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.
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).
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 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 future problems. Ade, together with Clinical Staff Pharmacist Sarah Amofah, RPh, presented the information to the nursing leadership during theNursing Leadership and Operations meetings chaired by Chief Nursing Officer and Vice President Gail Gordon, RN. The group developed an action plan to address the use workarounds; encourage adherence to proper procedure; and avoid the potential for medication errors.
GOAL STATEMENT(S)
Reduce the average number of MAK overrides hospital-wide by 10%, from 172 to 155.
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 Gordon's request) 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. Some of the most common reasons for overrides included: unreadable barcode (ripped or torn); downtime related to computer issues such as freezing up or loss of connectivity; and substitution usually for fluid volume used in mixing medications.
- 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)
Patient Safety Improvement
Exhibit EP19EOa: Homestead Hospital MAK Product Overrides
Analysis: Following the initiation of the data presentations regarding MAK product override rates to Operations and Medication Safety Committee members in January of 2013, the number of MAK product overrides began to drop significantly. By continuing the system of data review and individual feedback, pharmacy and nursing leaders have been able to sustain the reduction for 6 consecutive months.
Exhibit EP19EOb: Homestead Hospital’s Reported Medication Variance per 1000 Patient Days
Analysis: Above graph shows a decrease in reported medication variances after the team started tracking the data and the root causes. These medication variances were all Level 1 (no change in treatment required) and Level 2 (required treatment but no change in length of stay). They were able to maintain a low rate averaging at around 10 with the formation of the taskforce and one-on-one feedback to the nurses. The taskforce noted an increase in the number of medication variance reported from September to November 2013. This coincided with the education intervention roll-out spearheaded by another medication management taskforce, which further promoted awareness of medication safety among the nurses and staff.
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 EP19EOa: Homestead Hospital MAK Product Overrides
Exhibit EP19EOb: Homestead Hospital’s Reported Medication Variance per 1000 Patient Days