis at the Medication Safety Council meeting chaired by Patient Care Manager Raul Botana, RN.
In June of 2013, a subgroup consisting of pharmacy and nursing department leaders and staff agreed to use a system of education and feedback in order to address the problem of overrides:
- The data was regularly discussed during Medication Safety Council meetings, to determine the root causes of each override.
- The email system was utilized to provide general education bulletins to staff nurses regarding appropriate procedures in order to avoid the use of overrides.
- Pharmacy provided nursing leaders with unit-specific data and details regarding each incidence of MAK override.
- Pharmacy afforded nursing directors, managers, and clinical nurse educators daily access to unit-level reports enabling them to give individual feedback and education to nurses who had utilized the override option for any reason during that month.
PARTICIPANTS
Nurses Involvement
The MAK override taskforce members were:
Name/Credentials |
Title |
Department |
Role in the Team |
Ana M. Cabrera, DNP, ARNP, ACNP-BC, NEA-BC, CCRN |
Assistant Vice President |
Nursing Administration |
Participated in subgroup focused on the reduction of MAK overrides; Medication Safety Committee member. |
Raul Botana, MSN, RN |
Patient Care Manager |
Nursing Administration, Clerical |
Chair of Medication Safety Committee and participant in the subgroup to address MAK overrides. |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Executive sponsor |
|
Nurse Managers and Directors |
Various nursing units |
Ran daily report and provided individual feedback to clinical nurses |
|
Clinical Nurse Educators |
Various nursing units |
Assisted in providing individual feedback to clinical nurses |
Marie-Elsie Ade, PharmD, RPh |
Director of Pharmacy |
Pharmacy |
Problem identification; data tracking, interpretation and reporting of trends in MAK overrides to nursing leadership. |
Sarah Amofah, PharmD, RPh |
Clinical Staff Pharmacist |
Pharmacy |
Data tracking, identification and reporting. Medication Safety Committee member, participation in subgroup to address MAK overrides. |
OUTCOME(S)
Following the initiation of the data presentations regarding MAK product override rates to the Operations and Medication Safety Committee members in January of 2013, the number of MAK product overrides began to drop significantly. The team noticed a further reduction in the overrides when the nurse managers and clinical nurse educators started providing individual feedback to the nurses in June 2013. Consequently, MAK product overrides went down from a baseline average of 174/month to an average of 86/month in the immediate 6 months post-intervention. As a result of the work done by the interprofessional team in reducing MAK product overrides, a concomitant reduction in the hospital’s medication administration error rate (patient safety improvement) was also achieved.
Patient Safety Improvement
Exhibit EP19EOaa: Homestead Hospital Medication Administration Error Rate
Analysis: Above graph depicts that the team met their goal of decreasing medication administration error rate as evidenced by 3 consecutive post-intervention data points lower than the baseline. The group was able to achieve a 63% reduction in the medication administration error rate (from an average of 1 to 0.33).
References
Institute of Medicine. (1999). To err is human: building a safer health system. Retrieved from https://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-128.
Keers, R., Williams, S., Cooke, J., Ashcroft, D. (2013). Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Safety, 36, 1045-1067.
Lewis, P.J., Dornan, T., Taylor, D.,Tully, M.P., Wass, V., Ashcroft, D.M. (2009). Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Safety, 32(5):379-89. doi: 10.2165/00002018-200932050-00002. Review. PubMed PMID: 19419233.
Rack, L., Dudjak, L., & Wolf, G. (2012). Study of nurse workarounds in a hospital using bar-code medication administration system. Journal of Nursing Care Quality, 27(3), 232-239.
de Vries, E.N., Ramrattan, M.A., Smorenburg, S.M., et al. (2008). The incidence and nature of in-hospital adverse events: a systematic review. Quality & Safety in Health Care. 17(3), 216–223.
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP19EOaa: Homestead Hospital Medication Administration Error Rate