Thursday, January 7, 2016

Reducing Missing Medications By Studying The Incidents As They Happen

I remember one of our first visits to Unit 38, during Lean Daily Management (LDM) rounds, in April of 2013. The clinical unit coordinator reported that there had been 35 missing medications the previous day. This meant that 35 separate times, within a 24-hour period, a nurse went to give a patient his or her medication and it was not present. This report really bothered me. The nurses on that unit work incredibly hard. The beds are always full and the patients are very sick. There was nothing odd about that day…nurses were looking for meds that were not there about that many times every day! There had been an acceptance that this was just the way things were and nothing could be done about it.

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!
Let me particularly thank all of the staff of our pharmacy and the clinical unit coordinators of the SICU for their great work in making our processes more reliable to drive out wasted steps, improve our care, and make GBMC a better place to work!


  1. I am a RN on Unit 58 and we used to have missing meds all the time. I have noticed over the past number of months that I am not missing medications nearly as often as I used to. Thanks for focusing on this problem and coming up with a solution. Eliminating frustrations like these makes it much easier to do what we love: taking care of our patients.

    1. Thanks, Anonymous. I am so happy that you feel this way because we have focused on missing medications precisely to make it easier for you to do your work and to have more time for caring!


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