Case Study: Medication Error Reduction Through Improved Documentation and Communication

July 2006 - Vol. 3 No. 5

By Brian George, PharmD

A NON-PROFIT HEALTH CARE ORGANIZATION located in northern central Ohio, MedCentral Health System serves the largest medical community between Cleveland and Columbus. With 2,700 employees and 250 physicians, MedCentral offers a complete range of primary care and specialty practices. Comprised of two general, acute care hospitals – Mansfield and Shelby, with a combined total of 351 beds and 44 bassinets – the health system handles more than 16,000 admissions, 10,000 surgeries, 70,000 emergency visits, and 160,000 outpatient registrations each year. Mansfield, the larger of the two hospitals offers a level II trauma center and perinatal department. MedCentral also provides complete cardiac care at MedCentral HeartCare and comprehensive neurological, home care, and hospice services, and includes the MedCentral Rapid Response walk-in medical center, three laboratory sites, a health and fitness center, and the MedCentral College of Nursing.

We know the statistics by heart – an estimated 7,000 patients die every year as a result of preventable medication errors in U.S. hospitals, the very places they should be recovering from illness or injury. Improving medication safety has progressively become one of the most urgent issues facing health care today. Aside from needless injury and loss of life, adverse drug events (ADEs) have staggering economic costs of more than $2 billion annually. But perhaps more significantly, ADEs incur the intangible cost of patients’ loss of trust in their health care providers.

Despite the intense pressures to improve the medication administration process across the enterprise, many health care providers are still experiencing difficulty in establishing checks and balances to standardize the delivery and administration procedures of medications. The medication delivery process is inherently complex, involving the coordination of numerous steps and disciplines from the time an order is written until the patient receives a medication as ordered. A breakdown in processes or the interruption of workflow widens the margin for ADEs, greatly increasing the risk of harm to the patient. The prescription for healthy medication management – and the key to safe, efficient, and effective health care – is continuity in communication, delivery, and documentation.

For MedCentral Health System, our investment in a robust health care information solution (HIS) is enabling us to optimize medication safety, streamline information access, and improve fiscal health – enhancing efficiencies from the pharmacy to the bedside. Through the automation and standardization of our current processes, we are reengineering our medication administration workflow process to ensure that physicians, nurses, and pharmacists throughout our health system have the information they need to support optimal decisions and actions at every point in the medication cycle – from prescribing and dispensing, to administering and monitoring.
There is no doubt that we are at a time of unprecedented discovery; the science and technologies involved in health care – the knowledge, skills, care interventions, devices, and drugs – are advancing more rapidly than our ability to deliver them effectively and efficiently. For example, in an average year, more than 200,000 peer-reviewed journal articles are published on clinical medicine. And more than 48% of all drugs currently available were introduced in just the last decade. Without an automated, standardized system that supports the delivery of best practices and new research findings at the point of care, health care providers are challenged to put the right information in the hands of the right people at the right time.

The Prescription
Superior patient care – from X-rays and ultrasounds to medication administration – requires clinicians to work as a multi-disciplinary team, efficiently communicating the patient information that individual team members need to effectively do their jobs. Medication administration records (MARs) are the basis of communication between pharmacists, nurses, and physicians. However, in a paper-based environment, MAR documentation runs the risk of being incomplete, inconsistent, and untimely, resulting in an elevated risk for ADEs from unavailable or missed doses and variable administration times. When we partnered with Siemens Medical Solutions in 2004, MedCentral was experiencing process inefficiencies and inconsistencies, such as having both handwritten and electronic MARs. We conducted an audit to determine the degree to which the MARs matched the pharmacy profiles. Not surprisingly, the medications matched consistently at a high percentage; however, administration times did not – often resulting in unavailable medications or medications being compounded and unused due to communication gaps between nursing and pharmacy. Our decision to implement several Siemens solutions, including Soarian as our HIS, the Siemens Pharmacy information system, and Med Administration Check (MAK), was driven by our need to optimize patient safety, streamline workflow, improve communication, and reduce operational costs throughout our enterprise.

Four months after our Siemens Pharmacy go-live, we made the decision to pilot MAK in preparation to completely close the loop on our medication use processes – automating medication orders, dispensing, delivery, and administration, while capturing every step in an electronic, real-time MAR. We started several work groups to help formulate MedCentral’s vision for and expectations of our HIS. Part of the process involved selecting specific drug classes and setting mandatory documentation parameters unique to MedCentral – ultimately helping to drive use and acceptance throughout the enterprise, while allowing us to customize the system in a way that allowed our specific care teams to greatly improve medication safety.

For example, since administration is the last step in the medication use process, the administering nurse provides the final line of defense for the patient. In fact, the Adverse Drug Events Prevention Study Group reports that almost 40% of medication errors occur during medication administration. With MAK’s bar code technology, the “five rights” of medication administration are automatically verified, and rules-based notifications – triggered by the “rights” and clinical checks, such as allergies, duplicate therapies, and drug-to-lab and drug-to-drug interactions – detect discrepancies and contradictions at the point of care.

While reducing and preventing medication errors at the bedside is critical, it is equally important to capture potential problems in the pharmacy. With over 90% of medication doses dispensed by our pharmacy robot, we are able to provide an extra measure of safety by tracking and verifying all medications dispensed and retrieved, streamlining the inventory process by eliminating the need for manual counts. While this enables real-time charge capture and more accurate billing, it also frees the pharmacist to focus more on providing care.

Our integrated solution also provides cross-disciplinary decision support with real-time electronic communication capabilities, bringing pharmacists to the bedside, where they are a vital part of the patient care team. Together with streamlined, customized workflows, we have made it easier for our clinical professionals to work together, communicate, and share their expertise.

It is important to note that technology is only part of MedCentral’s patient safety solution. Effective implementation of medication decision support required a comprehensive approach, backed — first and foremost — by our care providers. Gradual implementation was vital to our success. We piloted two ICUs, their step-down units, and a larger medical-surgery unit before rolling out to additional units one month later and more thereafter. This helped us to continue building and fine-tuning our workflows, best practices, and protocols.

Staff education, facilitated via online modules and hands-on training, was coupled with executive leadership to champion evidence-based, data-driven protocols throughout MedCentral. Above all, the technology has helped us to create and support a culture in which each care provider – nurse, pharmacist, and physician alike – actively contributes to our continuous improvement by sharing critical information and assuming responsibility in moving MedCentral closer to eliminating medication errors.

Overall, we have achieved, and even exceeded, our expected medication safety goals every month since implementation. We have:

  • Reduced our actual medication error rate to less than 2%
  • Charted 98% of our scheduled doses
  • Prevented approximately 260 I Improved communication between pharmacy and nursing
  • Reduced chart auditing time from two weeks to just several hours

As we expand and enhance our HIS, specifically with regard to medication reconciliation and charge-on-chart capture, we aim to further enhance our clinical and financial workflow, while continuing to reduce opportunities for error by providing more comprehensive and timely information. Although many components of our strategic IT plan remain a work in progress, we have been successful in taking a holistic view of our enterprise, examining our processes, and implementing technology to dramatically improve the safety and quality of medication use, ultimately saving time, money, and patients’ lives.

Brian George, PharmD, has been the assistant director of pharmacy services at MedCentral Health System since July of 1999. He received his BS in pharmacy and PharmD degrees from the Ohio State University.


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