Veterans Affairs: Eliminating Veterans Affairs: Eliminating - - PowerPoint PPT Presentation

Veterans Affairs: Eliminating Veterans Affairs: Eliminating Medication Errors Through Medication Errors Through Point-of-Care Devices Point-of-Care Devices

Presenters:

Bill Malcom - Technical Manager Russell A. Carlson, BSN - Nursing Consultant Candice Willette - Phase Manager for Implementation Chris L. Tucker, RPh - Pharmacy Consultant

Introduction Introduction

◆ Medication administration errors have

long been recognized as a significant cause of morbidity and mortality in hospital patients.

◆ Most of the 98,000 American deaths due

to medical mistakes are caused by medication errors.

The Problem The Problem

◆ Multiple people are

involved in delivery

• f medications.

◆ Manual, paper-

based, systems provide many

• pportunities for

mistakes.

The Problem The Problem

◆ Incomplete order handoff. ◆ Order misinterpretation. ◆ Incomplete or improper

transcription.

◆ Communication

breakdowns.

◆ Faulty drug identity

checking.

The Problem The Problem

◆ Rule violations. ◆ Faulty dose checking. ◆ Drug stocking and

delivery problems.

◆ Dependence on human

memory.

◆ Standardization of terms

and procedures.

The Problem The Problem

Most medication administration errors are the result of multiple system failures created by faulty system design.

The Vision The Vision

◆ Create a software tool for point of care

validation of medication administration.

◆ Combine barcode technology and

wireless network technology to ensure accurate, real-time verification of both patient and medication.

Veterans Affairs Veterans Affairs

◆ The Colmery-O’Neil Veterans Affairs

Medical Center developed a prototype automated system using this technology and deployed it in the hospital in 1996.

◆ The prototype system has validated 5.7

million doses so far, preventing 378,000 errors to date.

The Solution The Solution

Make the right thing to do the easiest thing to do!

The Solution - System Design The Solution - System Design

◆ Ensure ease of use. ◆ Minimize training requirements. ◆ Augment, don’t replace, clinical

judgement.

◆ Use existing technology. ◆ Limit variations and exceptions. ◆ Require use.

The Solution - Features The Solution - Features

◆ Windows 98/ NT user interface. ◆ Wireless Ethernet technology for

connectivity.

◆ Barcode technology for patient and

medication validation.

The Solution - Wireless The Solution - Wireless

◆ Uses 2.4GHz wireless

Ethernet technology.

◆ Same as a wired network

without the wire.

◆ Spread Spectrum

technology reduces possible interference.

The Solution - User Interface The Solution - User Interface

◆ Laptops or pen-based computers ◆ Thin client ◆ PS/ 2 based bar code scanner

The Solution - Software The Solution - Software Features Features

◆ Virtual Due List. ◆ Automated PRN effectiveness

documentation.

◆ Paperless medication administration

documentation.

◆ Paperless patient medication log. ◆ Missing dose automation

The Solution - Workflow The Solution - Workflow

◆ Nurse scans the patient wristband and

validates the patient identity.

◆ Virtual due list is displayed. ◆ Nurse selects medications based on the

due list.

◆ If a dose is missing, the nurse creates a

missing dose report for pharmacy.

The Solution - Workflow The Solution - Workflow

◆ Each medication is scanned prior to

administration.

◆ Each scanned medication is validated

for medication ordered, dosage ordered and timeliness.

◆ Variances create alerts to the nurse

indicating the problem.

The Solution - Workflow The Solution - Workflow

◆ Additional required information is

requested from the nurse when necessary.

◆ Nurse uses clinical judgement to

determine if medications should be given when variances occur.

◆ BCMA documents the medication

administration information.

The Solution-Pharmacy The Solution-Pharmacy

◆ Multidisciplinary team

The Solution-Pharmacy The Solution-Pharmacy

◆ Order interpretation guidelines

The Solution-Pharmacy The Solution-Pharmacy

◆ Standardization

The Solution-Pharmacy The Solution-Pharmacy

◆ Missing dose delivery procedures

The Solution-Pharmacy The Solution-Pharmacy

◆ Labeling procedures

The Solution-Nursing The Solution-Nursing

◆ Multiple user access

The Solution-Nursing The Solution-Nursing

◆ Real time data

The Solution-Nursing The Solution-Nursing

◆ Enhanced communication

The Solution-Nursing The Solution-Nursing

◆ Enhanced workflow

The Solution-Nursing The Solution-Nursing

◆ Human element

Real Life - Implementation Real Life - Implementation

◆ Staff may be unfamiliar with use of

Windows functionality

Real Life - Implementation Real Life - Implementation

◆ Develop Policies and Procedures

Real Life - Implementation Real Life - Implementation

◆ Implementation Timelines:

◆ 1/ 3 of all wards implemented within 30

days of implementation date (4 phases).

◆ Full implementation within 90 days of

implementation.

◆ National implementation complete by

4/ 30/ 00.

Real Life - Implementation Real Life - Implementation

The Colmery-O’Neil Experience The Colmery-O’Neil Experience

◆ Improved inter-service information

access.

◆ Improved communication between

disciplines.

◆ Improved timeliness for dispensing,

delivery, and administration.

◆ Improved patient safety.

Automated Missing Dose Automated Missing Dose Requests Requests

◆ 0.63% prior to implementation. ◆ 0.20% after implementation. ◆ 68% reduction in missing doses.

Results of Missing Dose Results of Missing Dose Automation Automation

◆ Improved response time. ◆ Reduced interruptions for pharmacy

and nursing.

◆ Improved efficiency of dispensing,

delivery, and administration process.

◆ Improved patient care.

Alerts for Averted Errors Alerts for Averted Errors

◆ Alerts are generated at the point of care. ◆ Visual messages are displayed for the

nurse.

◆ Allows correction prior to administration. ◆ Provides electronic capture of deviations

from physicians order.

Alerts for Averted Errors Alerts for Averted Errors

◆ 5.64 alerts generated for each 100 doses

administered.

◆ 64.1% wrong time alerts. ◆ 31.5% drug, dose, or patient selection

alerts.

◆ 378,000 errors prevented through

system alerts.

Proven Effectiveness Proven Effectiveness

◆ Over 5,700,000 doses administered

using the bar code scanner.

◆ No administration errors have

• ccurred due to the use of the

software.

Before Implementation Before Implementation

5 10 15 20 25 30 35 40 45 50 Jan-93 Mar-93 May-93 Jul-93 Sep-93 Nov-93 Jan-94 Mar-94 May-94 Jul-94 Sep-94 Nov-94 Jan-95

After Implementation After Implementation

5 10 15 20 25 30 35 40 45 50

Jan-95 Apr-95 Jul-95 Oct-95 Jan-96 Apr-96 Jul-96 Oct-96 Jan-97 Apr-97 Jul-97 Oct-97 Jan-98 Apr-98 Jul-98 Oct-98 Jan-99 Apr-99 Jul-99 Oct-99

Incident Rate Trends By Year Incident Rate Trends By Year

0.0000% 0.0050% 0.0100% 0.0150% 0.0200% 0.0250% 1993 1994 1995 1996 1997 1998 1999

• net improvement 64.5%

Wrong Medication Incidents Wrong Medication Incidents

0.0000% 0.0005% 0.0010% 0.0015% 0.0020% 0.0025% 0.0030% 0.0035% 0.0040%

1993 1994 1995 1996 1997 1998 1999 % Errors

• net improvement 73.8%

Wrong Dose Incidents Wrong Dose Incidents

0.0000% 0.0005% 0.0010% 0.0015% 0.0020% 0.0025% 0.0030% 0.0035% 0.0040% 1993 1994 1995 1996 1997 1998 1999 # of Errors

• net improvement 56.6%

Wrong Patient Incidents Wrong Patient Incidents

0.0000% 0.0002% 0.0004% 0.0006% 0.0008% 0.0010% 0.0012% 0.0014% 0.0016% 1993 1994 1995 1996 1997 1998 1999 # of Errors

• net improvement 91.3%

Wrong Time Incidents Wrong Time Incidents

0.0000% 0.0002% 0.0004% 0.0006% 0.0008% 0.0010% 0.0012% 0.0014% 0.0016% 0.0018% 1993 1994 1995 1996 1997 1998 1999

• net improvement 91.6%

Incidents of Omission

Incidents of Omission

0.0000% 0.0010% 0.0020% 0.0030% 0.0040% 0.0050% 0.0060% 0.0070% 0.0080% 0.0090% 0.0100% 1993 1994 1995 1996 1997 1998 1999

# of Errors

• net improvement 69.6%

Veterans Affairs: Eliminating Veterans Affairs: Eliminating Medication Errors Through Medication Errors Through Point-of-Care Devices Point-of-Care Devices

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