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J Nurs Care Qual Vol. 30, No. 4, pp. 345–351 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Improving Medication Administration Safety in a Community Hospital Setting Using Lean Methodology Sandy Critchley, MHS, BScPT, RPT, HBA (Kin) Virtually all health care organizations have goals of improving patient safety, but despite clear goals and considerable investments, gains have been limited. This article explores a community hospital’s resounding success using Lean methodology to improve medication administration safety with process changes designed by engaged employees and leaders with the knowledge and skill to effect improvements. This article inspires an interdisciplinary approach to quality improvement using reproducible strategies. Key words: Lean methodology, medication administration, medication safety, patient safety, quality improvement
T
HE World Health Organization emphasized that there is a 1 in 300 chance that a patient is harmed during a health care experience.1 The Canadian Patient Safety Institute was established to spearhead national patient safety initiatives in partnership with other organizations, leaders, and health care providers. Nationally and internationally, a great deal of attention has been devoted to medication error prevention and improving
Author Affiliation: Quality, Practice and Patient Services, Headwaters Health Care Centre, Orangeville, Ontario, Canada. A portion of the work described in this article was supported by a nursing education grant from RBC Royal Bank of Canada.
safe medication use. Accreditation Canada continues to refine medication management standards to improve safe medication use.2 Similarly, the Institute for Safe Medication Practices Canada advocates for implementation of quality improvement (QI) initiatives leading to safer medication administration processes.3 Another national study revealed that the second most common patient safety events in acute care hospitals are related to medications.4 The economics of improving patient safety are compelling. Additional hospitalization, litigation costs, lost income, disability, and medical expenses have cost some countries between US $6 billion and $29 billion annually.1 PURPOSE
The author declares no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Sandy Critchley, MHS, BScPT, RPT, HBA (Kin), Quality, Practice and Patient Services, Headwaters Health Care Centre, 100 Rolling Hills Dr, Orangeville, ON L9W 4X9, Canada (scritchley@ headwatershealth.ca). Accepted for publication: December 7, 2014 Published ahead of print: January 16, 2015 DOI: 10.1097/NCQ.0000000000000112
This article describes an improvement initiative focused on medication administration safety in a community hospital using Lean QI methodology. OPPORTUNITY FOR IMPROVEMENT Headwaters Health Care Centre (Headwaters) is an 87-bed community hospital in Ontario, Canada, serving a combination of 345
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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rural and urban areas with inpatient and outpatient services. Improving access to care, quality, and safety within an integrated system is a priority. Headwaters has demonstrated commitment to high-quality, safe, and accessible patient care and reduction of medication errors.5 While committed to the use of electronic medical records, Headwaters does not use computerized provider order entry; thus, patient orders are written on paper by providers. Commitment to patient safety is not new for Headwaters. In 2010, Headwaters launched its Safety and Quality Information System, a reporting system for patient and employee safety events.6 The tool enhanced the reporting culture within the organization and allowed for analysis of patient safety events compared with the historic paper-based reporting. The system was rooted in the World Health Organization’s International Classification for Patient Safety.7 The classification system revealed that the majority of patient safety reports were medication related or patient accidents (see Supplemental Digital Content, Figure, available at: http://links.lww. com/JNCQ/A168). When the prevalence of medication-related safety events was identified, an action plan was developed. Targeting improvement Once the decision to improve medication administration safety was made, target-setting processes ensued. Baseline data were compiled and revealed that 1.3 serious medicationrelated patient safety events occurred per 10 000 medication orders. Serious patient safety events refer to the degree of harm suffered by the patient and include any events in which the patient has a symptomatic outcome requiring life-saving intervention or major medical/surgical intervention, shortening life expectancy, or causing major permanent or long-term harm, loss of function, or even death.8 The commitment to decrease serious medication-related patient safety events by half within the year was made publicly available in a QI plan.9 Headwaters also received a
grant that was dedicated to the education of nurses about medication safety and involvement in improvement initiatives described in this article. METHODS FOR MEDICATION ADMINISTRATION SAFETY USING LEAN Quality improvement at Headwaters Headwaters has been on a QI journey for several years including participation in Ontario’s Ministry of Health and Long Term Care’s Emergency Department Process Improvement Program and an ongoing commitment to Lean methodology. Defining the stakeholders and opportunities with Lean tools Team selection and planning Key participants in a Medication Administration Safety Steering Committee (Steering Committee) were identified using a project team charter. The Steering Committee was cochaired by a Quality and Patient Safety leader and a professional practice coordinator. Members included the information systems manager, clinical coordinators, the pharmacy manager, and the program director, and senior leader sponsorship was provided by the vice president of patient services and chief nursing executive. The Steering Committee expanded on the team charter to define the purpose of the team in relation to strategic priorities, scope of the project, membership roles, and team operations. Recognizing the sense of urgency with patient safety concerns, the team met for 1 hour weekly. The Steering Committee established a Medication Administration Safety Task Force (Task Force) representing areas for preparing, distributing, and giving medications to meet on an ad hoc basis for frontline engagement in decision-making processes for improvement. To establish the key stakeholders for Task Force participation, the Steering Committee used a SIPOC. SIPOC is a diagram representing the scope of a project for understanding relationships between suppliers, inputs,
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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Improving Hospital Medication Administration Safety Using Lean Methodology processes, outputs, and customers.10 It delineates the beginning and end of the process to be explored for opportunities for improvement and then distinguishes the customers and suppliers of the materials or actions for those processes. The resultant Task Force included a pharmacist, a pharmacy technician, nurses from every area of the hospital, an infection prevention and control coordinator, and a ward clerk in addition to the members of the Steering Committee. The Task Force requested the presence of additional stakeholders including housekeeping, physical plant, and employees from the finance departments to join discussions when indicated. Identifying the opportunities The Task Force first met to engage in a value stream mapping (VSM) exercise to identify the opportunities for eliminating waste, improving flow, and limiting variability in the medication administration processes from when physicians wrote medication orders until the patient received the medication. Value stream mapping is a pictorial display of how materials and information flow through a system from beginning to end.11 The Task Force met for a full day to map the current state, idealized process, and a realistic future state. The day was cofacilitated by the Quality and Patient Safety leader and quality and professional practice coordinators, all of whom were Lean green belt trained. The Task Force used additional Lean tools to identify waste during the VSM exercise. The team created a spaghetti diagram to document the motion of staff members through the VSM. The employees drew bird’s-eye view maps of their workspaces and then drew lines representing paths of motion in the workspace during the sequence of process steps described in the VSM. This tool quantified the wasted motion in the current process. The Task Force also created a communication circle as a pictorial display of the number of times information exchanges occur between different stakeholders in a sequence of process events. The combination of these 3 visual Lean tools allowed Task Force members to effi-
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ciently and effectively focus on wastes such as time spent inspecting for or correcting errors, waiting for the next event to occur, unnecessary transportation of information and materials within a process, excess inventory in terms of storage, excessive motion of employees within the system, and work that is not valued by patients. The Task Force collectively identified wastes within the system and then framed the wastes as 13 opportunities for improvement. The opportunities for improvement were evaluated by the Task Force and placed on a grid according to the difficulty of implementation and the degree of impact. The opportunities were subsequently ranked from ease of implementation and heightened impact to difficulty of implementation and minimal impact. This ranking facilitated the Steering Committee’s focus on tackling the opportunities over the course of the next calendar year. High-impact/low-difficulty improvement interventions Human factors and medication administration safety education To optimize success and sustainability of medication administration improvements, the Steering Committee equipped the entirety of the Task Force with educational experiences designed to enhance comprehension of patient safety concepts such as human factors, teamwork and communication, and medication administration.12 The educational session was 4 hours in duration and occurred approximately 12 weeks after the VSM exercises. The Task Force was charged with developing new processes for safer medication administration; thus, the education grounded the team in patient safety literature specifically focused on medication administration, team communication, and interactions of humans with technology. Fortunately, Headwaters’ leadership team boasts a master facilitator with the Canadian Patient Safety Institute’s Patient Safety Education Program and was able to draw upon the facilitator’s knowledge, skills, and resources to transfer knowledge of
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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patient safety concepts to the Task Force without additional expense.
Standardizing pharmacy order entry processes
Chart flagging system
Once faxed orders were received in the pharmacy, the subsequent processes for order entry varied on the basis of the individuals on duty in the department and often involved batched workloads. Lean methodology respects that employees value the ability to use judgment to make decisions in their job, and variations in processes develop in an environment that not only permits variability but also avows that standardization represents a current best way to safely complete an activity with the proper outcome and highest quality.11 The pharmacy team worked collaboratively to develop standard operating procedures to follow and for use training new pharmacy staff members during orientation.
The easiest opportunity to implement was perceived to have the greatest impact on improving the current state. The Task Force introduced visual cues in the form of plasticized chart page dividers with 4 color-coded pull tabs designed to alert care providers to specific actions for patient care orders. The Steering Committee implemented the flagging system with a PDSA (plan-do-studyact) cycle. A unit was selected for the smallscale test of change where solutions were refined through a series of structured experiments. The Steering Committee planned for the introduction of the flagging system with multimodal communications, evaluation strategies including satisfaction of stakeholders, and monitoring patient safety events on the unit related to patient orders. The PDSA cycle went well, and the spread of the improvement throughout other patient care areas ensued in the following 2 months. The processes for patient order actions and the flag tool were standardized throughout the hospital with a standardized operating procedure for ease of redeployed staff. The change was welcomed; however, in retrospect, additional strategies to engage physicians in the change would have been beneficial. Synchronizing fax machine clocks Another easy change with significant impact was the synchronization of fax machine clocks in the hospital. Once patient care orders are written, they are faxed to the pharmacy for order entry. When a multitude of faxes are received in the pharmacy for 1 patient or for many patients and fax times are inaccurate, pharmacy staff are required to investigate the urgency of orders. The Information Services department visited each fax machine to ensure synchronicity. They committed to repeating this process following each quarterly planned system downtime for sustainability. The pharmacy staff members were satisfied with this change, reporting significantly less wasted time and motion.
Medication administration records to bedside Another variation in practice was inconsistent use of processes to ensure that the provider confirms the right patient, medication, time, route, and dose, otherwise known as the 5 rights of medication administration, within the organizational procedures.12,13 The Task Force participated in a root-cause analysis using a fishbone diagram to develop a visual cause and effect figure. The greatest contributing factor was that the paper medication administration record was not consistently taken to the patient’s bedside; thus, the rights could not be verified against documentation. This was largely attributed to the cultural perception that medication administration records were a mode of transmission for infectious diseases. This myth was dispelled by the infection prevention and control coordinator’s communications. Posters, e-mails, screen savers, internal newsletter articles, and messages for unit-based performance huddles were introduced. To reinforce the importance of verifying the 5 rights of medication administration through use of the medication administration record, observational audits of the process by unit leaders were introduced with the provision of individualized, immediate feedback for care providers.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JNCQ-D-14-00113
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Improving Hospital Medication Administration Safety Using Lean Methodology Evaluation methods Improvement initiatives result in intended and unintended consequences. Improving medication administration safety was intended to reduce the rate of serious medication events, but other evaluation methods assessed the impacts of the changes. The Task Force sought to evaluate staff and physician satisfaction with changes at various intervals before and after implementation through unstructured conversational techniques.14 In addition, auditing techniques previously described were used to measure intended impacts and sustainability of improvements. OUTCOMES, NEXT STEPS, AND IMPLICATIONS Outcomes Medication administration safety improvements were initiated in April 2012. Baseline data for serious medication events were 1.3 per 10 000 medication orders, and the Steering Committee sought to reduce it to 0.65 per
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10 000 medication orders for the remainder of the calendar year. The Figure represents the rate of serious medication events over the 10-month period. The team effectively decreased the serious medication event rate from 1.3 to 0.07 events per 10 000 medication orders, exceeding the target. Changes were implemented by September 2012, and thereafter, the run chart demonstrated the elimination of serious medication events. Results were better than expected. Staff and physician satisfaction reflected positively on changes implemented and communication strategies used. As feedback was obtained, it was acted upon. Next steps for Headwaters Headwaters’ improvements in medication administration are not complete. There are still 9 opportunities remaining from the VSM exercise. The Steering Committee is currently focused on several initiatives including exploring an intravenous admixture program, standardizing stock and location of automated dispensing units between patient care units,
1.4 Rate of Serious Medication Events per 10,000 Orders
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Improvements #1,2 & 3 1.2
1
0.8 Goal 0.6
0.4
Improvements #4 & 5
0.2
0
Month
Figure. Rate of serious medication events per 10 000 orders.
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decreasing interruptions for transcription and preparation of medications on patient care units, and evaluating and improving medication reconciliation processes. Interpretation and implications Improvement initiatives were inexpensive, were easy to implement, and had a significant impact. The Steering Committee believes that accomplishments were attributable to the engagement of staff members in the opportunity identification, solution implementation, and follow-up evaluation. The rate of turnover in the Steering Committee due to role transitions such as maternity leave and retirements was challenging, as considerable time was spent orienting new members. A major success was the sustainability with audits and standard operating procedures. These strategies ensured visibility of deviations to support ongoing learning and continuous QI and prevent reversion to old processes. Limitations Successes reaped in this QI initiative could be adapted for spread within other community hospitals, but factors limiting reproducibility require consideration. Use of patient safety reports for measurement of improvement is not scientific. Reporting cultures rely on recognition of safety events, user-friendly reporting processes, and a just culture characterized by encouraging
reporting and focusing on systems rather than blame.15-17 Rate of internal patient safety reporting remained steady since 2010. Perhaps, the Hawthorne effect was present because staff members were aware of measurement. In exceptional patient safety cultures, patients are involved in improvement initiatives. This initiative did not engage patients. If hospitals regularly engage patients in QI initiatives, this would represent entrenchment of patient-centered values. CONCLUSION Patient safety concerns remain a high priority, but competing interests in the new era of cost constraint in health care may lead to complacency in striving for improvements. This article described extraordinary outcomes to relatively simple improvement initiatives for medication administration safety that are attainable in other organizations. Key contributing factors leading to success were the degree of engagement of staff in identifying opportunities for improvement and implementing solutions to those opportunities using tools from Lean methodology. Patient safety improvements do not need to be complex or resource intensive but require staff engagement and leadership capacity to lead improvement. Spread of such improvement is imperative for system transformation to make care safer for patients of our health care system.
REFERENCES 1. World Health Organization. Ten facts on patient safety. http://www.who.int/features/factfiles/patient _safety/patient_safety_facts/en/index8.html. Accessed June 3, 2013. 2. Accreditation Canada. Qmentum program standards: Medication management. https://www3.accredi tation.ca/StandardsOnline/stdQmentum.aspx?Std= bnxt5eJx+rSlrZf4Hun4qgza+pynvyHilvD7mhb 5vqKHU0Ol1PzXvbqAaJg+gGR9JxZGk9Vaw/k=. Published February 2011. Accessed June 8, 2013. 3. Institute for Safe Medication Practices. Medication errors and risk management in hospitals. http:// www.ismp-canada.org/Riskmgm.htm. Accessed June 3, 2013.
4. Baker R, Norton P, Flintoft V, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-1686. 5. Headwaters Health Care Centre. 2013-2016 strategic plan. http://www.headwatershealth.ca/ uploads/About%20Us/HHCC%20Strategic%20Plan% 202013-2016%20FINAL%20.pdf. Accessed June 4, 2014. 6. Hospital Insurance Reciprocal of Canada. Hospital “better equipped to manage safety risks.” http:// www.hiroc.com/News-Media/News/Archived-Detail .aspx?ItemID=897. Published August 2011. Accessed June 4, 2013.
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Improving Hospital Medication Administration Safety Using Lean Methodology 7. World Health Organization. Conceptual framework for the International Classification for Patient Safety version 1.1. http://www.who.int/patientsafety/ taxonomy/icps full report.pdf. Published January 2009. Accessed June 6, 2013. 8. Canadian Patient Safety Institute. Canadian disclosure guidelines. http://www.patientsafetyinstitute.ca/ English/toolsResources/disclosure/Documents/QA% 20National%20Call%20for%20Draft.pdf. Accessed June 5 2013. 9. Headwaters Health Care Centre. Quality Improvement Plan 2012-2013. Orangeville, ON, Canada: Headwaters Health Care Centre. 10. Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York, NY: CRC Press; 2009. 11. KPMG. Lean Healthcare Green Belt Training September 2011. Toronto, ON, Canada: KPMG; 2010. 12. Manias E, Williams A, Liew D. Interventions to reduce medication errors in adult intensive care: a systematic review. Br J Clin Pharmacol. 2012;74(3): 411-423.
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13. Institute for Healthcare Improvement. The five rights of medication administration. http://www .ihi.org/knowledge/Pages/ImprovementStories/ FiveRightsofMedicationAdministration.aspx. Accessed June 9, 2013. 14. Keers R, Williams S, Cooke J, Ashcroft D. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(11):10451067. 15. Manias E. Detection of medication-related problems in a hospital practice: a review. Br J Clin Pharmacol. 2013:76(1):7-20. 16. Louie K, Wilmer A, Wong H, Grubisic M, Ayas N, Dodek P. Medication error reporting systems: a survey of Canadian intensive care units. Can J Hosp Pharm. 2010;63(1):20-24. 17. Institute for Healthcare Improvement. Number of self-reported medication errors. http://www.ihi. org/knowledge/Pages/Measures/NumberofSelfRep ortedMedicationErrors.aspx. Published April 2011. Accessed June 5, 2013.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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August 8, 2015
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J Nurs Care Qual Vol. 30, No. 4, pp. 345–351 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Improving Medication Administration Safety in a Community Hospital Setting Using Lean Methodology Sandy Critchley, MHS, BScPT, RPT, HBA (Kin) Virtually all health care organizations have goals of improving patient safety, but despite clear goals and considerable investments, gains have been limited. This article explores a community hospital’s resounding success using Lean methodology to improve medication administration safety with process changes designed by engaged employees and leaders with the knowledge and skill to effect improvements. This article inspires an interdisciplinary approach to quality improvement using reproducible strategies. Key words: Lean methodology, medication administration, medication safety, patient safety, quality improvement
T
HE World Health Organization emphasized that there is a 1 in 300 chance that a patient is harmed during a health care experience.1 The Canadian Patient Safety Institute was established to spearhead national patient safety initiatives in partnership with other organizations, leaders, and health care providers. Nationally and internationally, a great deal of attention has been devoted to medication error prevention and improving
Author Affiliation: Quality, Practice and Patient Services, Headwaters Health Care Centre, Orangeville, Ontario, Canada. A portion of the work described in this article was supported by a nursing education grant from RBC Royal Bank of Canada.
safe medication use. Accreditation Canada continues to refine medication management standards to improve safe medication use.2 Similarly, the Institute for Safe Medication Practices Canada advocates for implementation of quality improvement (QI) initiatives leading to safer medication administration processes.3 Another national study revealed that the second most common patient safety events in acute care hospitals are related to medications.4 The economics of improving patient safety are compelling. Additional hospitalization, litigation costs, lost income, disability, and medical expenses have cost some countries between US $6 billion and $29 billion annually.1 PURPOSE
The author declares no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Sandy Critchley, MHS, BScPT, RPT, HBA (Kin), Quality, Practice and Patient Services, Headwaters Health Care Centre, 100 Rolling Hills Dr, Orangeville, ON L9W 4X9, Canada (scritchley@ headwatershealth.ca). Accepted for publication: December 7, 2014 Published ahead of print: January 16, 2015 DOI: 10.1097/NCQ.0000000000000112
This article describes an improvement initiative focused on medication administration safety in a community hospital using Lean QI methodology. OPPORTUNITY FOR IMPROVEMENT Headwaters Health Care Centre (Headwaters) is an 87-bed community hospital in Ontario, Canada, serving a combination of 345
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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rural and urban areas with inpatient and outpatient services. Improving access to care, quality, and safety within an integrated system is a priority. Headwaters has demonstrated commitment to high-quality, safe, and accessible patient care and reduction of medication errors.5 While committed to the use of electronic medical records, Headwaters does not use computerized provider order entry; thus, patient orders are written on paper by providers. Commitment to patient safety is not new for Headwaters. In 2010, Headwaters launched its Safety and Quality Information System, a reporting system for patient and employee safety events.6 The tool enhanced the reporting culture within the organization and allowed for analysis of patient safety events compared with the historic paper-based reporting. The system was rooted in the World Health Organization’s International Classification for Patient Safety.7 The classification system revealed that the majority of patient safety reports were medication related or patient accidents (see Supplemental Digital Content, Figure, available at: http://links.lww. com/JNCQ/A168). When the prevalence of medication-related safety events was identified, an action plan was developed. Targeting improvement Once the decision to improve medication administration safety was made, target-setting processes ensued. Baseline data were compiled and revealed that 1.3 serious medicationrelated patient safety events occurred per 10 000 medication orders. Serious patient safety events refer to the degree of harm suffered by the patient and include any events in which the patient has a symptomatic outcome requiring life-saving intervention or major medical/surgical intervention, shortening life expectancy, or causing major permanent or long-term harm, loss of function, or even death.8 The commitment to decrease serious medication-related patient safety events by half within the year was made publicly available in a QI plan.9 Headwaters also received a
grant that was dedicated to the education of nurses about medication safety and involvement in improvement initiatives described in this article. METHODS FOR MEDICATION ADMINISTRATION SAFETY USING LEAN Quality improvement at Headwaters Headwaters has been on a QI journey for several years including participation in Ontario’s Ministry of Health and Long Term Care’s Emergency Department Process Improvement Program and an ongoing commitment to Lean methodology. Defining the stakeholders and opportunities with Lean tools Team selection and planning Key participants in a Medication Administration Safety Steering Committee (Steering Committee) were identified using a project team charter. The Steering Committee was cochaired by a Quality and Patient Safety leader and a professional practice coordinator. Members included the information systems manager, clinical coordinators, the pharmacy manager, and the program director, and senior leader sponsorship was provided by the vice president of patient services and chief nursing executive. The Steering Committee expanded on the team charter to define the purpose of the team in relation to strategic priorities, scope of the project, membership roles, and team operations. Recognizing the sense of urgency with patient safety concerns, the team met for 1 hour weekly. The Steering Committee established a Medication Administration Safety Task Force (Task Force) representing areas for preparing, distributing, and giving medications to meet on an ad hoc basis for frontline engagement in decision-making processes for improvement. To establish the key stakeholders for Task Force participation, the Steering Committee used a SIPOC. SIPOC is a diagram representing the scope of a project for understanding relationships between suppliers, inputs,
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00113
August 8, 2015
17:51
Improving Hospital Medication Administration Safety Using Lean Methodology processes, outputs, and customers.10 It delineates the beginning and end of the process to be explored for opportunities for improvement and then distinguishes the customers and suppliers of the materials or actions for those processes. The resultant Task Force included a pharmacist, a pharmacy technician, nurses from every area of the hospital, an infection prevention and control coordinator, and a ward clerk in addition to the members of the Steering Committee. The Task Force requested the presence of additional stakeholders including housekeeping, physical plant, and employees from the finance departments to join discussions when indicated. Identifying the opportunities The Task Force first met to engage in a value stream mapping (VSM) exercise to identify the opportunities for eliminating waste, improving flow, and limiting variability in the medication administration processes from when physicians wrote medication orders until the patient received the medication. Value stream mapping is a pictorial display of how materials and information flow through a system from beginning to end.11 The Task Force met for a full day to map the current state, idealized process, and a realistic future state. The day was cofacilitated by the Quality and Patient Safety leader and quality and professional practice coordinators, all of whom were Lean green belt trained. The Task Force used additional Lean tools to identify waste during the VSM exercise. The team created a spaghetti diagram to document the motion of staff members through the VSM. The employees drew bird’s-eye view maps of their workspaces and then drew lines representing paths of motion in the workspace during the sequence of process steps described in the VSM. This tool quantified the wasted motion in the current process. The Task Force also created a communication circle as a pictorial display of the number of times information exchanges occur between different stakeholders in a sequence of process events. The combination of these 3 visual Lean tools allowed Task Force members to effi-
347
ciently and effectively focus on wastes such as time spent inspecting for or correcting errors, waiting for the next event to occur, unnecessary transportation of information and materials within a process, excess inventory in terms of storage, excessive motion of employees within the system, and work that is not valued by patients. The Task Force collectively identified wastes within the system and then framed the wastes as 13 opportunities for improvement. The opportunities for improvement were evaluated by the Task Force and placed on a grid according to the difficulty of implementation and the degree of impact. The opportunities were subsequently ranked from ease of implementation and heightened impact to difficulty of implementation and minimal impact. This ranking facilitated the Steering Committee’s focus on tackling the opportunities over the course of the next calendar year. High-impact/low-difficulty improvement interventions Human factors and medication administration safety education To optimize success and sustainability of medication administration improvements, the Steering Committee equipped the entirety of the Task Force with educational experiences designed to enhance comprehension of patient safety concepts such as human factors, teamwork and communication, and medication administration.12 The educational session was 4 hours in duration and occurred approximately 12 weeks after the VSM exercises. The Task Force was charged with developing new processes for safer medication administration; thus, the education grounded the team in patient safety literature specifically focused on medication administration, team communication, and interactions of humans with technology. Fortunately, Headwaters’ leadership team boasts a master facilitator with the Canadian Patient Safety Institute’s Patient Safety Education Program and was able to draw upon the facilitator’s knowledge, skills, and resources to transfer knowledge of
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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patient safety concepts to the Task Force without additional expense.
Standardizing pharmacy order entry processes
Chart flagging system
Once faxed orders were received in the pharmacy, the subsequent processes for order entry varied on the basis of the individuals on duty in the department and often involved batched workloads. Lean methodology respects that employees value the ability to use judgment to make decisions in their job, and variations in processes develop in an environment that not only permits variability but also avows that standardization represents a current best way to safely complete an activity with the proper outcome and highest quality.11 The pharmacy team worked collaboratively to develop standard operating procedures to follow and for use training new pharmacy staff members during orientation.
The easiest opportunity to implement was perceived to have the greatest impact on improving the current state. The Task Force introduced visual cues in the form of plasticized chart page dividers with 4 color-coded pull tabs designed to alert care providers to specific actions for patient care orders. The Steering Committee implemented the flagging system with a PDSA (plan-do-studyact) cycle. A unit was selected for the smallscale test of change where solutions were refined through a series of structured experiments. The Steering Committee planned for the introduction of the flagging system with multimodal communications, evaluation strategies including satisfaction of stakeholders, and monitoring patient safety events on the unit related to patient orders. The PDSA cycle went well, and the spread of the improvement throughout other patient care areas ensued in the following 2 months. The processes for patient order actions and the flag tool were standardized throughout the hospital with a standardized operating procedure for ease of redeployed staff. The change was welcomed; however, in retrospect, additional strategies to engage physicians in the change would have been beneficial. Synchronizing fax machine clocks Another easy change with significant impact was the synchronization of fax machine clocks in the hospital. Once patient care orders are written, they are faxed to the pharmacy for order entry. When a multitude of faxes are received in the pharmacy for 1 patient or for many patients and fax times are inaccurate, pharmacy staff are required to investigate the urgency of orders. The Information Services department visited each fax machine to ensure synchronicity. They committed to repeating this process following each quarterly planned system downtime for sustainability. The pharmacy staff members were satisfied with this change, reporting significantly less wasted time and motion.
Medication administration records to bedside Another variation in practice was inconsistent use of processes to ensure that the provider confirms the right patient, medication, time, route, and dose, otherwise known as the 5 rights of medication administration, within the organizational procedures.12,13 The Task Force participated in a root-cause analysis using a fishbone diagram to develop a visual cause and effect figure. The greatest contributing factor was that the paper medication administration record was not consistently taken to the patient’s bedside; thus, the rights could not be verified against documentation. This was largely attributed to the cultural perception that medication administration records were a mode of transmission for infectious diseases. This myth was dispelled by the infection prevention and control coordinator’s communications. Posters, e-mails, screen savers, internal newsletter articles, and messages for unit-based performance huddles were introduced. To reinforce the importance of verifying the 5 rights of medication administration through use of the medication administration record, observational audits of the process by unit leaders were introduced with the provision of individualized, immediate feedback for care providers.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JNCQ-D-14-00113
August 8, 2015
17:51
Improving Hospital Medication Administration Safety Using Lean Methodology Evaluation methods Improvement initiatives result in intended and unintended consequences. Improving medication administration safety was intended to reduce the rate of serious medication events, but other evaluation methods assessed the impacts of the changes. The Task Force sought to evaluate staff and physician satisfaction with changes at various intervals before and after implementation through unstructured conversational techniques.14 In addition, auditing techniques previously described were used to measure intended impacts and sustainability of improvements. OUTCOMES, NEXT STEPS, AND IMPLICATIONS Outcomes Medication administration safety improvements were initiated in April 2012. Baseline data for serious medication events were 1.3 per 10 000 medication orders, and the Steering Committee sought to reduce it to 0.65 per
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10 000 medication orders for the remainder of the calendar year. The Figure represents the rate of serious medication events over the 10-month period. The team effectively decreased the serious medication event rate from 1.3 to 0.07 events per 10 000 medication orders, exceeding the target. Changes were implemented by September 2012, and thereafter, the run chart demonstrated the elimination of serious medication events. Results were better than expected. Staff and physician satisfaction reflected positively on changes implemented and communication strategies used. As feedback was obtained, it was acted upon. Next steps for Headwaters Headwaters’ improvements in medication administration are not complete. There are still 9 opportunities remaining from the VSM exercise. The Steering Committee is currently focused on several initiatives including exploring an intravenous admixture program, standardizing stock and location of automated dispensing units between patient care units,
1.4 Rate of Serious Medication Events per 10,000 Orders
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Figure. Rate of serious medication events per 10 000 orders.
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decreasing interruptions for transcription and preparation of medications on patient care units, and evaluating and improving medication reconciliation processes. Interpretation and implications Improvement initiatives were inexpensive, were easy to implement, and had a significant impact. The Steering Committee believes that accomplishments were attributable to the engagement of staff members in the opportunity identification, solution implementation, and follow-up evaluation. The rate of turnover in the Steering Committee due to role transitions such as maternity leave and retirements was challenging, as considerable time was spent orienting new members. A major success was the sustainability with audits and standard operating procedures. These strategies ensured visibility of deviations to support ongoing learning and continuous QI and prevent reversion to old processes. Limitations Successes reaped in this QI initiative could be adapted for spread within other community hospitals, but factors limiting reproducibility require consideration. Use of patient safety reports for measurement of improvement is not scientific. Reporting cultures rely on recognition of safety events, user-friendly reporting processes, and a just culture characterized by encouraging
reporting and focusing on systems rather than blame.15-17 Rate of internal patient safety reporting remained steady since 2010. Perhaps, the Hawthorne effect was present because staff members were aware of measurement. In exceptional patient safety cultures, patients are involved in improvement initiatives. This initiative did not engage patients. If hospitals regularly engage patients in QI initiatives, this would represent entrenchment of patient-centered values. CONCLUSION Patient safety concerns remain a high priority, but competing interests in the new era of cost constraint in health care may lead to complacency in striving for improvements. This article described extraordinary outcomes to relatively simple improvement initiatives for medication administration safety that are attainable in other organizations. Key contributing factors leading to success were the degree of engagement of staff in identifying opportunities for improvement and implementing solutions to those opportunities using tools from Lean methodology. Patient safety improvements do not need to be complex or resource intensive but require staff engagement and leadership capacity to lead improvement. Spread of such improvement is imperative for system transformation to make care safer for patients of our health care system.
REFERENCES 1. World Health Organization. Ten facts on patient safety. http://www.who.int/features/factfiles/patient _safety/patient_safety_facts/en/index8.html. Accessed June 3, 2013. 2. Accreditation Canada. Qmentum program standards: Medication management. https://www3.accredi tation.ca/StandardsOnline/stdQmentum.aspx?Std= bnxt5eJx+rSlrZf4Hun4qgza+pynvyHilvD7mhb 5vqKHU0Ol1PzXvbqAaJg+gGR9JxZGk9Vaw/k=. Published February 2011. Accessed June 8, 2013. 3. Institute for Safe Medication Practices. Medication errors and risk management in hospitals. http:// www.ismp-canada.org/Riskmgm.htm. Accessed June 3, 2013.
4. Baker R, Norton P, Flintoft V, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-1686. 5. Headwaters Health Care Centre. 2013-2016 strategic plan. http://www.headwatershealth.ca/ uploads/About%20Us/HHCC%20Strategic%20Plan% 202013-2016%20FINAL%20.pdf. Accessed June 4, 2014. 6. Hospital Insurance Reciprocal of Canada. Hospital “better equipped to manage safety risks.” http:// www.hiroc.com/News-Media/News/Archived-Detail .aspx?ItemID=897. Published August 2011. Accessed June 4, 2013.
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Improving Hospital Medication Administration Safety Using Lean Methodology 7. World Health Organization. Conceptual framework for the International Classification for Patient Safety version 1.1. http://www.who.int/patientsafety/ taxonomy/icps full report.pdf. Published January 2009. Accessed June 6, 2013. 8. Canadian Patient Safety Institute. Canadian disclosure guidelines. http://www.patientsafetyinstitute.ca/ English/toolsResources/disclosure/Documents/QA% 20National%20Call%20for%20Draft.pdf. Accessed June 5 2013. 9. Headwaters Health Care Centre. Quality Improvement Plan 2012-2013. Orangeville, ON, Canada: Headwaters Health Care Centre. 10. Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York, NY: CRC Press; 2009. 11. KPMG. Lean Healthcare Green Belt Training September 2011. Toronto, ON, Canada: KPMG; 2010. 12. Manias E, Williams A, Liew D. Interventions to reduce medication errors in adult intensive care: a systematic review. Br J Clin Pharmacol. 2012;74(3): 411-423.
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13. Institute for Healthcare Improvement. The five rights of medication administration. http://www .ihi.org/knowledge/Pages/ImprovementStories/ FiveRightsofMedicationAdministration.aspx. Accessed June 9, 2013. 14. Keers R, Williams S, Cooke J, Ashcroft D. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(11):10451067. 15. Manias E. Detection of medication-related problems in a hospital practice: a review. Br J Clin Pharmacol. 2013:76(1):7-20. 16. Louie K, Wilmer A, Wong H, Grubisic M, Ayas N, Dodek P. Medication error reporting systems: a survey of Canadian intensive care units. Can J Hosp Pharm. 2010;63(1):20-24. 17. Institute for Healthcare Improvement. Number of self-reported medication errors. http://www.ihi. org/knowledge/Pages/Measures/NumberofSelfRep ortedMedicationErrors.aspx. Published April 2011. Accessed June 5, 2013.
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