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 event 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 our 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, 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 event data.
Similar to what happened to Mr. Isaacs, we had two
insulin events related to med rec within three months.
The wrong dose 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 our 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 is 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
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 transfered to our 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 ensure 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 talking about a webinar
that he 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.