Bon Secours St. Francis Hospital in Charleston, South Carolina is a 204-bed, acute care community hospital that began an organization-wide implementation of automated dispensing cabinets (ADCs) in 2004. While many facilities use these cabinets for the safekeeping and dispensing of controlled substances, it was our objective to use ADCs to store and dispense all our medications. Thus, we began a multiyear, multistep project to redesign the delivery of medications, from the initiation of the physician order to the actual administration at the patient bedside. To fully utilize ADC technology and achieve our goals, we knew a clear and unfettered communication channel would be required between pharmacy and nursing, as these departments each interact significantly with the technology and depend on each other for the system to function properly.
Pharmacy-Nurse Liaison as Arbitrator
The logic behind our long-term ADC plan was that automating each step in the medication administration process would directly improve the safety of medication administration for our patients and limit medication errors in general. To initiate this process, we created a new position to enable all stakeholders in pharmacy and nursing to contribute and take ownership of the new technology—the pharmacy-nurse liaison (PNL). The role of the PNL is to bridge the gap between pharmacy and nursing in order to better understand the needs and challenges facing both sides. The PNL also is tasked with developing a full understanding of the new technology and how best to use it, creating educational materials and interdepartmental training programs to provide staff with a clear depiction of how all parties will interact with it. From past experience, we knew that inadequate training and lack of understanding of a new process would quickly result in workarounds, potentially leading to errors.
To serve in the PNL position, an ability to see the big picture as it relates to medication safety is imperative. Therefore, the PNL helps pharmacy understand how the process of profiling medication orders and stocking ADCs affects nursing’s administration of medications, and works with nursing to communicate medication error trends to prevent them from reaching the patient. Certain pharmacy processes can contribute to nursing errors, and pharmacists and technicians are oftentimes not aware of these issues. The liaison, by design, digs more deeply into the reasons errors occur and encourages changes to both pharmacy and nursing practices to prevent errors from being repeated.
Early in the ADC integration process we found a discrepancy between the way drug names and strengths appeared in the pharmacy order entry program versus on the ADC screen. To fix this, pharmacy manipulated the drug names in their order entry program so nursing saw the same drug names when viewed on the ADC. Having run through the process of pulling drugs from an ADC with nursing, pharmacy was able to adjust so that the content displayed on the ADCs is sufficient, but not overwhelming. For example, “Sodium Chloride 0.45% 1000 mL — KCL 20 meq,” which used to display clearly on a pharmacy computer screen, had too many characters to properly display on the ADC screen and the drug name and route was obscured. Subsequently, the display name was shortened to “NACL 0.45% — KCL 20 meq 1000 mL,” allowing it to display completely on the ADC.
Another example of a process improvement that stemmed directly from a clearer understanding of both pharmacy and nursing practices related to controlled substances in the ADCs. Accounting for controlled substances is done through a blind count after each controlled medication removal. Because the average number of narcotic removals per nurse, per shift may be as high as 20, pharmacy limited controlled substances to a maximum of 30 medications per pocket, so the nurse would not have to count a large number of tablets or syringes each time a narcotic was removed. This practice change, along with limiting controlled substance verification to once a week, resulted in fewer narcotic discrepancies due to miscounts and improved nursing satisfaction with the ADC technology.
Often, small process changes can enable the most beneficial gains, but it can be difficult to qualify those details. Thus, when nursing initially voiced concerns about the most frequently used medications being placed in the bottom drawers of the ADC during stocking, the complaint did not seem significant to pharmacy staff. However, to a nurse who is constantly bending over throughout a long shift to access drugs, this is important. Once this issue was elucidated to pharmacy, the most frequently dispensed medications were purposely placed in the upper drawers during filling.
In order to maintain overall control over drug inventory, pharmacy staff review the medications dispensed from each ADC every six months to determine actual usage over time. They now stock the most utilized medications in the ADC and remove slow moving medications, all the while making modifications specific to the nursing unit served by the ADC. This process has allowed us to prestock 85% to 90% of all medications in the ADCs, enabling prompt access for nursing once medication orders are profiled by pharmacy.
During the early months of ADC implementation, the medication removal process was cumbersome, as locating the proper medication in a drawer containing multiple drugs was often frustrating and time consuming. This also led to so-called “one stop shopping,” where a nurse would “shop” for any other medications he or she might need while the drawer was open. To address this issue, we modified our ADCs such that each medication was placed in an individual pocket that was programmed to open only when the item was ordered. This made it much easier to find the requested drug quickly and eliminated any removal of non-ordered medications.
Further evidence of the effectiveness of our PNL position was found in the ADC restocking process. By communicating the respective responsibilities of the pharmacy technicians and the nurses, we initially set ADC stocking rounds at every two hours, but avoided the busiest medication administration times in the mornings. During this process, we stressed the need for nurses to be able to access the ADCs during restocking to avoid backups in medication administration; the ADCs were programmed to allow technicians to suspend stocking when access by nursing was needed. Because we kept communication open between the technicians and nurses, this process worked well for us. To improve the restocking process further, we are moving to a batch fill during night shifts to lessen the impact of stocking on timely medication administration.
Reduce Errors by Minimizing Distractions
It is common sense that distractions caused during ADC drug removal increase the risk of error. One simple way to combat distraction is to clearly delineate that when a nurse is interacting with an ADC, that person is to be left alone. To reinforce this concept, we changed the pattern of the floor tiles surrounding the ADCs to designate that area as a specific quiet zone. We also placed bold signage to remind staff to remain quiet in these areas and that any nurse working in the zone should not be interrupted. Some units added even more distinction to the zone by placing florescent tape around the ADC tower and refrigerator at each station. This reinforcement technique has helped, although vigilance is still required to ensure that all staff honor the quiet zones.
Along similar lines, pharmacy and nursing are currently working together on steps to reduce the number of phone calls from nursing to pharmacy to limit distractions to pharmacists when profiling medications. To enable this, we have focused on the timing of medication administration, which is the reason for many calls to pharmacy. It is common for new surgical patients’ medications to be timed to start as soon as they arrive from the PACU, but because patients are not able to take these medications so close to recovery, nursing calls pharmacy to get the times changed. Because phone calls can be a source of distraction for pharmacy, we emphasize the use of the electronic communication program built into our pharmacy system rather than phone communication.
The most recent initiative to reduce distractions was to move review and profile pharmacists into their own offices, away from the distractions of the main pharmacy, so they could concentrate on order entry with fewer interruptions. We are now tracking the characteristics of ongoing medication errors to determine the impact of pharmacist seclusion on profiling error rates.
Non-punitive ADE Reporting
From a medication safety standpoint, we have worked hard to put the focus on process improvement when dealing with adverse drug event (ADE) reporting, as opposed to leveling punitive measures. We view ADE reports as opportunities to expose processes that may not be working as intended and improve upon them. As such, simplifying the ADE reporting process was key to increased participation and reporting rates, and so we developed multiple mechanisms for staff to notify pharmacy of an ADE. Previously, our error reporting system had numerous required components that were not always necessary. To encourage reporting, we reduced the number of required elements to just a few and instead added a field for staff to describe the error; we also allow staff to report events by email or phone directly to the PNL. We are currently investigating the possibility of incorporating electronic error capture into the nursing documentation that transmits to the pharmacy system. This innovative idea originated with our nursing staff and is now being evaluated by our IT department for feasibility.
It is important to note that the PNL is not the only clearinghouse for information to pass between nursing and pharmacy. We recently added a medication safety team—chaired by a pharmacist and co-chaired by the PNL—to our facility’s professional practice nursing council. The interdisciplinary team comprises nurses, pharmacists, dieticians, diabetic educators, wound care nurses, and anyone else who wants to attend team meetings. At each meeting medication errors are reviewed in depth, particularly if the error reached the patient, caused harm, or extended patient monitoring. This team is responsible for bringing error information back to the nursing units and reviewing lessons learned with staff. The conversations and brainstorming sessions that develop as a result of this process often shed light on why errors happen and introduce possible solutions for decreasing them. A manager’s perspective of an error is only one piece of the puzzle; other staff members have unique insight into processes that contribute to errors that managers might not be aware of.
One of the most innovative ways we found to increase ADE reporting was to quantitatively include them as part of our pharmacists’ annual performance evaluations. Whenever a pharmacist discovers a near miss or error that reached the patient, it is recorded into the electronic error reporting system. In doing so, that pharmacist will increase the quality score of their annual evaluation. This practice has improved the error reporting process by making it personally beneficial to report errors. The best sources for communicating errors and potential errors are the frontline staff performing the task. Given this, it is critical to mitigate fear of reporting in order to achieve the safest possible processes for patients.
Most frontline practitioners are well aware of the potential for alert burnout when using modern automation. Because of this reality, we endeavored to limit ADC alerts only to critical instances. For example, an alert is triggered if a nurse removes promethazine IV, which has a black box warning, from an ADC. The alert includes a statement reminding the nurse that promethazine must be mixed in no less than 10 cc of saline during IV administration. This warning requires the nurse to acknowledge that the drug is to be diluted in saline for IV push administration. Automated double-checks, placing bright-colored labels on all look-alike/sound-alike drugs sent from the pharmacy, and implementing new technology, such as central pharmacy carousels that only deliver the specific drug requested, are all effective, cautionary methods when stocking high-alert medications in ADCs.
Scanning Medications for Continual Compliance
Clearly, one of the great benefits of BCMA is that it allows multiple people and systems to track the fidelity of a medication order from start to finish. Pulling a drug from the central pharmacy carousel requires one scan of a drug’s bar code, and the carousel will only deliver that one drug. Another scan is required at the ADC when filling it, and a third scan of the drug bar code is required at the time of administration when that scan is compared to the scan of the patient’s bracelet to confirm the patient’s identity. The results of these activities—monthly and quarterly scanning compliance reports—are presented during our professional practice nursing council/medication safety team meetings by the PNL. This gives everyone a chance to review scanning rates and compliance for the facility, and also confirms that nurses are being held accountable for their scanning rates. As part of this review, we discovered that a key factor in nursing compliance with scanning lies in pharmacy’s ability to guarantee that no medications will leave their department until proper bar code scanning has been verified. Through this initiative, we have achieved 98.9% compliance in scanning medication bar codes at the bedside prior to administration.
The implementation of ADCs and the complete automation of the medication administration process were extremely successful in assisting with improved levels of patient safety at Bon Secours St. Francis. Assigning a specific person to bridge the gap between pharmacy and nursing during the build was a critical factor in our success, and key to ongoing innovations and process improvements. The PNL role gives both departments someone to go to who can assist with questions, issues, errors, communication, and process improvements. The collaboration of pharmacy and nursing was, and continues to be, an example of goal-directed teamwork, the purpose of which is to provide a safe, effective medication administration process for patients that is efficient for both nursing and pharmacy.
Aline Greene, BSN, MHA, RN, CEN, is a nursing supervisor at Bon Secours St. Francis Hospital in Charleston, South Carolina. She also has served as the pharmacy-nurse liaison since 2004. Aline received her BSN from the Medical University of South Carolina and her MHA from Independence University, California College for Health Sciences.
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