Institutional Assessment for Change—Focusing on Medication Safe PracticesEYONG ATEM, LINDSEY SAUNDERS, & LAURA BELL

NUR 7250

NOVEMBER 1, 2013

Content Outline

Analysis of Assessment Concepts & Selected Tool Needs Assessment

Key FindingsRecommendations for Change

Conceptual Framework for Change Considerations for the Change

Vested Interests, Drivers, Resistors, Resource Implications

Conclusions

Introduction

EAMC Highlights Major Changes in Patient Safety Initiatives Underway

Computer Physician Order Entry (CPOE) Implementation

Bedside Barcoding ImplementationEnhanced Medication Reconciliation

Safe Practices Culture of Continuous Learning and Improvement

Cutting edge safety and quality initiatives are strategic activities

Analysis of Assessment Evaluation Concepts for Project Inception

Performance Measurement Matrix Framework (Malloch, 2011)

Goals-Based Theory (Osselaur & Janiszewshi, 2012)

HOT-fit Evaluation Framework (Yusof, Kuljis, Papzadeiropoulou, & Stergioulous, 2008)

Assessment Summary

Review of quality and safety assessment toolsHospital Engagement Network Assessment Institute for Healthcare Improvement Capacity

Assessment Institute for Safe Medication Practices Self

Assessment

Institute for Safe Medication Practices (ISMP) Self-Assessment

Created through a strategic partnership with the American Hospital Association (AHA) and the Health Research and Educational Trust (HRET)

Represents proven safety practices and processes that impact medication safety, new research findings on error prevention, and new technologies

Stakeholders—Patient Safety & Medication Safe Practices

Patients Employees—Nurses, Pharmacists, Techs Senior Leaders Board Members Community Insurance Companies—Reimbursement Changes

based on Adverse Events Government—state and national mandates and

monitoring

Assessment Components

Patient Information Drug Information Communication of Drug Orders and Other Drug Information Drug Labeling, Packaging, and Nomenclature Drug Standardization, Storage, and Distribution Medication Device Acquisition, Use, and Monitoring Environmental Factors, Workflow, and Staffing Patterns Staff Competency and Education Quality Processes and Risk Management

Findings

Patient Information

Strengths Prescribers and nurses can

easily access lab values while working in respective areas

Enhanced Information Technology

Easy to review patient allergies

Opportunities Improvement in Computer Order

Entry System(CPOE) Bar-coding Active computer surveillance

system

Drug Information

Strengths CPOE system tested after

adding a new drug or formulary to verify clinical warning

Designated team assigned to search drug literature

Complete drug history New drug approval

Opportunities Most drug information is available

for pharmacy view only Dosing chart readily available for

certain medications Designated pharmacist

Communication of Drug Orders and Other Drug Information Strength

CPOE

Standard Order Sets

Communication Safety

Error Prone Abbreviations

Drug Name, Dose, Frequency and Route

Verbal or Phone orders

SBAR

Electronic Medication Administration Record (EMAR)

Easy access to patient medication profile

Opportunities Verbal Face-to-Face Orders

Process of Conflict Resolution

Outpatient Pharmacy Communication

Drug Labeling, Packaging, and Nomenclature

Strengths Literature Review

Newly added drugs

Formulary changes

Labeling

Computers used to print medication labels produce clear and distinctive labels to prevent errors

Examining Medications

Standard process for addressing home medications brought into EAMC

Opportunities Look-alike or Problematic Medications

Alerts can be built into CPOE to remind practitioners about problematic drug names

Unit-dose Packaging

Drug Standardization, Storage, and Distribution

Strengths

Centralized monitoring system for medication refrigerator temperatures

Standards

Concentrations, Administration Times, Order Sets, Parameters

Medication and Pharmacy Availability

Commercially Prepared, Medication Shortage Process, Overrides

Hazardous Chemicals

Opportunities

Confusing Medication Labels

Patient Specific Dosages (Barcode Technology will correct practice)

Outpatient Overrides

Medication Device Acquisition, Use, and Monitoring

Strengths Infusion Control Devices

Limitations on type of pumps

Differentiation between pumps

Infusion, Feeding, Epidural

Programming

Tubing Safety

Access Ports

Labeling

Opportunities Pump Malfunctions

Infusion Control Device Criteria

Smart Pump Technology

Connection to Order System

Error Prevention

Safety Software

Environmental Factors, Workflow, and Staffing Patterns

Strength Opportunities

Work Space Trained Staff

NursingPharmacy

Leadership

Preparing and administering medications one patient at a time

Staff Competency and Education

Strength

Time of Orientation Error Experiences High Alert Medications Education Programs

Opportunities

Pharmacy - Nursing Unit Orientation

Pharmacist participation during new staff orientation

Share safety events and root cause analysis for learning and continuous improvement

Quality Processes and Risk ManagementStrengths

Fair and Just Safety Culture

Commitment from leaders

Formal training

Proactive assessments (FMEA)

Round Tables/Root Cause Analysis

Double check processes

Opportunities

Use of incentives for error reporting

Medication Safety Officer

Computer markers for drug orders and lab tests to enhance detection of potential adverse drug events

Interdisciplinary team evaluation of literature for new technologies and successful EBP regarding error reduction

Patient representation on patient safety committees

Double checks for high-alert drugs before administration

Key Changes Identified for Improvement

Improving strategies to identify high alert drugs

Standard medication administration process to one patient at a time

Ongoing medication competency and medication error prevention classes

Improve communication among practitioners

Conceptual Frameworks for Change

Review of three change modelsMelnyk and Fineout-Overholt’s ARCC ModelTranslational Research ModelPromoting Action on Research Implementation

in Health Services Framework

Framework for Change: Translational Research Phases for Preventing Adverse Health Care Events

Translational Phase

Patient Safety Interventions

Phase T0 Discovering opportunities and approaches for preventing adverse events through surveillance, outbreak investigation, epidemiologic studies, and basic science

Phase T1 Using T0 discoveries to develop and test novel interventions in a small sample of patients or in limited health care settings

Phase T2Broadening and strengthening evidence base for promising interventions through research and distilling evidence into evidence-based guidelines

Phase T3 Moving evidence-based guidelines into practice, through delivery, dissemination, and diffusion research

Phase T4 National or international implementation and evaluation

Pronovost, P. J., Cardo, D. M., Goeschel, C. A., Berenholtz, S. M., Saint, S., & Jernigan, J. A. (2011). A research framework for reducing preventable patient harm. Clinical Infectious Diseases 52(4), 507-513 doi: 10.1093/cid/ciq172

Vested Interests

Who will benefit from the change?

The whole institution will benefit from this change Patients Prescribers Staff Members

Who will NOT benefit from the change?

Some opportunities for change listed might cost the institution some money but have the potential to save money in the long run.

Patient safety benefits everyone

Change Drivers and Resistors

Drivers of Change: Health Care Providers

Senior Leaders Board Members Management Team

Members Government—Carrot

and Stick

Resistors of Change: Staff level positions

NursesPharmacistsUnit clerksPharmacy technicians

Resource Implications

Technological Resources Computers/Computerized Solutions

Enhanced Medication ReconciliationComputerized Physician Order EntryBedside Bar-Coding

Automatic Dispensing/Pyxis Machines Packaging with appropriate wording and lettering for

distinguishing medications

Concluding Remarks: Recommendations

Performance Measurement Matrix evaluation theory and Translational Research Model to guide improvement processes from assessment

Key changes recommended to enhance medication safe practices Strategies to improve

High alert medications

Medication administration one patient at a time

Ongoing education and training specific to error reduction standards

Communication of the care team

Q&A

References

Armitage, G., & Knapman, H. (2003). Adverse events in drug administration: A literature review. Journal Of Nursing Management, 11(2), 130-140. doi:10.1046/j.1365-2834.2003.00359.x

Hospital needs assessment. (2011). Retrieved from http://www.hret-hen.org

How-to guide: Prevent harm from high-alert medications. (2012). Retrieved from www.ihi.org.

Institute for Healthcare Improvement: Improvement capability self-assessment tool. (2012). Retrieved from http://www.ihi.org

ISMP Medication Safety Self Assessment for Hospitals (2011). Retrieved from http://www.ismp.org

Kim, J., & Bates, D. (2013). Medication administration errors by nurses: adherence to guidelines. Journal Of Clinical Nursing, 22(3/4), 590-598. doi:10.1111/j.1365-2702.2012.04344.x

Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7(3), 149-158.

References

Malloch, K. (2011). Living leadership: vulnerability, risk training, and stretching. In T. Porter-O’Grady & K. Malloch (Eds.), Quantum Leadership (3rd ed, pp. 249-280). Sudbury, MA: Jones & Bartlett

Learning

Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams & Wilkins.

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., & ... Gandhi, T. K. (2010). Effect of Bar-Code Technology on the Safety of Medication Administration. New England Journal Of Medicine, 362(18), 1698-1707. doi:10.1056/NEJMsa0907115

Pronovost, P. J., Cardo, D. M., Goeschel, C. A., Berenholtz, S. M., Saint, S., & Jernigan, J. A. (2011). A research framework for reducing preventable patient harm. Clinical Infectious Diseases 52(4), 507-513 doi: 10.1093/cid/ciq172

Van Osselaur, S.M.J. & Janiszewski, C. (2012). A goal-based model of product evaluation and choice. Journal of Consumer Research, 39. doi: 10.1086/662643

Yusof, M. M., Kuljis, J., Papazafeiropoulou, A., Stergioulas, L. K. (2008). An evaluation framework for Health Information Systems: human, organization and technology-fit factors (HOT-fit). International Journal of Medical Informatics, 77(6), 386-398. doi: 10.1016/j.ijmedinf.2007.08.004.