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 of medications. ◆ Manual, paper- based, systems provide many opportunities 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
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.
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 occurred due to the use of the software.
Jan-95 Nov-94 Before Implementation Before Implementation Sep-94 Jul-94 May-94 Mar-94 Jan-94 Nov-93 Sep-93 Jul-93 May-93 Mar-93 Jan-93 50 45 40 35 30 25 20 15 10 5 0
Oct-99 Jul-99 Apr-99 After Implementation After Implementation Jan-99 Oct-98 Jul-98 Apr-98 Jan-98 Oct-97 Jul-97 Apr-97 Jan-97 Oct-96 Jul-96 Apr-96 Jan-96 Oct-95 Jul-95 Apr-95 Jan-95 50 45 40 35 30 25 20 15 10 5 0
Incident Rate Trends By Year Incident Rate Trends By Year • net improvement 64.5% 0.0250% 0.0200% 0.0150% 0.0100% 0.0050% 0.0000% 1993 1994 1995 1996 1997 1998 1999
Wrong Medication Incidents Wrong Medication Incidents • net improvement 73.8% 0.0040% 0.0035% 0.0030% % Errors 0.0025% 0.0020% 0.0015% 0.0010% 0.0005% 0.0000% 1993 1994 1995 1996 1997 1998 1999
Wrong Dose Incidents Wrong Dose Incidents • net improvement 56.6% 0.0040% 0.0035% 0.0030% # of Errors 0.0025% 0.0020% 0.0015% 0.0010% 0.0005% 0.0000% 1993 1994 1995 1996 1997 1998 1999
Wrong Patient Incidents Wrong Patient Incidents • net improvement 91.3% 0.0016% 0.0014% 0.0012% # of Errors 0.0010% 0.0008% 0.0006% 0.0004% 0.0002% 0.0000% 1993 1994 1995 1996 1997 1998 1999
Wrong Time Incidents Wrong Time Incidents • net improvement 91.6% 0.0018% 0.0016% 0.0014% 0.0012% 0.0010% 0.0008% 0.0006% 0.0004% 0.0002% 0.0000% 1993 1994 1995 1996 1997 1998 1999
Incidents of Omission Incidents of Omission • net improvement 69.6% 0.0100% 0.0090% 0.0080% 0.0070% # of Errors 0.0060% 0.0050% 0.0040% 0.0030% 0.0020% 0.0010% 0.0000% 1993 1994 1995 1996 1997 1998 1999
Veterans Affairs: Eliminating Veterans Affairs: Eliminating Medication Errors Through Medication Errors Through Point-of-Care Devices Point-of-Care Devices Questions
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