Thanks, everyone, for coming.
We've made some great progress on our CUSP
team's medication reconciliation project.
Med rec is really complex, and it affects ever one of
our patients whether they are a new admission or
they are being discharged on a lot of medications.
This project has required us to work with
physicians, pharmacists, our nursing colleagues,
and the medication safety committee.
It was really helpful when the med safety meeting
suggested that we focus on out high-risk medications first.
I think we should also share our success with
some of the other units that need to improve their
med rec process.
Just two days ago I was taking a transfer from the
surgical unit, and I caught an error on an
insulin order when we did the hand-off.
Great catch, Jeff.
The med rec process the team developed and tested
on your floor could be helpful for the other
floors in the hospital, and help the hospital
achieve out patient safety objectives.
It would be great to see this process implemented
on all floors, so that no matter where the patient
might be transferred the same med rec process would
be in place.
I'm going to see if I can get it on the agenda for
the next hospital wide medication safety
committee meeting.
Jeff, would you be willing to go to that meeting and
talk about this?
Sure.
I really appreciate the opportunity to share the
work we've done to improve med rec on our floor.
We're really excited because we've seen a big difference
in our adverse drug events rates.
Thanks for joining us.
Improving patient care is important to all of us.
Our adverse drug event rate has been decreasing
slightly over the last six months, but harming even
one patient is one too many.
Now, I don't know if you're all aware of what happened
to Mr. Isaacs last week on our surgical unit.
When he was admitted to our unit there was a
mistake in his medication orders and unfortunately
we all missed it.
He got the wrong dose of insulin.
He became severely hypoglycemic and had to be taken
to the step-down unit to be stabilized.
A reliable medication reconciliation process may
have prevented this adverse drug event.
I'm really sorry to hear that.
I hope by discussing out CUSP team's project and
what we did to reduce adverse drug events that
we can prevent any more harm from happening to our
patients.
Let me begin by providing a short summary of our project.
Okay, I think we'd all appreciate that.
Okay.
Our CUSP team identified a problem with patients on
high-risk medications like insulin, anti-coagulants,
Digoxin, and narcotics when we reviewed our
monthly adverse drug events data.
Similar to what happened to Mr. Isaacs, we had two
insulin events related to med rec within three months.
The wrong does of insulin was ordered at the time of
admission or during transfer to our floor for
both of these patients.
They both became hypoglycemic and we had to
give them D50.
When we reviewed out med rec process, we realized
we didn't have a double check in place for
patients on high-risk meds.
We also didn't have the pharmacist's knowledge and
expertise to understand some of these medications,
so we pulled our team together and did some process mapping.
Process mapping; it's a tool for outlining
processes to help explore factors that may
negatively impact the process, right?
It is, and by doing this, it allowed us to see where we
had to makes some changes and standardize our
process around double-checks and tap into
the pharmacy for help.
We came up with some ideas, and completed a
couple of plan-do-study-act cycles,
and what became clear was that we needed our
pharmacist's help to develop a process to fix
our existing issues.
Tom really helped us with that.
I really appreciated having the chance to work on this
with the team.
We now have a process that generates an automatic
consult to a pharmacist at the time of the time of
transfer when a patient's on high-risk medications
or has over ten medications ordered.
As a result, we've seen great improvement.
Great improvement?
Huh, I'd like to hear more about that.
Well, we haven't had an insulin related event for
the past two months on the medicine floor and, as a
matter of fact, we haven't had any adverse drug
events related to high-risk meds.
At first we were a bit worried we didn't have enough
pharmacists to verify all the medication orders,
but focusing on the high-risk medications
was a great idea and we really have seen a
positive impact.
[General sounds of approval]
Now, Jeff, what was
the biggest barrier for putting this process in place?
Well, one worry was the time it would take
pharmacists to do this check.
We all knew we wouldn't have the resources to
hire more pharmacists, but Tom helped us see that this
doesn't take an excessive amount of time
as long as it's flagged in the EHR and resources are
prioritized for patients with the highest risks.
Yeah, that's right.
Well, it sounds good, but I don't think that's going to
work on our surgical unit.
Mary, why do you say that?
The staff is already over-burdened without
complicating the admissions and transfer process by
adding pharmacy consults.
Do we really have that many medication errors on our floor?
We only had two in the last two months, and the
patients were not seriously harmed.
I think it's impossible to avoid all medication errors.
So, as long as no one is seriously harmed, I think
we're doing okay.
You know, Mary, I used to feel the same way, but
once we started to focus on this and realize that
these adverse drug events really can be prevented,
it became clear that even one or two events are too many.
And personally, if the patient were my mother,
even moderate harm is not okay.
I didn't think about it that way.
One event is too many.
The change will be difficult on my unit, but,
it'll be worth it.
Change often is difficult, but Jeff just made a very
important point.
What did the rest of you think?
Well, I know there is some variability in the number
of medication errors across different units but,
I agree with Jeff.
Even one adverse drug event is too many, and not
only for a patient, but also for us.
I once gave a dose of morphine to a patient who had been
transfer to out floor, but I didn't know
that had already gotten a dose only an hour before.
That detail had been dropped from the hand-off from
the PACU and I ended up having to call
the rapid response team and my patient was
transferred to the ICU.
I still feel terrible about that.
I'm so sorry, Kay.
And you're right, adverse events take a toll on us
because we never intend for them to happen.
Kay, would you be willing to champion the med rec
project on the surgical floor where you work?
I'd love to Regina, but I really don't have a lot of
experience leading these types of initiatives in my unit.
Would someone be able to help me?
I'd just like to insure that my unit does as well
with this as the gen-med unit on 3-South did.
Well, I heard Philip, the pharmacist who helps cover
the surgical areas is talking about a webinar
that her participated in through ISMP, the Institute
for Safe Medication Practices...
I bet Philip would be a champion for the surgical unit.
You know, that would be great.
I like working with Philip and so do the other nurses
on the surgical unit.
Can we set up a time to talk with him?
I'll help arrange it.
Awesome.
Great.
This sounds like a good plan to help decrease the
adverse drug events throughout the hospital.
[knocking]
Kavita.
Thanks for coming to meet with me.
There was a lot of excitement at our med safety
meeting about spreading our med rec improvement process
to your floor.
I heard about that form some of my teams members.
I'm looking forward to learning more.
Well, we've been brain-storming and
thinking of champions who might be willing to take on this
project on different units and your unit came up
because it's one of the floors that Philip covers.
He does, and it's been wonderful having Philip on our team.
One of the best things about Philip is that he's
already familiar with the IT systems that were going to be
rolling out across the hospital in two months.
So, it's a good feeling to know that we're going to be
improving our systems and then we're going to be
able to hard-wire it once the new IT system is in place.
But, before we can hard-wire it, we need to
make sure this process you're talking about
actually works on this floor.
One of the things that helped our nurses become
receptive is the shadowing opportunity that
Philip suggested.
I'd like to hear more about that.
Do you know Laura Lopez?
She's one of our most senior nurses and she
shadowed Philip for a day and it became very clear
to her how helpful it is to have the pharmacist
double-check the high-risk meds during admissions or
transfers.
Once she was convinced, that's all it took
for the other nurses to get on board.
And I'm glad that our unit buys into this, because I
know from our last hospital leadership meeting
that decreasing adverse drug events is a
priority for the whole hospital.
Looks like it's all lining up.
So let's review this; most of the people on our floor
are pretty much engaged.
You've given me the talking points that you
used to educate your staff - I really appreciate that.
We're going to start testing the new process tomorrow.
Really?
Yes.
The way that you explained the process,
it addresses my concerns and I think we should start
right away.
One of our unit's nurses is actually going shadow
Philip and then use the new process with our patients.
That's great.
We're going to do a small test first like you did,
because our culture is a little different from yours,
but once we're sure that this new process works
with Meredith Brown, our senior nurse, we'll begin to
share it with other nurses.
And then you can track your progress by looking
at the data from your medication errors.
Sounds like you've covered the four E's: engage,
educate, execute, and evaluate.
You've got the engagement of several team members;
you understand how to strategically aline this project
with existing organizational goals;
you know that certain environmental factors may
influence the success or failure of the attempt to
spread this intervention; and you understand how
important it is to customize this intervention
to fit the interests and needs of your unit.
I have covered the four E's, haven't I?
Our last CUSP projects were successful because of the
four E's.
Absolutely.
So, Kavita, how's your team doing with the new
high-risk medication process?
So far, so good.
Meredith tested the process with Philip and
they made a few changes.
Meredith doesn't work weekends, so she shared it with
Mitch, who works weekends and sometimes he works nights.
We wanted to test it and makes sure the process
would work across shifts and on the weekends.
The shifts on our unit are so different.
During the evenings, our unit clerk is shared
across two other units and during the weekends we
don't have a unit clerk, so alerting the team members
between the shifts will ensure that the
process we designed works across all shifts.
How did you get Mitch to agree to help?
Well, Meredith told Mitch that Philip actually found
a dosing error, and she really believes in
preventing a patient from getting hurt.
That's pretty powerful.
It was.
Sadly, though, there are still some nurses on our
floor that will probably resist this.
We just don't have a pharmacist available all
the time and the nurses certainly don't need
any more delays.
Well, that's why the EHR gets flagged.
The pharmacy doesn't need to be right there; he can be
standing in the pharmacy or see the alert.
Yeah, I guess you're right.
I still think the medication error data will be
powerful for your nurses.
For example, do you include the names of the patients
who were harmed and when you look at the medication
error data, do you look at what time of
day or what day of the week the errors occur?
With Philip's help, we've actually been able to get to
that level of detail.
So now, as we spread this across our unit, we're going
to be tracking the total number of medication
errors and break it out into day of week and time of day.
That will allow all the nurses to see the impact
of the new process, no matter when they work.
I can't wait to hear about your progress.
Well, I'll be back in a week and I'll let you know
how it goes.
Great, I look forward to it.
Alright, thanks.