# Presentation: 468449

## AHRQ Patient Safety Conference

- June 6-10th
- Washington DC

## Re-Engineering an Acute Care Pharmacy Department

- Improving Patient Safety

## Tanner Health System

- TMC/C – 202 bed, acute care facility
- TMC/VR – 50 bed, acute care facility
- Higgins –25 bed, critical access hospital
- 24 hour pharmacy services

**Notes:**
TMC/C – include services
Licensed beds

## TMC/C Pharmacy Department

- 19-20 FTEs
- 	9.5 pharmacists
- 	8 technicians
- 	2.5 ancillary personnel

**Notes:**
6 pharmD
7 Certified techs PTCB

## Why Re-Engineer the Pharmacy Department?

- Improve Patient Safety
- Improve Patient Outcomes
- Improve Interdepartmental Relationships
- Job Satisfaction

- Efficiency / Productivity
- Improve JCAHO compliance
- Financial benefits
- Lack of 24 hour pharmacy coverage at Villa Rica and Higgins

**Notes:**
Re-engineer Medication use system
“ build a safer medication use system”
Patient safety-driving force behind change-IOM 199 report
Outcomes-studies in literature documenting impact of phceutical care
Relationships-history of less than ideal relationship b/t phcy/nursing
Satisfaction-sever problems in phcy
Productivity-
JCAHO-MM Standards
Financial-measureable impact on cost impact to institution
Higgins/VR-safety,outcomes, JCAHO compliance

## Tanner Health System 24 hour Pharmacy Coverage

- JCAHO
- 8-4:30 RPh Coverage
- Order clarification/drug information
- After hours pharmacy access

**Notes:**
JCAHO-TX3.5.2 new MM .4.10-phcy review of all orders prior to admin
VR/Higgins hours-after hour review, clarification/entry
-dialogue b/t caregivers
-Meditech-access to pt EMR
After Hours
VR-expanded pyxis use to decrease after hour phcy entry
Hig-developed a pt safety initiative (PHA award) by creating a night phcy cabinet-drastically decreased after hours phcy entry
* Decrease opportunities for medication errors *

## Pharmaceutical Care Definition	

- The direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient's quality of life.  The principal elements include accepting responsibility for the patient, caring for the patient, direct provision of care (direct patient contact), achieving and avoiding definite patient outcomes (each medication should have a goal), improving the patient's quality of life (through the medication use process), and solving medication related problems.

**Notes:**
JCAHO Standard-Each medication ordered should have an indication.Standard borrowed from Long Term Care.

## How Do We Get There?

- Develop a Plan
- Gain Acceptance
- Employ a Pharmaceutical Care Coordinator
- Interhospital cooperation
- Staff Re-Education and Development
- Re-Deployment of Pharmacy Human Resources
- Optimize Automation
- Documentation and Justification

**Notes:**
Automation-pyxis at vr and higgins for after hours profiling
Plan-meet goals specified earlier,(safety,outcomes,relationships,etc.)
Acceptance: Pharmacy staff-automation can replace dispensing pharmacists. Nursing-changes. Administration-very important (Pharmacy is suppose to dispense from basement). Inter-hospital cooperation-vital, impossible without cooperation. Resistance-during their work. Educate and talk about later. Re-deployment:Pharmacy to the floor. Automation:Pyxis. Documentation:Interventions.

## How Do We Get There?

- Technician Certification
- Staff Re-Education and development
- ASHP Modules
- Internal Classes
- External Classes
- CE

**Notes:**

Another vital component of this process is the re-education 
and development of our current RPh staff.

This can be accomplished thru the use of ASHP Clinical 
Skills Program & Drug Information Modules, internal & 
external classes on ph’kinetics, nutritional support, and 
disease state management, and specialized 
CE programs.
Classes taught-PTCB-national exam (benefited system and techs).

## How Do We Get There?

- Re-Deployment of Pharmacy Staff
- RPh on Nursing Units
- Changing Roles of RPh and Technicians

**Notes:**
Re-deployment of the RPh staff involves sending RPhs to 
the nursing units and the patients.This, will of course,
necessitate role and job standard changes for our RPhs and 
technicians.  With this increase in the expectations and
responsibilities of the techs, technician certification will 
soon become a minimum requirement.

Documentation of our expanded ph’cetut. care activities
will be vital to their existence & should provide positive 
feedback from the medical staff of TMC as well as
positive financial benefits to the institution.
Plan approved Fall 2000-Registered Pharmacists to the floor April 2002.
Changed responsibilities. Dispensing- no carts now allows time for after hours order entry for Villa Rica and Higgins. Delivery-Pyxis. Techs checking orders(2nd check).

## How Do We Get There?

- Meditech
- Pyxis
- Current equipment is at less than 25% of capabilities
- -Free time for pharmaceutical care

**Notes:**
From an automation standpoint, we are committed to the.
pyxis system.
Our goal is to optimize our current capabilities and expand as the 
technology advances.
As technology and technicians take on more dispensing 
responsibilities, the RPh will be better able to provide 
ph’ceutical care.
Automation of medication dispensing processes has been proven 
to be more accurate than human dispensing alone.
Bar Coding Technology – can enhance pt safety further..As the 
industry evolves, meds will come directly from the wholesaler to 
pyxis units at the pt’s bedside.
JCAHO – requires, and literature supports, that a RPh reviews all 
non life-threatening medication orders prior to their administration
This must occur before we increase the pyxis utilization – pyxis profile.
Meditech IS-completely integrated system allowing caregiver access to EMR ( Labs, Nursing Care Documentation and Physicians Reports)
We were not effectively using our automation (PRN’s, “Floor stock”)
As technology makes dispensing more efficient
Pharmacist can spend more time on patient care

## Why Change the Medication Distribution System?

- Traditional cart-fill system vs. Pyxis optimization

**Notes:**
Advantages/Disadvantages of Both:
-Medication Safety is key (opportunity for error)
-Access to quantity of medications
-Timeliness of Medication access
-Labor intensive
-Record keeping
-Fill, return,credit, etc.

Pyxis Profile: 
-Access to profiled medications
-95% of all medications in the Pyxis
-Documents missed doses,dosing times,etc.
-Reduces missing/ borrowed medications
-Reduces calls between Nursing and Pharmacy and Increases efficiency

## Slide 13

**Notes:**
Example of Patient’s Med drawers from Cart-fill
-Medication Safety Issues-Full of potential errors
-Once open-access to any patient medication in any drawer at any time
-Borrowing-Charges and Credits, Missing doses “I don’t have-I sent”
-Nurse grazing
-Look alike/Sound alike
-Repackaging unit dose
-Controlled substances Class 3-5 Lack of control
-*Access to too many medications

**Notes:**
Even Worse
-How many nurses have experienced this after a new admission?
-No medications available
Meditech/Pyxis
-Allow almost instant access after order entry
-Our RN may not agree with instant access
-Turn around times- studies showed 60-90 minutes and 3 hours even in some instances reduced to less than 20 minutes and 1 to 2 minutes for “stat” medications
-Reduces RN and Pharmacy Calls- “I don’t have medications or the courrier has it”
-Increases efficiency

**Notes:**
Pyxis Cubie Drawers
-Access to 1 medication at a time
-Pyxis profile

**Notes:**
Pyxis Carosel
-Access to one profiled medication
*Over-ride- definite,list

## Distribution, now Administration?

- No carts
- No cups
- No Service?

**Notes:**
Goal-Safety Medication Use System
-Improve not only distribution but entire system
How to improve Administration?
-Co-operation with Nursing or not possible

## Medication Administration

**Notes:**
Site visits for Distribution/Administration Options
-Combined the best of those
-How many times in Med room...
-Med cups with or without room# full of pills
-RN going down hall with cups in hand/pocket
Notebooks-profiled-MAR
-Med container-Ziplock
-Reduces opportunity for Errors

## Medication Administration

**Notes:**
Medication Removal
-Profiled on Pyxis
-Patient Specific Notebook with MAR *unopened meds
-Only 2 patients at a time
*Reduces opportunity for Errors

## Documentation/Justification

- Evaluation of data
- Medication error data
- Departmental surveys
- Pharmacists interventions

**Notes:**
*Extremely important
-Had to sell project and then back it up with the Data

## Medication Error Data

- <date/time>

**Notes:**
Goal-Safer Medication Use System
 Results:
Increase Potential Errors-expected Pharmacist to find process problems and work to improve these
Reduce Actual-Preventing errors before they reached the patient
Spread between Potential/Actual

## Medication Error Data

- <date/time>

**Notes:**
New graph from Wendy – updated
Another Slide
-more recent data
-reduced Actual

## Medication Error Data

- <date/time>

**Notes:**
More recent data
-Reduced Potential
-Expected as the previously identified processes have been improved

## Nursing Department Survey

- Participants from various nursing units
- 12 question survey
- Results:
- 	76% felt relationship was much better/better
- 96% felt RPh on the nursing unit made a positive impact on care
- 	84% felt meds available more timely
- 	86% felt med. delivery/administration safer

**Notes:**
Nursing Department Survey- 1 year after Pharmacist on floor
Goals- Increase Relationship
        -Increased Outcomes
        -Increased Efficiency
*Safer Medication Use System

## Pharmacy Department Survey

- 7 question survey
- Results:
- 69% felt job satisfaction was much better/better
- 80% felt relationship was much better/better
- 100% felt ability to impact pt care was much better/better
- 94% felt medication delivery safer

**Notes:**
-Pharmacist and Techs
Same Goals:
-Job Satisfaction-In our department, crowded, not using education, Clinical versus Staff

## Pharmacists Interventions

- Comprehensive Medication Management
- Daily Chart Review and Pharmacotherapy Assessment
- Comprehensive Renal Drug Dosing and Monitoring
- Nutritional Support Management

- Expanded/Automatic IV to PO Conversions
- Interactive Pharmacotherapeutic Information
- Pharmacotherapy Consultation at Patient Discharge
- Medication Error Prevention/Tracking/ Assessment

## Pharmacists Interventions

- <date/time>

**Notes:**
Clinitrend-ASHP Software
 measuring financial impact
-hard/soft costs
-based on 1996 dollars
-Conservative

## Pharmacists Interventions

- <date/time>

## Barriers to Re-Engineering

- Nursing Concerns
- Pharmacy Concerns

**Notes:**
Nursing:
-taking “my” cart
-delay
-lines at the Pyxis
-only 2 patients-up and down hallway
-Pharmacist on the floor-doing what?In the way?
-Any change in general

Pharmacy:
-leave security of basement- “see/talk” to patient?
-competency/confidence?
-Pharmacist on floor-doing what? In the way?
Techs doing what?
-Up and down loading//refilling
-Checking orders?

Other Facilities
-Waiting on order entry
-Increased workload

## Bedside Medication Verification

## Slide 31

## Slide 32

## CPOE....

## Keys to Success

- Support
- Education
- Preparation
- Cooperation
- Justification
- $$$$$$

**Notes:**
Support-Administration, Quality, Risk Management, Medical Staff
Education-Competence-Clinical and Technical
Preparation-From idea to implementation over 18months
Cooperation-Nurses and Pharmacist
Justification-Literature then Documentation
Money-Capital
 -you can justify the dollars and prove the projects value

## Questions ?????