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Quality Update
Spotlight: On the Trail of Medication Errors
Spurred by a pharmacist’s zeal, an ICU tracks down system failures and goes for the fix.
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| Faramarz Zarfeshanfard feels like he became the point-of-care pharmacist for the cardiac surgery intensive care unit at just the right time. |
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When Faramarz Zarfeshanfard talks about no harm by medication error, the look in his eyes and the steel in his voice confirms that this isn’t a principle he tosses around lightly. “On average, there are 12,000 medication doses dispensed every day around the hospital,” says The Johns Hopkins Hospital point-of-care pharmacist. “If there is one error on any given day, that’s one too many.”
Zarfeshanfard infused his zeal to protect patients from the first day he joined the staff of the hospital’s cardiac surgery intensive care unit (CSICU). He arrived as Hopkins’ new patient safety committee was turning up the pressure to make the hospital mistake free, and the Center for Innovation in Quality Patient Care was assisting numerous safety projects in units, including work with the CSICU’s safety and quality care team.
According to Institute of Medicine white papers on medical errors, medication mistakes cause the majority of patient injuries or deaths. One of the areas the institute noted is the most prone to mistakes is the availability of patients’ medications on hospital units. “In an ICU setting,” Zarfeshanfard points out, “if the medications aren’t there when the patient needs them, it starts a whole cascade of events that likely will have negative consequences for care and result in costly, longer hospitals stays.” It takes nurses away from the bedside, he adds, to hunt down missing medications and request replacements, and pharmacists have to interrupt their work to renew orders.
It was understandable then, that one of the first issues the CSICU team targeted was medication errors. The team tracked medication availability for two patients for a week and discovered that during the busiest time of administering medications, 10 a.m., 30 percent of the doses were missing.
After reviewing each step in the medication delivery process, the team devised a simple, cost-free remedy. During the night when activity on the CSICU slowed down, the nurses on that shift would check the medication inventory. If any doses turned up missing, nurses would place a reorder with the pharmacy so the drugs were on the floor ready for use the next morning. The safety team monitored this intervention for a week and found only one case of a missing dose.
This small pilot project also revealed a lack of sufficient inventory control and the low quality of the information pharmacists and nurses used to dispense and administer medication. So, the CSICU team refocused its efforts on how medication orders get to the pharmacy. Normally, physicians hand-write the medication order on a form, with the original sheet going into the patient’s chart and the carbon delivered or faxed to the pharmacy. The team compared the orders in the charts with the pharmacy patient medication profiles and the unit’s medication administration record, which list the drugs for each patient, but don’t interface with each other. “These comparisons should match every time,” Zarfeshanfard says. “But we found discrepancies up to 50 percent of the time.”
In reviewing these inconsistencies, the team discovered that in most cases the written orders were illegible because of the physician’s handwriting or the poor quality of the carbon copies or faxes. The review also indicated, for example, that when a physician used a stack of forms to write multiple orders, cross outs and substitutions of medications or doses on one form would be transferred to the carbon of subsequent orders.
The CSICU’s solution in this case wasn’t simple or inexpensive. The safety team looked at two PYXIS products: one, scanning/ communications software; the other, an inventory storage device, much like a vending machine with restricted access. These products would allow the original orders to be scanned into the computer system linked to the pharmacy. Once the orders were filled, they would appear on the unit’s PYXIS profile machine, allowing nurses access to the medication. The outcome would eliminate carbon copies and patient-specific medication carts, increase significantly the accuracy of entering orders and decrease turnaround time of medication availability from hours to minutes. But Hopkins also is set to spend $21 million on a physician order entry system and, the question remains whether both systems are needed.
The CSICU isn’t alone in taking on medication errors. The Weinberg intensive care unit, for example, has put together a medication reconciliation project that uses crosschecks to make sure patients are discharged on the proper medicines. On oncology floors, the Hopkins Hospital pharmacy is checking each step of the chemotherapy delivery process to detect flaws and recommend improvements. And the Hopkins pharmacy, among several hospitalwide projects, has placed point-of-care pharmacists on every ICU and 17 clinical pharmacy specialists on other inpatient units and some outpatient clinics.
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The Numbers Count
Complexity of Medication Delivery at Hopkins (mean values):
Patients per day: 720
Doses per day: 12,000
New orders per day: 3,000
Drugs in the formulary: 900
Missing doses per day: 150 (1%-1.6%)
Steps in medication delivery process: 100+
Orders transcribed from a piece of paper into a computer per day: 3,000
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