Methodology: To successfully complete this project we used value-stream mapping
in conjunction with root-cause analysis, process improvement, and
the PDCA cycle.
Current Knowledge of Task: Root-cause analysis revealed that a lack of communication
and understanding between the Nursing and Pharmacy
departments seemed to cause most of the problems. To
correct the problem we observed and then mapped out the
current process.
We also:
- Looked at our current medication error rates and the
most common reasons and times that errors occurred.
- Interviewed Licensed nursing staff to ask when and how
they reorder medications to check for patterns and
consistency & interviewed pharmacy staff to check for
consistent issues on their end.
Best practices came from utilizing the knowledge of our
consultant pharmacist and Omnicare representatives.
Resources Used:
1. Aging Services of MN: Recommendations on Best
Practices to Prevent Drug Diversion
2. The Lewin Group: CMS Review of Current Standards of
Practice for Long-Term Care Pharmacy Services
3. DEA Narcotic regulations & recommendations
4. MN Board of Pharmacy recommendations
5. CMS & Federal/State Pharmacy & Medication
Regulations
6. ATTAX & AE Antipsychotic Medication Resources
Problem: It became apparent that our medication ordering process
as well as some other facets of the pharmacy-nursing
system had major gaps such as:
- Lack of Pharmacy policies
- Inconsistent ordering practices
- Little understanding of the pharmacies process
These process errors led to a gap in communication
between the two departments which ultimately led to high
stress & the opportunity for medication errors.
RN orders meds on floor Resident by resident 1.pull resident meds out 2.Med by med—put dose in cup 3.Count remaining pills -should be enough to get through next order day 4. check remaining meds 5. if refill is needed - pull label - Attach to sheet - Sheet -> bucket If label not pulled until later, sheet taken down separately (time?)
Rx “Hold” sheet returned 1. Collect “Hold” sheet from Dr. box 2. Scan in hold sheet 3. enter in computer that “hold” sheet is completed & returned 4. When refill comes up it will be ready
Summary of Success: This project became larger and more complicated as we peeled
back the layers of what all fed in to the Pharmacy and
Medication Ordering process.
Accomplishments:
- Increased quality improvement focus on pharmacy for the first
time at Saint Therese.
- 14 Policies identified as needing to be updated or created
- New Medication Error form & excel tracking system created
- Tighter auditing process implemented – consultant
pharmacist forms now show greater detail directly related to
factors tracked for F329. – *See results in graph
Barriers:
- Inadequate staffing within the Pharmacy led to difficulties in
staff time to attend weekly meetings.
- Industry changes took priority over this project causing delays
in starting this project
Calls coming in STAT orders—(10-15 every AM) Checking on orders - tab pulled & their not sure when - making sure they are ordered to come up *Staff has to go into computer and look up resident—check date of last fill, other reasons for new refill request — RN then comes down to collect refill to be told they can’t be filled/are already on the floor [All in Pharmacy Answer] Fill orders that were entered or called in
1. fill STAT calls first 2. 1W & 3rd floor requested earlier pickup times 3. Pull med/fill based on what computer says 4. Attach label securely 5. Put in correct bucket [Tech 1 Starts, Tech 2 helps after finishing label input]
Narcotic Orders 1. Label number is entered separately [RED] highlighted order means they are on hold - sheet was sent to Dr. to authorize refill 3. take off hold -> push through to refill 4. print new authorization hold sheet for Dr. to sign 5. Write “Hold” on it 6. put in Dr. box to get signed
Recommendations: 1. Continue to audit orders coming off the floor and number of
calls going to pharmacy for stat/inaccurate refill requests.
2. Educate nursing staff on new medication error form & tracking
system and on causes of common errors. Educate both nursing
and pharmacy on new medication order/fill process.
3. Update nursing orientation to ensure correct ordering system
is understood.
Surveyor Recommendations:
1. Ensure pharmacy does not put labels over expiration date on
bottles
2. Look into smeared labels – possibly from chemical reaction of
using hand sanitizer or lotion before touching label
By 4pm Buckets picked up by floor RN
1. RN initials med list to verify that they are all in the bucket 2. Takes basket to floor and puts meds in carts *Med list remains in bucket, goes back to Pharm, is saved for *3mo. No separate accountability for Narcotics? Pharmacy—Residence
Medication Order & Fill Initial Process Map
Acknowledgements: Sandra Delgehausen – QI ADON
Barb Hanle – RCC Project Director
Stacy Lind – Campus Clinical Director
Karen Vetter – Education Coordinator
Dr. Joe Sicora – Medical Director
Denise Johnson – Pharmacist Consultant
Al Brosseau – Pharmacist
Saint Therese Pharmacy Staff
Saint Therese Nurses
Processing Exceptions: 1. Refill too soon/on hold—includes date of last order & date new order can be filled 2. Prior authorization—needed from insurance or physician before med can be filled 3. Med out of Stock—can usually get following business day. If not, ordered from Omnicare
Medicare Refills—10 days Private Pay Refills—3 days
By 8/8:15am Tech enters label numbers into
computer @ Pharmacy [Tech 1. If any left @ 8 -> Tech 2] Pharmacy— Residence
7:30am Med Tech picks up buckets
- asks if there are any changes/updates [Tech 1]
8 total 1st, 2nd, 3rd floors of Care Center
Time Whom
Location
Pharmacy also fills for: - Residence - Oxbow - 2 outside facilities
6/20/13
Steps 1 & 2
•Create Pharmacy Adhoc QI Committee & hold preliminary meeting to do root-cause analysis to decide what would be included in this project
•Schedule weekly 30 minute meetings to work through action plan and policies
Steps 3 & 4
•Observe & document our current order and fill process in the form of a process map
•Policy development – update nursing/pharmacy policies and create pharmacy specific policies
Steps 5 & 6
•Review & update medication error forms and create & implement new medication error tracking system
•Review pharmacy consultant forms & developed internal auditing tools
Steps 7 & 8
•Review & update RSO & Ekit list and policies
•Adopt Aging Services Narcotic Diversion Plan
Steps 9 & 10
•Educate Pharmacy & Nursing staff on updated processes and policies
•Complete PDCA cycle by auditing for effectiveness
0
2
4
6
8
10
12
2013 Baseline Q4 2013
10.29 9.31
4.66
1.81
Prevalence of Antipsychotic Meds without a Dx*
MN Risk
Adjusted
State
Average
MN Risk
Adjusted
Facility
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