2014 Minnesota Hospital Association Awards Call for Entries
Category: Small hospital patient safety improvement
In 2013 the Owatonna hospital pharmacy was asked to find a way to make medication distribution safer. The goal was to find a project that would involve the entire hospital and have a true impact on patient safety.
Since the hospital had gone to bedside bar coding (BBC) in 2012 data from the BBC near miss reports and from Patient Visitor Safety reports (PVSR) was used to help determine the goal. The data was analyzed to determine common themes. One theme that emerged was medication errors and near misses were occurring as a result from nursing removing medications from automated dispensing cabinets (ADC’s) before pharmacy has verified the order. Nursing was picking the incorrect medication from the list of all medications in the ADC. When pharmacy verifies the order the ADC will only allow nursing to choose the correct product. When nursing removes the product without waiting for pharmacy it is known as an override.
The data was showing medications were being removed on override as a matter of convenience and the importance of the ADM’s was not being seen by nursing. The culture around overrides had shifted so much that staff was even removing medications on override during pharmacy hours. It was clear that the focus should be to reduce overrides from the automated dispensing cabinets. The reason was that by overriding a medication all of the safety processes in place around medications were now unable to be used.
The override rate at Owatonna hospital was measured at about 5.4% and the goal was set to reduce this by 25% in the 2013. The first phase of the project was to share the override reports with department managers and nursing staff. Medications with the highest amount of overrides were identified and staff was asked to help review the process that led to the override. The approach used was one of collaboration and learning. This allowed for open dialog from all hospital departments with pharmacy around why medications were being overridden.
It quickly became clear that were a number of processes around obtaining medications that were not efficient and these inefficiencies were resulting in overrides. In turn the frequent overrides were leading to nursing departments to see overrides as the norm rather than an exception. The culture around medication distribution had become cavalier. This feedback from nursing in addition to the PVSR summaries pointed out which process around medication distribution needed to change.
Over the course of the next twelve months pharmacy worked with multiple departments to improve processes around removing medications from the ADC’s. Hospital leadership helped support the project through a series of communications and development of unit scorecards.
The results were nothing short of amazing. Overrides went from 5.4% to 2.4% by the end of the year. Every process improvement allowed nursing to spend more time with patients or corrected a patient safety issue related to overrides. This collaborative culture has continued into 2014.