Change Package Hospital Leadership Module External Use - Version 2 KP Innovation Consultancy
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LDR 1 February 2008
Table of Contents 03
Executive Summary
04
What is MedRite?
05
Context / Project Overview
07
What are the Benefits?
08
Where did MedRite come from?
09
MedRite Components
10
MedRite Component: Process
12
MedRite Component: No Interruption Wear
13
MedRite Component: Sacred Zone
14
What They’re Saying about MedRite!
15
Pilot Data: Metrics, Interruptions, Time per Med Pass, On Time Meds, Nurse Satisfaction, NonNurse Satisfaction, Reliability
24
Getting Started: How to Begin, What does my support team look like?, What do I do as a Hospital Leader?
28
Sustainability & Competency: RiteTrak, Sustainability
30
Implementation Costs
33
Appendix: The Stories for Change
40
Innovation Consultancy: About LDR 2
Executive Summary In the United States alone over 1.5 million are harmed by medication errors each year. Our own research here at Kaiser revealed a fragmented approach to medication administration riddled with interruptions and distractions. The Innovation Consultancy, supported by KP HealthConnect, Patient Care Services and Quality & Safety, conducted an innovation collaborative with Hayward, South Sacramento and West Los Angeles Medical Centers.
The output of this collaborative is a three component system called MedRite: MedRite Process // The step by step workflow for RNs to administer medications. No Interruption Wear (NIW) // A sash or a vest signals that no one should interrupt (talk to) the RN who is wearing the sash unless there is an emergency.
Sacred Zone // A space marked out on the floor with tape in front of the area where the nurse pulls and prepares meds in the med room. This Zone signifies that no one should cross or talk to an RN who is in the space.
MedRite was piloted on four units (Med/Surg at Hayward, Med/Surg/Tele at Hayward, Med/Surg at West Los Angeles and Surgical at West Los Angeles). The results of the pilots show: • 50% reduction in the number of staff interruptions to the medication administration process from approximately .7 interruption per med pass to .3 interruption per med pass • 15% faster per med pass from approximately 10:00 to 8:30 (minutes:seconds) • 18% increase in On-Time Med Passes from 61% to 79% • Significant increase in process reliability from 33% to 78%
Finally because of the increased nurse and patient satisfaction, and because of the results detailed above, both pilot hospitals have crafted work plans to roll out MedRite throughout their systems.
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What is MedRite?
MedRite is a safer, warmer and more reliable medication administration experience for nurses and patients. …….……….………………………….…………….……………………………………….…………..…….. For the RN, it clearly guides one through the medication administration process and provides support tools to minimize interruptions and maintain the nurses’ focus on safe medication administration ………………………………………………………..…………………………………….…………..…..….. For the Patient, it creates an opportunity for deeper involvement and understanding, and increases their sense of personal safety
…………………………………………..…………….……….…..……………………….…………..…..….. For managers and educators, it is a clear standard that can be taught and maintained, and provides a better understanding of what is happening on the unit during medication administration …………………………………………………………...…………………………………….……………..….. For the other staff, it assures them that their patients are receiving focused, non-interrupted attention during the med- admin process ……………………………………………………………………………………………….…………..…..….. Finally, it’s a system designed by the frontline for the frontline. LDR 4
Context / Project Overview In the United States alone… ………7,000 deaths each year are caused by medication errors* ………1.5 million people each year are “harmed” by medication errors ………1 medication error per day per hospital patient ………$3.5 billion is spent each year treating medication injuries *1999 report “To Err is Human: Building a Safer Health System”
In 2007… A cross-regional effort began which focused on Medication Administration. Kaiser’s Innovation Consultancy, supported by Quality and Safety, Patient Care Services and KP HealthConnect, was commissioned to frame the problem, and generate and try out ideas with front-line staff from three Kaiser Hospitals.
Hayward Patient Care Services
Quality and Safety
West Los Angeles Innovation Consultancy
KP HealthConnect
South Sacramento
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Context / Project Overview (cont)
1
Insight from field observations & research Constant interruptions of nurses & inconsistent processes Clinicians want focused time; Patients want to participate
2
3
Staff & patients brainstormed & tried ideas • Cross Regional “Deep Dive” held at KP’s Garfield Innovation Center • Nurses, physicians, pharmacists, and other experts attended •Generated hundreds of ideas that led to KP’s MedRite solutions
Developed human centered solutions • Clear and safe med admin process • “No Interruption wear” i.e. sash, vest • Zones for focused work
4
Positive results measured & celebrated: “MedRite” Metrics Decrease in: Interruptions, Time to perform medication administration, Increase in: On time med passes, In-room Documentation, Clarity/Ease LDR 6 of the process
What are the Benefits? ……………………………………………………………………………………………….………….. Normalized, easy to follow, medication administration process. Nurses now have a standardized approach to medication administration, which can help them to follow the 5 Rights of Medication Administration. ……………………………………………………………………………………………….………….. Warmer way of giving medications. MedRite incorporates time to ask patients if they have questions about their medications. It encourages patients to have a deeper level of involvement by providing an opportunity for their questions to be answered. ……………………………………………………………………………………………….………….. Consistent timely delivery of scheduled medications. Nurses are more able to administer medications within the timeframes ordered by physicians. ……………………………………………………………………………………………….………….. Fewer medication errors. Interruptions and distractions of nurses is a cause of medications errors. [1]. MedRite has been shown to reduce interruptions and distractions which can lead to a reduction in medication errors.
[1] The Journal for Continuing Education in Nursing, May/June 2005 – Vol 36, No 3 LDR 7
Where did MedRite come from? MedRite was developed through the hard work of our frontline staff and innovation facilitators.
……………………………………………………………………………………………….………….. MedRite is a solution generated by an innovation collaborative between Hayward, South Sacramento and West Lost Angeles. ……………………………………………………………………………………………….………….. No Interruption Wear (a component of MedRite) was independently developed and fully implemented by South San Francisco. South San Francisco’s hard work jumpstarted the MedRite evaluation process as 1/3 of the solution was already proven!
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Components
Process
NIW
Sacred Zone
A step by step workflow for RNs to administer medications that incorporates the “5 Rights.”
No Interruption Wear (NIW) signals that no one should interrupt (talk to) the RN who is wearing it unless there is an emergency. The RN only wears the NIW when “passing” meds, and removes it in-between med passes; this opens the nurse up for interruption at appropriate times. NIW may be a sash or a vest.
A space marked out on the floor with tape in front of the area where the nurse pulls and prepares meds in or out of the med room. This tape signifies that no one should cross into the space or talk to a RN who is in the zone.
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Components
Process
The step by step workflow for RNs to administer medications. The Process is the foundation of MedRite. It incorporates the 5 Rights and standardizes the basic flow. This allows for a clear understanding by patients, caregivers and management on what to expect.
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__Review MAR __Verify Correct Time __Enter Med Room __Put on NIW
Components
Process
__Check Allergies __Pull Medication(s) __Verify Right Patient __Verify Right Medication __Verify Right Dose __Verify Right Route __Go to Patient’s Room __Gel or Wash Hands __Turn down TV/radio __Turn on Lights __Verify Correct Patient using 2 identifiers
__Explain the Med and its purpose to the patient (Verifies Right Med 2nd time) __Ask Patient if they have any questions __Re-Verify Dose __Re-Verify Route __Re-Verify Time __Administer Medication __Document on MAR __Gel or Wash Hands __Remove Sash __Exit Patient Room
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Components
NIW
No Interruption Wear (NIW) is the tool that helps minimize interruptions during Medication administration. It is put on in the Med Room and removed before exiting the Patient’s Room. It is worn ONLY during the MedRite Process and NOT between med passes. This allows the nurse to not be interrupted while giving medications and support the other medical staff at appropriate times. NIW is not meant to reduce friendliness! Nor is it meant to turn our nurses into robots. You are still feel free to smile while wearing NIW! LDR 12
Components
The Sacred Zone is an area marked out in front of the PYXIS with tape. We recommend the use of tape as this is a common zone indicator in the OR and Pharmacy.
Sacred Zone
The space marked out should allow enough room for the drawers of the PYXIS to open and still allow the RN to stand comfortably in the zone. Remember the nurse will need to bend at times to pick the medications from the drawers. Work with local engineering to select and apply the tape. LDR 13
What They’re Saying about MedRite! Hayward RN… A patient gave the medical record number to the nurse before she asked because she learned from the nurse on the previous shift about the MedRite Process. West Los Angeles RN… A traveler nurse caught her own error because of following the five rights using the MedRite process. Hayward Unit Manager… There was one patient who refused to accept medications from the nurses unless they wore the sash AND had a conversation around the medication purpose and dosage.
West Los Angeles Department Administrator… The Department Administrator was a nurse for the day; since she does not regularly practice as a nurse she would not have felt comfortable giving meds but with the MedRite process she did; She said it was “Just like baking a cake…Follow the directions and you will be fine” .
Hayward RN… “When I explained the sash to a patient, the patient said that he felt safer.” LDR 14
Pilot Data
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Pilot Data: Metrics We use metrics to understand the effect of a change on a system. There are three types: outcome, process and balancing. Outcome A measure of the direct item you are trying to change. For example, for MedRite one outcome metric is interruptions. We are trying to reduce them. Process A measure of the “process steps� used to achieve the outcome. This is an indirect measure. In MedRite, it is the MedRite Process we are measuring. The theory is that if the MedRite Process is followed there will be fewer interruptions and less errors. Balancing A measure of other items that may be affected by your change. For MedRite, we are measuring non-nurse satisfaction to ensure that it is not negatively impacted by MedRite. What are innovation pilot metrics? The innovation pilot metrics that are presented on the following pages help us understand the effects of the innovations, and the four KP MedRite units do show changes in all the right directions. However, from an improvement science perspective more data points are needed to statistically determine if a significant and sustainable effect has occurred.
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Metrics Definition Interruptions Type Measure
Outcomes The number of times the RN is interrupted from the moment that medications for a single patient are pulled to the moment the medications are documented on the MAR Time to Administer Medications
Type Measure
Outcomes The time it takes to administer one medications pass Timing Meds
Type Measure
Outcomes Percentage of medications being given within the compliance window for the pilot unit Nurse Satisfaction
Type Measure
Outcomes Survey of RN satisfaction with the medication administration process Non-Nurse Satisfaction (MD,NA, UA, PT, RT)
Type Measure
Balancing Survey of non-RN satisfaction with the medication administration process Reliability
Type Measure
Process Percentage of RNs who follow the full med administration process in lean order or any order
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Pilot Data - Interruptions There was a significant reduction in staff interrupts during the medication process. On average, from about .7 interrupts per med pass before MedRite to .3 after MedRite (Two-Month post go-live). At least a 50% reduction for each pilot site!
Average Interrupts Per Med Pass (n≈68) 1.2
Average Interruptions
1.0 0.8 0.6 0.4
1.0 0.8 WLA - 2A WLA - 3W 0.6 0.4
HAY - 3CW 0.4 0.3 0.3 0.2
0.2
0.5
HAY - 3E
0.1 0.1
0.0 Baseline
OneMonth
Tw oMonth
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Pilot Data - Time per Med Pass There was a 15% reduction in average time per med pass. On average, from about 10:00 (min:sec) per med pass before MedRite to 8:30 after MedRite. West LA 2A shaved over 3 minutes off per med pass and Hayward 3E, 1.5 minutes off per med pass. A nurse who has ten med passes in a shift (and that’s conservative), is given back 15 – 30 minutes per shift! Average Tim e Per Med Pass (n≈68) 14:24
Average Time Per Med Pass
12:58
13:15
11:31 10:05 08:38 07:12
10:45 09:44 09:21 07:44
10:10 WLA - 2A
08:20 07:19 07:09
08:10 08:00 07:46
WLA - 3W HAY - 3CW
05:46
HAY - 3E
04:19 02:53 01:26 00:00 Baseline
OneMonth
Tw oMonth
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Pilot Data - On Time Meds On average there was a 18% increase in the number of med passes that fell within the “on-time” window after MedRite implementation. The “on-time” window for West LA is ±60 minutes, and for Hayward is ±30 minutes.
Percent of OnTim e Med Passes (n≈55) 100% Percent of OnTime Med Passes
90% 80%
80% 76%
70%
88% 87%
96% 89%
72%
72%
64%
60%
WLA - 2A 58%
50% 40%
WLA - 3W HAY - 3CW
43%
HAY - 3E
30% 20% 10% 0% Baseline
OneMonth
Tw oMonth
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Pilot Data - Nurse Satisfaction Nurses were asked if the medication administration process was clear, safe and easy. Satisfaction went from 68% before MedRite to over 90% after MedRite. Yep, nurses not only like it‌they trust it.
Percent of Nurses Satisfied w ith the Med Adm in Process (n≈17) 100% 95% 93% 90%
90% 80%
98% 96% 94%
80% 78%
70% 60% 50%
WLA - 2A WLA - 3W
46%
HAY - 3CW/E
40% 30% 20% 10% 0% Baseline
OneMonth
Tw oMonth
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Pilot Data - Non-Nurse Satisfaction Our goal for non-nurses (which include all care team roles other than nurses) was to either increase satisfaction or maintain the status quo. Satisfaction went from 68% before MedRite to 88% on average post MedRite. Not bad.
Percent of Non-Nurses Satisfied w ith the Med Adm in Process (n≈19) 100%
98%
90% 80%
78%
92% 86% 80%
70% 60%
67%
65% 62%
WLA - 2A
50%
WLA - 3W
40%
HAY - 3CW/E
30% 20% 10% 0% Baseline
OneMonth
Tw oMonth
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Pilot Data - Reliability The “basic” five steps of medication administration are: 1)Compares medication with MAR, 2)Checks two forms of ID, 3)Explains the medications to the patient, 4)Opens blister packs in front of patient, and 5)Charts medications immediately. MedRite improved the reliability that these five steps are completed from 33% before MedRite to close to 80% after MedRite! Percent of Med Passes w here all five basic steps w ere com pleted (n≈68) 100% 90% 80%
79% 74% 68% 66%
70%
84% 81% 74% WLA - 2A
60%
WLA - 3W
50% 40% 30%
HAY - 3CW 37% 33% 32% 28%
HAY - 3E
20% 10% 0% Baseline
OneMonth
Tw oMonth
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Pilot Data Getting Started
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What does my support team look like?
Project Manager A highly skilled and respected individual that has the ability, willingness, patience and positive energy to manage the MedRite implementation.
“You can’t throw habits out a second story window; they must be coaxed downstairs, one step at a time.”
MedRite Unit Team A sample Unit Implementation Team might include: Manager, Assist Manager & Nurse Champion. You will need support from the nursing staff. Ask the Unit Manager and local union representatives to help designate a nurse or nurses each shift that are committed to this project. They will provide initial and ongoing training to RNs. This group of folks will also provide feedback to localize the flexible parts of the solutions. They are your champions.
--Mark Twain
Quality Analyst Choose an analyst from your Quality department to organize and support the collection of metrics using the RiteTrak tool (see Sustainability and Competency) to measure the success of the implementation and ongoing improvement to ensure sustainability. LDR 25
What do I do as a Hospital or Labor Leader?
You: Hospital leaders
Project Manager
Unit staff
Successful implementation requires that you, as a leader, take an active role in supporting this effort. Clearly & continuously communicate the rationale for the changes before, during, & after implementation.
You will be looked to for your commitment to the changes that will be made, and for your support of the implementation team that you put in place. This will be a multiple week implementation effort, but it will go by quickly and will require moments of flexibility and quick decision-making that can make or break its success. Manage the nurses during medication administration times: Your role here is primarily one of helping RN staff understand that you are committed to the new solutions, and that you will help your implementation team overcome any barriers that might slow the process down. Help Guide People • Guide the selection of the right implementation manager and unit team. • Ensure that the stakeholders (don’t forget about patients, physicians, pharmacists and other clinical and non-clinical staff) understand the rationale, know the benefits of the changes, and how the changes will take place. • Sense the right pace for the solutions to spread across your hospital and support the natural flow of the ideas.
Sustainability & Competency
LDR 27
Sustainability RiteTrak is a measurement tool and is how you will understand the state of MedRite. The information from RiteTrak is meant to be acted on; meaning if you see a slip in one of the measures, you should create an intervention to bring that measure into green light status. For full details on RiteTrak please see the Sustainability and Competency section in the Project Managers Module. Leadership Walkarounds are another important component of sustainability. They should occur randomly several times a month for the first 3 months of MedRite and then a few times a month thereafter. RiteTrak, coupled with Leadership Walkarounds, will help you achieve green light status for MedRite, and in-turn, create a safer, warmer medication administration process.
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Implementation Cost
LDR 29
What will it cost to implement MedRite? People Costs One Project Manager at your facility to help implement MedRite Backfill for at least three unit staff per unit (one from each shift) that will implement MedRite. You and the Project Manager will need to determine the amount of time needed for the staff’s participation on the MedRite Implementation Team. MedRite Tool Costs MedRite Sash cost is $8.50* per nurse (Pricing varies – see ordering form in appendix for order information and discount pricing). Sacred Zone requires permanent tape. This is procured from your engineering department and is done by completing a work order. Budget 2 – 4 hours of time for engineering to complete the project professionally. (Please estimate $120-$240) This will allow EVS to clean and even wax the floor. Our finest example of a true completion of this concept is the one created by South San Francisco. (see photo on pg. 13) Estimated costs associated with this product are $900.00. (Please check with your local engineering department for actual cost) Other Costs Printing of MedRite flow diagram cartoon (internal printing costs) Cost of any thank you gifts for those who may go the extra mile. As a sponsor, the cost is your full-time support.
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“No Interruption Wear� Ordering Information It is recommended that a facility choose only one option: the MedRite Sash or the Medication Vest. Although we recommend the MedRite Sash as it was developed by frontline nurses, other hospitals have successfully used medication vests. Generally each nurses will need his/her own NIW. Multiply the number of NIW needed by 1.15 to calculate the total number you should order. This will give you an extra 15% supply. MedRite Sash
Medication Vest
Jogalite Company
American Identity
PO Box 149, Silver Lake, NH 03875
A Division of Staples, Inc.
Judy LaBonte (Judy@jogalite.com)
7500 W. 110th Street, Overland Park, KS 6210
Wendy Damon (Wendy@jogalite.com) P 800.258.8974, ext.25
Lisa Justus, Lead Account Consultant
F 603.367.8098
lisa.justus@americanid.com P 800.743.4543, ext.5
KP Style Number Regular - Product
F 888.543.3549
U4718A (recommendation: 90-95% of order) KP Style Number Large - Product U4719A (recommendation: 5-10% of order) Pricing Please contact Jogalite for pricing and use the KP Style Numbers
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Appendix : The Stories for Change
The following are some of the signature stories from Hayward, South Sacramento and West Los Angeles collected during the observation phase (March 2007) of the project.
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LDR 33
The Shortest Distance
This is the story of a liquid orange drug and its amazing travels The RN begin the med admin process by going to the med room and pulling meds from the Pyxis. Before she finished getting all her meds, a Physical Therapist entered the med room to ask where his patient was since he was “already 20 minutes late!”. The RN replied that the patient had just taken Vicodin and would be sent down promptly. She finished getting her meds, including an orange liquid med in a cup. All good to go right? Except that she still needed one other Item from the supply room. So, balancing all her meds on her
paper MAR, she carefully made her way to the supply room, where she was promptly interrupted by a doctor who asked her for a culture kit. She let him know the kits were stored at the other end of unit. He said that was too far, and asked her to go get it. The nurse obliged, and she along with all her patient’s drugs went on a trip to the other end of the unit to hunt down a culture kit. As she got the culture kit, the Physical Therapist made a cameo appearance and asked why his patient had not been sent down yet. So, with all her meds In hand, orange liquid Med precariously balanced on her MAR, culture pack under her elbow. She swung by the Nurse’s Station, passed the culture kit to the doctor like a relay runner’s baton and made a call to send down the patient to Physical Therapy...FINALLY she got to her patient’s room with all the meds safe and secure without having spilled a drop of the orange liquid med. The RN re-centered herself to concentrate on giving her Meds, then realized there wasn’t a drop of water for the patient to use to take them with. So she had to gather everything back up and go to the kitchen area to get a pitcher of water. When she returned she was FINALLY able to focus, go over the meds and administer the orange liquid med, along with all of the other meds, to the patient. LDR 34
I Do it My Way… Ask 12 nurses how they “Administer Medications” and you will get 12 different answers…
“I chart my medications in the Pyxis room. I already have the patient chart open there so it saves me a step later.” “I chart in the hallway so I can focus on what I am doing without patient questions.” “ I chart in the patient room so I don’t forget what I just did.”
“I open my medications in the med room so I can get them ready to go for the patient. It makes it easier.” “I wait and open each medication in the room. That way the patient can see that it is clean, if they don’t take it, it’s not wasted. If they do take it we can double check the medication together.”
LDR 35
Patient’s have a structured processes keep safe. Shouldn’t we? How do you track what medications you need to take? “Oh, the wife, she takes care of that. She had one of those plastic things, the containers with Monday, Tuesday, Wednesday, Friday on it, where you put a pill in each part so you can see what to take. She puts it in there and when it’s out, it means you took it already. Then there is no chance of taking it twice.”
LDR 36
Chaotic, Interruptions, Unclear Process Nurses were asked to draw the first thing that came to mind when they thought of “Medication Administration.” “Interruptions” was the most frequently used word. The drawings showed frazzled staff working with unclear processes to achieve the “Five Rights.”
This drawing by a Hayward nurse summarized the voice of the nurses across the pilot sites.
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Always Something to Do… RN: “You leave a room with a set ‘something to do’…before you can even start that something you’re interrupted two or three times with immediate requests…THEN, you need to back track and figure out where you left off on that first ‘something to do.’”
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Innovation Consultancy, Nice to Meet You!
Christi Zuber
Scott Heisler
Scott Heisler
Chris McCarthy
ABOUT the Consultancy Our Kaiser Innovation Consultancy (IC) is a group of creative people who help challenge conventional thinking to develop human-centered designs and solutions. Our ultimate goal is to positively impact the work experience of our employees and the health of our KP members. We test out the usability of new products, workflows and space designs, and conduct simulations in real and mock patient environments. We work together with our KP employees, physicians, and members to better understand challenges and develop and prototype human-centered ideas using proven methodologies from both IDEO and IHI Other designs from the IC: 1) Nurse Knowledge Exchange , 2) Perinatal Journey Home Board 3) Med Surg Care Boards, 4) TCare Innovation Teams Email: Innovation.Consultancy@kp.org LDR 39
Executive summary – FAQ - Citations Pilot Data
LDR 40
Executive Summary In the United States alone over 1.5 million are harmed by medication errors each year. Our own research here at Kaiser revealed a fragmented approach to medication administration riddled with interruptions and distractions. The Innovation Consultancy, supported by KP HealthConnect, Patient Care Services and Quality & Safety, conducted an innovation collaborative with Hayward, South Sacramento and West Los Angeles Medical Centers The output of this collaborative is a three component system called MedRite: MedRite Process // The step by step workflow for RNs to administer medications. No Interruption Wear (NIW) // A sash or a vest signals that no one should interrupt (talk to) the RN who is wearing the sash unless there is an emergency. Sacred Zone // A space marked out on the floor with tape in front of the area where the nurse pulls and prepares meds in the med room. This Zone signifies that no one should cross or talk to an RN who is in the space. MedRite was piloted on four units (Med/Surg at Hayward, Med/Surg/Tele at Hayward, Med/Surg at West Los Angeles and Surgical at West Los Angeles). The results of the pilots show: • 50% reduction in the number of staff interruptions to the medication administration process from approximately .7 interruption per med pass to .3 interruption per med pass • 15% faster per med pass from approximately 10:00 to 8:30 (minutes:seconds) • 18% increase in On-Time Med Passes from 61% to 79% • Significant increase in process reliability from 33% to 78%
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Frequently Asked Questions Question: What does it mean when the nurse is wearing their Sash? Answer: The Sash indicates that the nurse is in the process of giving medications to your or one of your peers patient’s. Question: When the nurse is wearing the Sash can I interrupt them? Answer: Studies have shown that when our nurses were less distracted they paid more attention to the Medication Administration process and followed it more reliably. It is important to refrain from interrupting the nurse while they are administering medications to keep you patient’s safe unless there is an urgent need. Question: I am concerned that the nurse will wear their sash at times other than Medication Administration and will not be available in a timely fashion? Answer: We have found that nurses do not abuse wearing of the sash. There is a small learning curve when they must learn when to put it on and take it off. Their goal is put the sash on as they prepare to give their patient their medications and then take it off immediately after medication administration. Question: I have heard that nurses have used this an excuse to not speak with physicians or use common sense about physician’s need to communicate with them. Answer: There may have been isolated instances of this occurring, but as hospitals have implemented KP MedRite, this has not surfaced as recurring theme. Question: Are their published studies or articles that show benefits of reducing interruptions during medication administration? Answer: Yes, many. Specifically The Joint Commission has published a book entitled The Nurse’s Role in Medication Safety. In Chapter 7, entitled First: Do Not Distract, the author, Tess M. Pape, PhD, MSN. RN, C.N.O.R., cites studies that have been done that show the benefit to nurses by reducing distractions. The chapter challenges the reader to implement programs based on the research. KP MedRite is a National program, supported by Kaiser Permanente, that builds on this research.
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Question: What happens if there is a code or Rapid Response Team call? Answer: As with any emergency, it is expected that nurses will respond in a timely fashion as appropriate. Question: How was the Sash and the Medication Administration Process developed? Answer: The Sash and Medication Administration optimized processes were developed by front line staff and physicians using human centered design processes and piloted at 4 different Kaiser Permanente Units. Results showed a decrease in interruptions, an increase in timely medication passes and nurses being more reliable in giving medications accurately. Question: Has KP MedRite resulted in the outcome of decreased Medication Errors? Answer: Some Kaiser Permanente Hospitals have seen a dramatic decrease in Medication errors from historical norms using their traditional methods of reporting. (examples are in South San Francisco and Sacramento Medical Center). More data is being collected to show statistical significance in the coming months. Question: Why do you feel that KP MedRite really works? Answer: Process metrics are an indication that a system is on track to improve outcome metrics. KP MedRite pilot units were analyzed and shown to have statistically significant improvement in 1) reducing the number of distractions encountered by nurses during medication administration, and in 2) Improving the standardized process of giving medications. Both of indicators have been shown to be valuable by the Institute for Safe Medication Practice. (see citations on following slides) Question: Does KP MedRite address specific challenges noted in our industry Answer: KP MedRite was designed to meet the following process recommendations from the book Medication Errors, by Michael Cohen, RPh, MS, ScD, DPS, President of the Institute for Safe Medication Practice. LDR 43
Citations Relating to KP MedRite
Here are Medication Administration challenges addressed by KP MedRite Source: Medication Errors, 2nd Edition by Michael Cohen, 1. Preventing adverse drug interactions by knowing a patient’s diagnosis Recommendation: Match the patient’s medications to his/her diagnosis and make sure the drug’s intended purpose makes sense for the patient. 2. Preventing administration of medications to the wrong patient Fact: Misidentification errors can originate in any phase of the medication-use process (physician orders, nurse transcription of orders, and pharmacist entry mistakes) Recommendation: Use at least two unique patient identifiers. [i] Recommendation: Take the MAR to the patient’s bedside for the required verification. [ii] Recommendation: Keep unit dose medications in the manufacturer or pharmacy packaging up to the point of administration. [iii] i] Medication Errors, Michael R. Cohen, Editor, American Pharmacists Association, Washington D.C., 2007, pg. 238. [ii] Ibid. [iii] Ibid. 3. Creating safety strategies for look-alike and sound-alike drug names/packages Recommendation: Double check with the patient: ensure that the medication’s purpose makes sense and that the medication looks similar to what the patient took at home. [i] Ibid., pg. 252 4. Labeling to the point of administration Recommendation: Leave medications in unit dose packages until the point of administration. [i] Ibid., pg. 255 5. Maintaining focus in a challenging work environment Fact: Distractions are a greater problem for nurses than for pharmacists, pharmacy technicians, and physicians LDR 44
Recommendation: Establish “do not disturb� times in the medication room during drug administration. [i] Ibid., pg. 265 Recommendation: Educate staff on the importance of working as a team, staying focused during staff administration, and avoiding unnecessary distractions while others are administering medications. Ibid., pg. 265 Recommendation: Provide phone and call-bell support for nurses who are administering medications. [i] Ibid., pg. 265 6. Assessing practices that result in a culture of safety Recommendation: Establish safe work environments for medication preparation, administration, and documentation. [i] Ibid., pg. 268 Recommendation: Work to improve systems that address most common near misses in the work environment. [i] Ibid., pg. 268 7. Preventing errors through the input of observant patients and their families Recommendation: Encourage patients to ask questions about their medications and seek satisfactory answers. [i] Ibid., pg. 270 8. Enhancing double-check systems during drug administration so that potentially harmful errors are detected and corrected before they reach patients Fact: About 1 in 5 medications reach patients in error; 38% of these errors originate during drug administration Fact: Just 2% of errors that originate during drug administration are intercepted and corrected Fact: More than half of the medication errors that cause harm originate during drug administration Recommendation: Use a unit dose drug distribution system so that the pharmacist and the nurse (or two nurses) can independently interpret, transcribe, and verify each dose before dispensing or administering it. [i] Ibid., pg. 272
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