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Declaring victory in the war against drug errors, if only for a month

September 2005

Published in the September 2005 issue of Today’s Hospitalist

When McLeod Regional Medical Center began examining ways to improve medication administration, few could have predicted that the community hospital would be able to all but eliminate adverse drug events. But the hospital’s efforts to reduce drug errors have been so successful that during one month last year, it did just that.

McLeod is no stranger to quality improvement initiatives. The hospital began to ramp up its quality improvement efforts in the late 1990s, and it won a Pursuing Perfection grant from the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement in 2001.

While McLeod has tackled a wide range of clinical areas as part of its quality improvement efforts, the hospital’s medication safety program has brought national acclaim.

To get an idea of just how successful that initiative has been, you need to look at a national indicator known as the medication rate of harm. The measure determines how many adverse drug events occur for every thousand doses of drugs that are administered.

On average, U.S. hospitals report that for every thousand doses of drugs they administer, there are between two and eight adverse events.

In 2001, when McLeod was starting its medication administration project, the hospital’s rate was already on the low end of the spectrum at 3.5. The hospital’s medication safety efforts have gradually reduced that rate. While the rate today hovers at one, in February of 2004 the hospital achieved a perfect score, eliminating adverse drug events for that month.

Here’s a look at how McLeod has drastically reduced adverse drug events within its walls:

  • Drug dispensing machines. McLeod began to use drug dispensing machines in 2002 to address concerns about both safety and speed.Physicians write an order, which is scanned at the nursing station and sent electronically to the pharmacy. Once the pharmacy verifies that the medication is correct and the dose is appropriate, the order is reviewed for allergies, interactions and contraindications. Within minutes, the drug is entered into the system.A nurse then signs onto the system, enters a password and identifies the patient and the medication. A drug dispensing unit on the floor automatically opens a drawer and tells the nurse in which compartment she can find the medication. (Each of the drawers contain four medications, but the drugs do not sound or look alike to avoid confusion.)The machines helped McLeod reduce the number of steps in the medication delivery process from 17 to five, eliminating many opportunities for error. In addition, the time from when the order is sent to the pharmacy and received by nursing was slashed from about 90 to seven minutes.
  • Medication administration checker. After introducing automatic dispensing machines, McLeod began piloting its medication administration checker (MAC) in December 2003.Before a nurse administers a drug, she must scan in her name badge, the medication and the patient’s wristband. A computer then verifies that the medication, dosage, route, time and patient are all correct. In the first week it was rolled out, the MAC detected nearly 40 instances in which a mistake would have been made “and most likely never detected.
  • Decentralized pharmacists. An approach that is lower-tech but just as effective in reducing errors puts pharmacists in satellite locations on floors throughout the hospital. Pharmacists have cordless phones so they can easily consult with physicians, nurses and patients.Pharmacists regularly call physicians to discuss orders and suggest changes because of contraindications or other concerns about how a patient might tolerate a drug. Physicians say this interaction not only improves safety by adding another check to the system, but it saves them time to have someone else processing drug orders.
  • Universal medication form. As part of the medication reconciliation process, which is now required by JCAHO, McLeod’s universal medication form gives physicians and nurses a complete list to compare the patient’s current medications with new medicines ordered during admission, transfers and discharge.Patients are told to carry the form with them at all times to make sure physicians, nurses and pharmacists always have an accurate list. The list is updated when medications are added or deleted.