1

“The Stash”: Contributing to a culture of quality and medication safety on

inpatient units

Melanie Rydings, Clinical Nurse Educator, 2 South, Richmond Hospital

Monica Redekopp, Director, Professional Practice, Richmond

Nadine Lambert, Pharmacist, Richmond

Our Purpose

• To explore the use of unauthorized medication collections (UMCs) on the Medical/Surgical floors of our community hospital.

• To develop and implement collaborative action plans to eliminate these collections.

2

3

The Problem1. Culture of “stashing” medications on inpatient units poses

patient safety issues

2. May lead to drug diversions by staff

3. Adverse drug events related collections may contain:

– High Alert Medications*

– Easily Confused Medications*

– Expired, Recalled Medication

– Improperly Stored Medications *as per ISMP

Methodology1) Study investigators: (Pharmacy, Professional Practice and Nursing)

conducted a thorough search and collection of medications found outside the automated dispensing system (Omnicell) on 5 inpatient units on the same day.

2) Analyzed collections and conducted Focus Groups of staff nurses on each unit to share data. Results were reviewed with these groups to determine reasons behind “stashing” culture and to develop action plans to eliminate UMCs.

4

THE STASH!

5

Project Results at RH

6

Project Results at RH

Reporting included per unit:

oNumber of unique products oTotal # of medication itemsoTotal # of different productsoTotal dollar amount

All medications collected were categorized per unit as:

oHigh Alert*oEasily confused*oExpiredoImproperly storedoControlled Substances

*as per ISMP

Number of Medications by Unit

7

High Alert and Easily Confused Medications by Unit

8

Value of Medications by Unit

Inpatient UnitTotal Number of

MedicationsMean Value Total Value

Unit 1 617 $1.05 $671.45

Unit 2 247 $1.39 $342.45

Unit 3 28 $1.74 $48.58

Unit 4 44 $0.56 $24.59

Unit 5 84 $1.69 $142.10

TOTAL 1020 $1229.17

High Alert Medications by Unit

Inpatient UnitTotal Number of

MedicationsNumber of High

Alert Medications% of Total Number

Unit 1 617 48 8%

Unit 2 247 16 6%

Unit 3 28 5 18%

Unit 4 44 1 2%

Unit 5 84 6 7%

TOTAL 1020 76 7%

Easily Confused Medications by Unit

Inpatient UnitTotal Number of

MedicationsNumber of Easily Confused Meds

% of Total Number

Unit 1 617 239 39%

Unit 2 247 74 30%

Unit 3 28 2 7%

Unit 4 44 16 36%

Unit 5 84 27 32%

TOTAL 1020 348 34%

Number of Products by Unit

Inpatient UnitTotal Number of Products

High Alert Number %

Easily Confused Number %

Unit 1 127 8 6.3% 41 32.3%

Unit 2 70 4 5.7% 17 24.3%

Unit 3 10 3 30.0% 1 10.0%

Unit 4 13 1 7.7% 3 23.1%

Unit 5 33 4 12.1% 12 36.4%

TOTAL 253 20 7.9% 74 29.2%

In SummaryStashes contained:• Minimal Expired Medications or improperly stored meds.• High Alert and Easily Confused Medications• Easily Confused Medications accounted for 1/3 of all

medications• Multiple different products. No real themes emerged for any

unit. Wide variety of medications point toward a culture of “stashing”.

• 1 unit was significantly more represented in the data. Reasons for this include:o High turnover of patientso Highly variable patient population

13

Focus Groups • Focus Groups on each of the 5 were conducted by the study investigators. These

groups were focused on eliciting reasons for the existence of UMCs and feedback as to the contributing factors. Common themes included:

o Availability of medications after pharmacy closes (@ 2000) o Pharmacy verification before able to access medications.o Takes too long to wait for the night cupboard medications (i.e. porter

delays, no nursing access at this time).o Medications not transferred with patients from ED, other units.o Not enough doses of certain medications in the night cupboard.o Process of returning medications via Omnicell is onerous and not well

understood. o Selection of medications in the dispensing machines (Omnicell’s) may not

meet unit needs (i.e. cardiac meds). o General overall belief that medications should be kept “just in case”.

14

Focus Group Recommendations:

• Review the selection of ward stock in the Omnicell and Nightcupboard to reflect specific unit needs.

• Additional Omnicell units to increase supply of medications available.

• Medications transferred with pt from ED, other units.• More awareness of UMC risk to patient safety (i.e. safety

huddles)• *Staff expressed appreciation about being “asked and

listened to”.

• Staff were surprised at the results!

15

Action Plans

• Ongoing evaluation plan to monitor the presence of UMCs on the units.

• Working with pharmacy staff to review “workarounds” & explore possible solutions (ward stock review, nightcupboard access)

• ED: Nurse-to-Nurse Handover report to address transfer of medications to inpatient unit.

• Education for staff regarding the implications of UMCs (i.e. Safety Huddles)

• Monitoring of adverse patient events involving UMCs (Med Safety Committee)

• Development of a formal reporting system to clinical staff and leadership.

16

Questions?

17