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Nurses and other Unit Staff ModuleExternal Use - Version 2

Change Package

KP Innovation Consultancy

February 2008

This information (or program) was developed by Kaiser Permanente. Please feel free to use and reproduce these

materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition.

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Table of Contents

03 What is MedRite? 04 What are the Benefits?05 Where did MedRite come from?06 MedRite Components07 MedRite Component: Process09 MedRite Component: No Interruption Wear10 MedRite Component: Sacred Zone11 What They’re Saying about MedRite!12 Innovation Consultancy: About

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What is KP MedRite?

MedRite is a safer, warmer and more reliable medication administration experience for nurses and patients.……………………………………………………………………………………………….…………..…..…..

For the RN, it clearly guides one through the medication administration process and provides support tools to minimize interruptions and maintain the nurses’ focus on safe medication administration

……………………………………………………………………………………………….…………..…..…..For the Patient, it creates an opportunity for deeper involvement and understanding, and increases their sense of personal safety

……………………………………………………………………………………………….…………..…..…..For managers and educators, it is a clear standard that can be taught and maintained, and provides a better understanding of what is happening on the unit during medication administration

……………………………………………………………………………………………….…………..…..…..For the other staff, it assures them that their patients are receiving focused, non-interrupted attention during the med- admin process

……………………………………………………………………………………………….…………..…..…..Finally, it’s a system designed by the frontline for the frontline.

RN 4[1] The Journal for Continuing Education in Nursing, May/June 2005 – Vol 36, No 3

What are the Benefits?

……………………………………………………………………………………………….…………..Normalized, easy to follow, medication administration process.Nurses now have a standardized approach to medication administration, which can help them to follow the 5 Rights of Medication Administration.

……………………………………………………………………………………………….…………..Warmer way of giving medications.MedRite incorporates time to ask patients if they have questions about their medications. It encourages patients to have a deeper level of involvement by providing an opportunity for their questions to be answered.

……………………………………………………………………………………………….…………..Consistent timely delivery of scheduled medications.Nurses are more able to administer medications within the timeframes ordered by physicians.

……………………………………………………………………………………………….…………..Fewer Medication errors.Interruptions and distractions of nurses is a cause of medications errors. [1].MedRite has been shown to reduce interruptions and distractions which can lead to a reduction in medication errors.

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Where did KP MedRite come from?

MedRite was developed through the hard work of our frontline staff andinnovation facilitators.

……………………………………………………………………………………………….…………..MedRite is a solution generated by an innovation collaborative between Hayward, South Sacramento and West Lost Angeles.

……………………………………………………………………………………………….…………..No Interruption Wear (a component of MedRite) was independently developed and fully implemented by South San Francisco. South San Francisco’s hard work jump-started the MedRite evaluation process as 1/3 of the solution was already proven!

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Components

ProcessA step by step workflow for RNs to administer medications that incorporates the “5 Rights.”

No Interruption Wear signals that no one should interrupt (talk to) the RN who is wearing the sash/vest unless there is an emergency. The RN only wears the NIW when “passing” meds, and removes it in-between med passes; this opens the nurse up for interruption at appropriate times. NIW may be a sash or a vest.

A space marked out on the floor with tape in front of the area where the nurse pulls and prepares meds in or out of the med room. This tape signifies that no one should cross into the space or talk to a RN who is in the zone.

NIW

SacredZone

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Components

Process

The step by step workflow for RNs to administer medications.

The Process is the foundation of MedRite.It incorporates the 5 Rights and standardizes the basic flow. This allows for a clear understanding by patients, caregivers and management on what to expect.

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Components

Process

__Review MAR__Verify Correct Time__Enter Med Room__Put on NIW

__Check Allergies__Pull Medication(s)__Verify Right Patient__Verify Right Medication__Verify Right Dose__Verify Right Route

__Go to Patient’s Room__Gel or Wash Hands__Turn down TV/radio__Turn on Lights__Verify Correct Patient using 2 identifiers

__Explain the Med and its purpose to the patient (Verifies Right Med 2nd time)

__Ask Patient if they have any questions__Re-Verify Dose__Re-Verify Route__Re-Verify Time

__Administer Medication__Document on MAR__Gel or Wash Hands__Remove Sash__Exit Patient Room

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Components

No Interruption Wear (NIW) is the tool that helps minimize interruptions during Medication administration.

It is put on in the Med Room and removed before exiting the Patient’s Room. It is worn ONLY during the MedRite Process and NOT between med passes. This allows the nurse to not be interrupted while giving medications and support the other medical staff at appropriate times.

NIW is not meant to reduce friendliness. You are still feel free to smile while wearing NIW!

NIW

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SacredZone

Components

The Sacred Zone is an area marked out in front of the PYXIS with tape. We recommend the use of tape as this is a common zone indicator in the OR and Pharmacy.

The space marked out should allow enough room for thedrawers of the PYXIS to open and still allow the RN to stand comfortably in the zone. Remember the nurse will need to bend at times to pick the medications from the drawers.

Work with local engineering to select and apply the tape.

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What They’re Saying about MedRite!

Hayward RN…A patient gave the medical record number to the nurse before she asked because she learned from the nurse on the previous shift about the MedRite Process.

West Los Angeles RN…A traveler nurse caught her own error because of following the fiverights using the MedRite process.

Hayward Unit Manager…There was one patient who refused to accept medications from thenurses unless they wore the sash AND had a conversation around the medication purpose and dosage.

West Los Angeles Department Administrator…The Department Administrator was a nurse for the day; since she does not regularly practice as a nurse she would not have felt comfortable giving meds but with the MedRite process she did; She said it was “Just like baking a cake…Follow the directions and you will be fine” .

Hayward RN…“When I explained the sash to a patient, the patient said that he felt safer.”

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Scott Heisler

ABOUT the ConsultancyOur Kaiser Innovation Consultancy (IC) is a group of creative people who help challenge conventional thinking to develop human-centered designs and solutions.

Our ultimate goal is to positively impact the work experience of our employees and the health of our KP members. We test out the usability of new products, workflows and space designs, and conduct simulations in real and mock patient environments. We work together with our KP employees, physicians, and members to better understand challenges and develop and prototype human-centered ideas using proven methodologies from both IDEO and IHI

Other designs from the IC:1) Nurse Knowledge Exchange , 2) Perinatal Journey Home Board3) Med Surg Care Boards, 4) TCare Innovation Teams

Email: Innovation.Consultancy@kp.org

Innovation Consultancy, Nice to Meet You!

Chris McCarthyScott HeislerChristi Zuber

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Pilot DataExecutive summary – FAQ - Citations

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Executive Summary

In the United States alone over 1.5 million are harmed by medication errors each year. Our own research here at Kaiser revealed a fragmented approach to medication administration riddled with interruptions and distractions. The Innovation Consultancy, supported by KP HealthConnect, Patient Care Services and Quality & Safety, conducted an innovation collaborative with Hayward, South Sacramento and West Los Angeles Medical Centers

The output of this collaborative is a three component system called MedRite:MedRite Process // The step by step workflow for RNs to administer medications.No Interruption Wear (NIW) // A sash or a vest signals that no one should interrupt (talk to) the RN who is wearing the sash unless there is an emergency.

Sacred Zone // A space marked out on the floor with tape in front of the area where the nurse pulls and prepares meds in the med room. This Zone signifies that no one should cross or talk to an RN who is in the space.

MedRite was piloted on four units (Med/Surg at Hayward, Med/Surg/Tele at Hayward, Med/Surgat West Los Angeles and Surgical at West Los Angeles). The results of the pilots show:

• 50% reduction in the number of staff interruptions to the medication administration process from approximately .7 interruption per med pass to .3 interruption per med pass

• 15% faster per med pass from approximately 10:00 to 8:30 (minutes:seconds)• 18% increase in On-Time Med Passes from 61% to 79%• Significant increase in process reliability from 33% to 78%

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Frequently Asked QuestionsQuestion: What does it mean when the nurse is wearing their Sash?Answer: The Sash indicates that the nurse is in the process of giving medications to your or one of your peers patient’s.

Question: When the nurse is wearing the Sash can I interrupt them?Answer: Studies have shown that when our nurses were less distracted they paid more attention to the Medication Administration process and followed it more reliably. It is important to refrain from interrupting the nurse while they are administering medications to keep you patient’s safe unless there is an urgent need.

Question: I am concerned that the nurse will wear their sash at times other than Medication Administration and will not be available in a timely fashion?Answer: We have found that nurses do not abuse wearing of the sash. There is a small learning curve when they must learn when to put it on and take it off. Their goal is put the sash on as they prepare to give their patient their medications and then take it off immediately after medication administration.

Question: I have heard that nurses have used this an excuse to not speak with physicians or use common sense about physician’s need to communicate with them.Answer: There may have been isolated instances of this occurring, but as hospitals have implemented KP MedRite, this has not surfaced as recurring theme.

Question: Are their published studies or articles that show benefits of reducing interruptions during medication administration?Answer: Yes, many. Specifically The Joint Commission has published a book entitled The Nurse’s Role in Medication Safety. In Chapter 7, entitled First: Do Not Distract, the author, Tess M. Pape, PhD, MSN. RN, C.N.O.R., cites studies that have been done that show the benefit to nurses by reducing distractions. The chapter challenges the reader to implement programs based on the research. KP MedRite is a National program, supported by Kaiser Permanente, that builds on this research.

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Question: What happens if there is a code or Rapid Response Team call?Answer: As with any emergency, it is expected that nurses will respond in a timely fashion as appropriate.

Question: How was the Sash and the Medication Administration Process developed?Answer: The Sash and Medication Administration optimized processes were developed by front line staff and physicians using human centered design processes and piloted at 4 different Kaiser Permanente Units. Results showed a decrease in interruptions, an increase in timely medication passes and nurses being more reliable in giving medications accurately.

Question: Has KP MedRite resulted in the outcome of decreased Medication Errors?Answer: Some Kaiser Permanente Hospitals have seen a dramatic decrease in Medication errors from historical norms using their traditional methods of reporting. (examples are in South San Francisco and Sacramento Medical Center). More data is being collected to show statistical significance in the coming months.

Question: Why do you feel that KP MedRite really works? Answer: Process metrics are an indication that a system is on track to improve outcome metrics. KP MedRite pilot units were analyzed and shown to have statistically significant improvement in 1) reducing the number of distractions encountered by nurses during medication administration, and in 2) Improving the standardized process of giving medications. Both of indicators have been shown to be valuable by the Institute for Safe Medication Practice. (see citations on following slides)

Question: Does KP MedRite address specific challenges noted in our industryAnswer: KP MedRite was designed to meet the following process recommendations fromthe book Medication Errors, by Michael Cohen, RPh, MS, ScD, DPS, President of the Institute for Safe Medication Practice.

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Citations Relating to KP MedRiteHere are Medication Administration challenges addressed by KP MedRiteSource: Medication Errors, 2nd Edition by Michael Cohen,

1. Preventing adverse drug interactions by knowing a patient’s diagnosisRecommendation: Match the patient’s medications to his/her diagnosis and make sure the drug’s intended purpose makes sense for the patient.

2. Preventing administration of medications to the wrong patientFact: Misidentification errors can originate in any phase of the medication-use process (physician orders, nurse transcription of orders, and pharmacist entry mistakes)Recommendation: Use at least two unique patient identifiers. [i]Recommendation: Take the MAR to the patient’s bedside for the required verification. [ii]Recommendation: Keep unit dose medications in the manufacturer or pharmacy packaging up to the point of administration. [iii]i] Medication Errors, Michael R. Cohen, Editor, American Pharmacists Association, Washington D.C., 2007, pg. 238. [ii] Ibid. [iii] Ibid.

3. Creating safety strategies for look-alike and sound-alike drug names/packages Recommendation: Double check with the patient: ensure that the medication’s purpose makes sense and that the medication looks similar to what the patient took at home. [i] Ibid., pg. 252

4. Labeling to the point of administrationRecommendation: Leave medications in unit dose packages until the point of administration. [i] Ibid., pg. 255

5. Maintaining focus in a challenging work environmentFact: Distractions are a greater problem for nurses than for pharmacists, pharmacy technicians, and physicians

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Recommendation: Establish “do not disturb” times in the medication room during drug administration. [i] Ibid., pg. 265 Recommendation: Educate staff on the importance of working as a team, staying focused during staff administration, and avoiding unnecessary distractions while others are administering medications. Ibid., pg. 265Recommendation: Provide phone and call-bell support for nurses who are administering medications. [i] Ibid., pg. 265

6. Assessing practices that result in a culture of safety Recommendation: Establish safe work environments for medication preparation, administration, and documentation. [i] Ibid., pg. 268Recommendation: Work to improve systems that address most common near misses in the work environment. [i] Ibid., pg. 268

7. Preventing errors through the input of observant patients and their familiesRecommendation: Encourage patients to ask questions about their medications and seek satisfactory answers. [i] Ibid., pg. 270

8. Enhancing double-check systems during drug administration so that potentially harmful errors are detected and corrected before they reach patientsFact: About 1 in 5 medications reach patients in error; 38% of these errors originate during drug administrationFact: Just 2% of errors that originate during drug administration are intercepted and correctedFact: More than half of the medication errors that cause harm originate during drug administrationRecommendation: Use a unit dose drug distribution system so that the pharmacist and the nurse (or two nurses) can independently interpret, transcribe, and verify each dose before dispensing or administering it. [i] Ibid., pg. 272