Friday, January 11, 2019

Missing Medications Revisited

It’s been a while since we discussed “missing” medications in this blog. When a nurse goes to administer an ordered and verified medication to a patient and it is not there on the unit, we have a system that is not 100% reliable (reliability = what should happen, happens and what should not happen, doesn’t). Physicians and advanced practitioners order medications and pharmacists verify the order. The verification step is a protection that the medication is of the correct dose, that the patient is not allergic to it or has contraindications to its use, and that it will fit in with the other medications the patient is taking without untoward drug interactions.

We have made huge progress in reducing “missing” medications since 2013, when we first started studying the causes and testing changes to our delivery system. The pharmacy has a two-hour window from the time a medication is ordered to verify the order and deliver the medication to the unit if it is not already stored there. We saw considerable changes once we began studying one unit at a time and looking at each case of missing doses in real time. It’s difficult to tell what happened when looking back in time at an event. It is much easier to do the 5 Whys as soon as a miss occurs. Remember, the 5 Whys process is asking the “why” question FIVE times before you get to the fixable cause of a defect.

Prior to working on improving our system, busy Medicine units could have 30 or more missing medications per day. This has been reduced to 0-3 per day. The most recent work between our pharmacists and units 34 and 35 has resulted in many days with zero missing medications! This is a great achievement.

There are several Pharmacy leaders who oversee this work: Julia West, Assistant Director of Pharmacy, Julia McDonnell, Pharmacy Operations Manager, and Vaishali Khushalani, Pharmacy Medication Safety Officer. The Pharmacy Lean Daily Management (LDM) lead team also communicates with Pharmacy Director, Yuliya Klopouh, and the observations from LDM are used to make practical improvements in the pharmacy. These leaders are also in close communication with the nurse managers to study the defects and, when necessary, change the standard work.

A recent example of improvement involves the transfer of medications between the Emergency Department and inpatient units. The previous process was to send all the patients’ medications with them on transfer. The Pharmacy team worked with Emergency Department Manager, Mark Fisher, Assistant Nursing Director for the ED, Monica Goetz, and Unit 35 Manager, Temitope Oseromi, to create a better process for expanding the stock of medications on the inpatient units and in the Emergency Department. This allows for fewer medication transfers and improves access to and visibility of patient-specific bins. After this change, medication tracking became significantly easier and there was higher accountability between emergency and inpatient units. Now, there are fewer medications missing during the transfer process.

An added benefit of the daily improvement work is the better relationship and collegiality between pharmacists and nurses!
Congratulations Gilchrist!
Gilchrist Care Choices (GCC) is a national test program which allows qualified Medicare beneficiaries who qualify for hospice to continue receiving curative treatment simultaneously. This is being tested under the belief that many people forego hospice fearing their providers will “give up” on them. The idea of the program is that allowing patients to continue curative treatment will allay their fears and encourage many people to choose hospice care sooner. This has certainly been the case with GCC! The program has grown exponentially — since 2017, with referrals increasing by 100 percent. GCC, the fourth-largest program in the country, is one of the first to focus on continually improving internally-developed quality measures. This major achievement in growth from outpatient providers, was highlighted by the Centers for Medicare and Medicaid Services (CMS) in a recent publication. Congrats to Rene Mayo, MSW, GCC program manager, and her colleagues for this recognition!

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