Reliability means that what should happen happens and what should not happen … doesn’t. A highly reliable medication delivery system would have all of the medications present for the nurse as they were needed. Our nurses found themselves in a very unreliable medication delivery system.
The “old” way to fix this problem was to find out who made the mistake. There must have been someone in the pharmacy who didn’t know what they were doing or didn’t care or both. But nothing could have been farther from the truth.
GBMC has always had outstanding pharmacists and technicians who really care and work as hard as the nurses. The real problem is that moving thousands of doses of medications from the pharmacy to the nursing units in the correct doses, and always on time, as patients are being discharged and new patients are arriving is a really, really complex problem. Our processes were not reliable enough to get the job done.
We have made phenomenal strides in reducing missing medications over the past three years. The missing meds team, which includes nurse managers and pharmacy staff, began working with individual units, like Unit 38, to study the causes of missing medications and test system changes to reduce them.
Over the past year, under the leadership of Pharmacy Director Cherryl Peterson and Lead Clinical Pharmacist Vaishali Khushalani, the team has been studying individual missing doses as soon as they happen to heighten the learning and find more specific process improvements to test. The Pharmacy has worked with SICU, under the direction of its nurse manager Jen McDonnell, and they have made incredible progress toward 100 percent reliability. The SICU, which added ‘missing meds’ to its LDM board in June 2015, started with a monthly average of 28 missing meds. A pharmacist began conducting a real-time assessment to find the cause of the defect. Representatives of the SICU team and pharmacy began meeting with the missing meds team weekly to share the previous week’s learning. This has helped identify unit-specific and house-wide issues and solutions. One of the earliest interventions was the addition of an extra tower to the SICU’s Acudose machine, housing electrolytes and other IV medications that would often be missing. Another recurring issue was that of missing medications on transfer from the ED or GOR PACU. The Pharmacy developed a process to ensure delivery of medications to the appropriate unit after such transfers by getting an hourly transfer report. There were only 11 missing medications in the SICU in the entire month of December. What great improvement!