Medication safety program focuses on pharmacy-led training of workers
Program even helps gift shop volunteers
There was a "Wow!" moment during a new medication safety education program at a Florida hospital when central materials staff reported they didn't handle any drugs.
An intern at the University Community Hospital in Tampa, FL, was helping the pharmacy director assess the medication knowledge of various, non-licensed hospital workers. But when she asked the central materials workers which drugs they handled, they were bewildered by the question.
"They didn't realize the kits in different parts of the hospital had drugs in them," says Kathleen A. Moorman, BS, PharmD, CPh, director of pharmaceutical services at University Community Hospital. Moorman also is the chair of the hospital's medication management committee.
"They didn't realize the IV solutions, dialysis solutions, and Betadine® were drugs and the contrast media were drugs," Moorman says. "So this was a great opportunity to educate them."
These workers knew what they were supposed to do when handling the solutions, but they didn't know why they had to put certain items in the refrigerator or in secured locations, for instance.
"When we educated them about why they had to put the drugs in a secure environment, they said, 'Wow! We never understood why,'" Moorman says. "How do you handle something if you don't even know what the product is?"
Moorman volunteered to improve the hospital's medication safety through an assessment and education project that she undertook with help from an intern.
"I was so intrigued by Kathy's passion for patient safety," says Ranu Sai, MHA, the former intern who assisted Moorman.
"During the course of this project we discovered surprising factors in the way medications are handled," Sai says.
"We conducted interviews with nine different staff categories, and based on those interviews we figured out their level of handling medication, and we made special competencies for them about medication handling," Sai explains.
Employees were tested on their medication knowledge, provided education, and then were tested again.
"Since this was a simple competency measurement test, we decided that 95% was a passing score," Sai says.
The education program was structured on a Pareto analysis in which all possible sources of medication errors were identified.
"We looked at which specialty or job classification could be responsible for these errors, such as storing medication incorrectly or delivering a drug to the wrong location or billing the wrong patient," Moorman says.
"When we analyzed medication safety in the hospital, we realized a lot of people that we hadn't thought of before were touching medications," she adds.
After digging further, they learned that many people came into contact with hospital medications.
"We found no medication errors related to this, but when we drilled down the information we realized there were transporters, volunteers, anesthesiology techs, etc., handling medications."
Education tailored to responsibilities
Moorman and Sai determined which medications various staff handled and what were their education deficits through a thorough process of spending time in each department, asking staff questions.
"We sat down with them for a couple of hours on a couple of different instances, and then Ranu would shadow them for a day," Moorman adds.
Sai took notes as she followed the staff around.
"This was a learning process for me, also, because I do not have a clinical background," Sai says. "So a lot of times I would observe things, but I didn't know if they were following the correct practice."
When Sai and Moorman discussed Sai's notes and observations, Moorman would explain what the proper medication safety procedures were, and Sai soon learned to watch for these practices.
"As I got better at this, it was easier to observe the technicians," Sai says.
Moorman also would walk around the hospital and visit various areas to observe their routine.
"I'd ask them how the pharmacy was doing and what their challenges were," Moorman says. "I'd ask, 'How can we make your life easier?'"
The biggest problem she found was that the staff in the central materials area had never received an inservice by the pharmacy services staff, Moorman says.
Teaching departments to do inservices
"I didn't realize there was a knowledge gap," Moorman says. "You can have the best policies, but if people don't know what they are, they're not worth anything."
So she started the educational program by teaching professionals in each department how to do their own medication inservices.
"We taught a woman in radiology to do the radiology inservices; we taught people in surgery to do the surgery inservices," Moorman says.
"One thing we talked about when working with them is how to prevent medication errors or events and how drugs can look alike," she explains. "They need to look at the brand and expiration date."
The education process also helped to identify changes that could be made to improve medication safety.
For instance, surgery technicians asked Moorman if certain medications could be changed because they looked so much alike, Moorman recalls.
"They asked if we could buy a different brand because two different drugs looked alike," she adds. "We moved some medications around so it would be easier for surgery staff to grab what they needed and to keep the drugs separate."
When Moorman speaks with hospital staff she typically tells them to ask questions about anything they find confusing.
"You get great ideas from the staff — they're the best source of how to improve medication safety," Moorman says.
The typical education session involves a 15-minute inservice, a quiz, and a feedback session, with handouts and examples of the medication products.
"We took photos of the products that showed the labels and expiration dates and safety warnings about things like storing with refrigeration," Moorman says.
When educating the hospital's leadership and other pharmacy directors, Moorman used a PowerPoint presentation. The sessions were interactive and hands-on at times.
"We'd say, 'Show us an example of tall man lettering," Moorman says. "We explained that if two products look alike or sound alike, then you put certain letters in capitals on the label and other letters small, so people can distinguish between new products."
The visual aids helped people understand, she adds.
The inservices were held in all of the health system hospitals and included even unit secretaries and volunteers.
"Volunteers hardly ever handle medications," Moorman says, "But as we worked through the process we realized that we have medications in the gift shop, and so we needed to make sure volunteers are competent to look at expiration dates."
With volunteers, Moorman gave them drug labels and asked them to describe what the room label and medication were.
"They enjoyed that because they now had the room number and name of patient and could go to the nurse and say, 'This is for so and so,' and the nurse was able to assist them," Moorman says.
After the volunteers received the medication education, some people expressed surprise that medications had expiration dates, Moorman notes.
"Everyone who took the competency test after the inservices did well," Moorman says. "Everyone scored over 95%."
There have been no medication errors reported, either before or after the training, but there were a few near misses, which suggested that hospital staff had taken to heart their education on medication training, Moorman says.
"They were looking for ways to improve safety," she says.
Another indication that the inservices have helped improve medication safety and quality assurance is that shortly after the educational sessions, the hospital had a surprise visit by the Joint Commission on Accreditation for Hospital Organizations, and the hospital was not cited on the standard regarding medication safety, Moorman says.
The education project probably took about 400 to 500 hours to prepare and conduct initially, Moorman says.
"I was lucky to have a student who did a lot of this," she says.
The project has grown and now is a part of orientation and annual on-line education for hospital employees, Moorman notes.
"I walk around and make sure everyone is doing well, and the pre- and post-tests are available in each department," she adds. "And we monitor for near misses and medication events to make sure [no errors] happen."
There was a "Wow!" moment during a new medication safety education program at a Florida hospital when central materials staff reported they didn't handle any drugs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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