Agency creates tool to reduce medication errors
Now information is more complete, accurate
Health care providers have increased their attention to medication issues in the last year, particularly since the federal government said that medication errors are a nationwide problem causing thousands of deaths.
One way home care agencies can prevent medication problems is by improving their documentation of patients’ medication. For instance, Decatur (AL) General Home Health Services launched an extensive quality improvement (QI) project last spring in order to clean up some documentation problems related to the agency’s medication patient profile.
A chart review showed that nurses accurately and completely documented patients’ medications 84% to 86% of the time, and that was not good enough, says Jimmie Galbreath, RN, MSN, director of the rural, hospital-based agency that covers 10 counties in northern Alabama.
Making it better
Since the QI process ended, the agency’s compliance on medication documentation has risen to the 98% to 100% range, Galbreath says.
The QI process works step by step:
1. Form a quality management (QM) team to make changes. After a 25% sampling of medication profile charts revealed a problem with incomplete and inaccurate information, Decatur General formed a multidisciplinary quality management team to address the issue, Galbreath says.
The QM team, consisting of a physical therapist, an occupational therapist, nurses, and managers, met biweekly for a month. They brainstormed and came up with ideas for changing the agency’s medication profile tool, he explains.
The chart audits had identified the major problem areas, so they targeted these items:
• Staff did not always indicate specifically when a patient began or discontinued a particular medication.
• Staff didn’t identify where the patient obtained the drugs, such as in a hospital or from a pharmacy.
• Staff didn’t identify the medication route of administration, such as through an IV, orally, or intramuscularly.
"These were things that the form did not specifically ask for," Galbreath says. "The performance improvement person saw that the forms consistently were missing this information, so she brought it to our attention."
The team also suggested some changes of their own. For example, team members thought the form wasn’t as user-friendly as it could be, and they wanted to change the order of some items and add specifics to others.
"For instance, they wanted a column that said start date of the drug,’ and wanted a separate column for the discontinued date," Galbreath says.
Team members also suggested adding a column to identify whether a drug was a new drug, a changed dosage, or a different administration route. "They wanted the lines on the form to be wider so they had more space to be able to enter the information without it being so compact," Galbreath adds.
The team also decided that changes would be needed in how the tool was filed. The previous process was to keep an original medication file in the patient’s active chart. Then staff would copy the active file and place that in the travel packet so they would have it available when they did a home visit. "There would be identifiable information specific for that patient, such as a plan of care and medication profile and any modification orders to include the address and travel information to the patient’s residence on a clipboard," Galbreath explains. "We have one prepared for every single client, so the visiting staff only needs to pull out the clipboard, and they have all the current information."
The problem was that when staff revised or updated the medication profile contained in their travel packet, they often forgot to copy those changes to the original medical profile in the patient’s permanent chart.
So the team corrected this problem by putting the original medication profile in the travel packet, and a copy in the active patient’s chart. When a patient is recertified or discharged, the current medication profile is taken out of the travel packet and put into the patient file, and the medication profile copy is tossed out.
This change also has made it easier for the agency to give physicians the most accurate and up-to-date medication information. When a physician calls in for an update, the nurse handling the case is paged, and that nurse reads information to the physician from the medication profile in the travel packet. (See medication profile, inserted in this issue.)
"We have not had a problem with nurses losing the form," Galbreath adds.
Use staff’s ideas
2. Present changes to staff and modify according to their ideas. The next step: make copies of the revised form and show these to the staff for their comments and review.
"We had the quality management team inservice the staff on the use of the revised form, and also the QM team gave the visiting staff the rationale for why the changes were made," Galbreath says. "They told them the problems that were identified and the reason they felt that if they changed the form it would be more user-friendly."
Employees then volunteered some information about problems that the team had not considered, so they essentially became members of the quality management team, Galbreath says.
"We took a small team that instantly became a large QM team because when the small team rolled it out to the staff, everyone was interested and everyone was concerned and wanted information on how they could improve the agency’s medication profile compliance rating," he explains.
They held a large brainstorming session and came up with a list of modifications to the revised form.
One of those changes was to put a place on the form for the rehab staff to sign the form after listing patient medications. The previous form had only a place for the nursing staff, who reviewed the medications, to sign the form. Since therapists were not permitted to review the form — they could only list medication information on it — there was no place for them to sign it.
"The large team said we needed a place for the signature of people who listed medications and a space for the person who reviewed the medications," Galbreath says.
This change made a lot of sense and meant that everyone who added to the form or changed or reviewed the form was accountable.
"If you identify more than one drug that’s contraindicated and there has not been an intervention to solve this problem, then you know who reviewed the form and who to talk with about the problem," Galbreath says.
Likewise, if there’s a mistake on a medication’s dosage or administration on the form, then a manager will know to speak with the person who listed medications.
The larger QM team also decided to combine some columns to simplify the form. For example, the revised form had a column to check if the drug listed was new and a separate column to check if the drug listed was for a changed dosage.
"The large team convinced the small team that they could combine those two columns, and they would still know whether it was new or changed because rather than putting a checkmark in the space, they could write in the letters N’ or C,’" Galbreath explains.
The original QM team made changes to the form according to the suggestions at the staff meeting, and then they copied it to be used during a trial period.
3. Use new tool during a trial period and revise as needed.
At Decatur General, the new medication profile was used only on new patients. This made it simpler for the staff, and gave a large enough sample to use during a trial period.
During the trial period, the entire staff continued to discuss the form at weekly staff meetings. The discussion was open and gave employees time to bring up any problems they had identified, trends, or issues relating to using the new form.
Then, rather than making changes after each weekly meeting, the QM team kept track of the comments and would repeat them at following meetings to see if the problems, trends, or issues were consistent over time, or if they were simply a part of the adjustment period that accompanies any change in procedure.
After several months of the trial period, some minor changes were made, and the QM team showed the new and professional-looking form to the entire staff for review and correction of any errors. Once approved by the staff, the form was copied and tried for a month.
"We continued to do QI audit checks, and the statistics were improving, and by the end of the month of the second revision everything seemed to be okay," Galbreath says.
The agency’s medication documentation compliance rose to 98% to 100%, and the agency created a presentation about its successful QI project to show surveyors of the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL, at a survey in January.
"The surveyors loved it, and we were accredited with no Type 1 citations," Galbreath adds.
• Jimmie Galbreath, RN, MSN, Director, Decatur General Home Health Services, P.O. Box 2239, Decatur, AL 35609. Telephone: (256) 350-4182. Fax: (256) 341-2656.
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