South Carolina hospital cuts 'rate of harm'
In the wake of the Institute of Medicine report on medication errors, Florence, South Carolina's McLeod Regional Medical Center initiated a series of steps to improve patient safety and reduce the hospital's "rate of harm." McLeod director of pharmacy services Natasha Nicol and associate vice president of nursing Leanne Huminski described their success for Modern Healthcare.
They said the hospital turned to a "significant top-to-bottom culture change" to bring about a reduction in the rate of harm from 3.5 per 1,000 doses to less than one per 1,000 doses. In the process, they also have cut the number of steps in filling medication orders from 17 to five, and the time it takes to deliver a drug to the bedside from 90 minutes to less than 20.
The hospital's three key areas of focus were culture, automation, and process, Nicol and Huminski said. The goal of the culture change was to create a sense of urgency regarding medication practices that lead to harm, and to engage employees to create a safer environment for themselves and patients. Another fundamental culture shift was to attempt to remove the shadow of blame, which Nicol and Huminski believe inhibits progress toward improving medication error rates. One of the first steps in changing perspective was to rename the Adverse Drug Events Committee the Medication Safety Committee, which had as its vision to "be safe for every patient, every time, while making it easier for caregivers to do the right thing and impossible to do the wrong thing."
McLeod received a Pursuing Perfection grant from the Robert Wood Johnson Foundation and was helped by medication safety experts at the Institute for Healthcare Improvement in developing a four-year medication safety strategic plan that includes the nation's documented best practices in preventing adverse drug events.
Process and automation changes first required a thorough review of what processes were in place and why. The authors say McLeod's existing pharmacy system was not able to accommodate the sheer number of available medications and the new types of drugs, along with restrictive storing conditions and the often immediate need for pharmaceuticals in patients' rooms. Technology acquisition focused on four core areas — automated drug dispensing, bar coding, computerized physician order entry, and medication reconciliation.
Cutting steps through automation
The team leaders say automatic drug dispensing was critical to reducing the number of dispensing steps, a desirable goal since each of the existing 17 steps represented an opportunity for error to be introduced. Switching from a system in which drugs were stored on a centralized cart to one in which drug dispensing units were positioned throughout the facility, but only accessed through a computer, was an immense undertaking that met some resistance from nursing staff. But they report the reluctant nurses quickly became fans of the ease of use and the ready supply of medication at every unit.
Based on the initial success with dispensing automation, the Medication Safety Committee decided to install a bar coding system, which now has been fully implemented. With this system, nurses scan the code on their badges, the patient's wristband, and every drug to ensure the right drug is administered in the right dose to the right patient. The bedside system includes an electronic medication administration record. One challenge, Nicol and Huminski report was getting the right bar code on each drug since there still is no industry standard. They use a system that gives them the flexibility to deal with such issues. Today, some 80% of the drugs coming into the hospital already contain a bar code they can use, while they code the remaining 20%.
Because the hospital feels a responsibility for ongoing patient safety even after discharge, they turned again to technology to be sure patients are sent home with specific and clear medication orders. "Our drug reconciliation plan started with a computerized admission assessment history form that the nurse fills out at the initial patient assessment," they said. "In addition to talking with the patient and the family, the nurse may also call the patient's pharmacy."
The physician reviews the medication list either on-line or on paper and is then able to change or continue home-use medications. An electronic form goes to the pharmacist for verification, cutting transcription errors to nearly zero, Nicol and Huminski said. The process is repeated any time a patient changes location or level of care.
Other states may adopt their changes
The two said the final step of the reconciliation process is providing each patient with complete and accurate medication information on discharge. They worked with the South Carolina Hospital Association to develop a universal medication form that is now the statewide standard and also is being considered by several other state hospital associations.
"The cost of deploying these technologies was considerable," Nicol and Huminski reported, "and the Robert Wood Johnson Foundation grant was helpful. In retrospect, however, our costs were minor compared with the results. Our adverse drug events have been reduced by 90% and our rate of patient harm is 0.34 per 1,000 doses."
In the wake of the Institute of Medicine report on medication errors, Florence, South Carolina's McLeod Regional Medical Center initiated a series of steps to improve patient safety and reduce the hospital's "rate of harm."You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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