Small changes can greatly improve patient outcomes
June 1, 1997
Small changes can greatly improve patient outcomes
Focus on single projects for maximal success
Yes, there are hospitals where the wheel needs reinventing. But not always. Even small changes can have a big impact on patient care. For example, the Fairview Health System, a group of affiliated hospitals and clinics in Minneapolis, took on several separate initiatives over the past year, including a program to reduce falls in elderly patients taking central nervous system depressants.
"We really wanted to look at why patients are falling and how," says Linda Sershon, RN, MA, Fairview’s department manager of medical and surgical services. She adds that falls in the elderly are no joke they can lead to serious injuries, including bone fractures.
A secondary goal was to see whether elderly patients were being prescribed antipsychotics and antidepressants too readily. "One of the things I’ve noticed over time is that if older people get a little agitated and confused, we tend to go right to the medications," Sershon says.
She began the project by collecting data from the previous year, 1995. Those data showed five falls related to psychoactive drugs. They also showed that drugs like Halcion, Haldol, and Ativan habitually were dosed too high in elderly patients.
The health system instituted an automatic dosage reduction for psychoactive drugs in patients ages 65 years and older, using information from package inserts. Pre-printed order sheets also were changed to include a reminder that dosage reductions were necessary for older patients. Sershon says staff education also was an important component in preventing falls, with emphasis on catering to the patient’s at-home habits to reduce confusion while they were staying in the hospital: "Are they used to getting up in the middle of the night to go to the bathroom? Do they need glasses? The staff has really made a conscious effort to look for other things before saying Let’s just start the Ativan,’" she says.
The pharmacy gets involved in an auditing program whenever an elderly patient is taking a high number of drugs with special emphasis on flagging those products that might cause dizziness. Another important pharmacy contri-bution, Sershon says, was the elimination of Dalmane from the formulary, with automatic interchange to Restoril. Since the program began, there has not been a single fall related to CNS depressant medication.
Allergy reporting improved
Another area of concern for Fairview was the identification and documentation of patient allergies. "It was a known problem for us, and it’s crucial to the medication administration process," says Judith M. Pechacek, RN, MS, nurse manager of medicine at Fairview. "That’s why we felt we needed to fix it once and for all."
The problem, Pechacek says, was that allergies were recorded in too many places, and they weren’t always accurate as a result. "There was just so much variation with it," she explains. "There were seven different ways we found people could write allergies, including: on the admission form, on the chart, the Kardex, the MAR. Then some units got real creative and put it over the patient’s bed."
The problem, of course, is that patients change beds, and it wasn’t unusual to find the wrong allergy chart posted above the bed. "The accuracy rate plummeted as the number of places [allergies] were recorded increased," Pechacek says.
The solution, finally, was to settle on three places, and three places only, to record allergy information. The first time a patient comes in contact with an RN, the information is recorded on a band that fits around the patient’s wrist. It also can be found on the medication administration record, since pharmacy needs to know, and in the hospital’s database.
"We brought our overall compliance from 60% to 65% to more than 90%," Pechacek says. "Now we’re looking into whether we’re holding the gains," she adds, given the propensity for systems to collapse without constant reinforcement.
Team approach crucial
These objectives couldn’t have been undertaken alone. Lucien Leape, MD, adjunct professor of health policy at Harvard University, says it’s crucial to use a team approach when it comes to changing the medication use system because members of the pharmacy and therapeutics committee, pharmacists, nurses, doctors, and even dietitians sometimes play a role in getting the right medication to the right patient at the right time.
One way to get everyone working together is to use a customer service approach. Leape urges you to focus on helping the patient the end-user instead of on excoriating an individual department.
Individual departments can do something on their own, however, to improve the safety of the medication system. In the case of the pharmacy, Leape offers the following common-sense suggestions:
• Use a formulary.
• Reduce the number of suppliers you use and the number of dosage strengths. If you can get by with a single strength of captopril, for example, do it.
• Keep in mind that some drugs are more dangerous than others. Develop a plan to deal with those products separately.
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