Nursing Home Medication Safety: Bringing New Tools to Old Challenges (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Amy Vogelsmeier, Ph.D., R.N., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (835 KB).

Slide 1

Nursing Home Medication Safety: Bringing New Tools to Old Challenges

Amy Vogelsmeier PhD RN
Jill Scott-Cawiezell, Principal Investigator, PhD RN FAAN
AHRQ 5 UC1 HS014281-02HRQ
University of Missouri (MU) Sinclair School of Nursing

Slide 2

Primary Study Aim

Evaluated the impact of technology and focused quality improvement efforts upon medication safety practices.

Slide 3

Study Overview

• Five nursing homes in three states participated in the study:
  • Ranging in size from 60 to 400 beds.
  • Both urban and rural.
  • Both profit and not-for-profit.
• The nursing homes implemented full Electronic Health Records (EHR) and then Electronic Medication Administration Records (eMAR).
• The team observed medication administration and related processes for approximately 16,000 medications.
• Nursing homes each had a focused quality improvement team that met monthly throughout for about two years.

Slide 4

Slide shows photo of a staff member of a nursing home using a computer with Electronic Health Records (EHR) and Electronic Medication Administration Records (eMAR).

Slide 5

How Has Technology Helped the Medication Administration Process?

• Documentation of assessment parameters correlated to specific medications helped link clinical data to medication administration.
• Elimination of monthly MAR changeover reduced risk of medication errors and saved valuable staff time.

Slide 6

How Has Technology Helped the Medication Administration Process? (continued)

• "Flags" on eMAR are helpful—the addition of green flags for new orders and yellow highlight for PRN ["as needed"] monitoring have seen a positive response from staff.
• Reduced transcription from five points to two points—with the potential to go to remote physician access.

Slide 7

Pre eMAR Order Entry

Slide shows a decision tree with this sequence:

• New medication order received.
• Transcribe order to physician order sheet.
• Compare new order to existing orders
• Does order require clarification?
  • If Yes:
    • Nursing home (NH) contacts physician to clarify order.
    • Order clarification received.
    • Transcribe revised order to physician order sheet.
    • Transcribe order to physician order sheet MAR section.
  • If No:
    • Transcribe order to physician order sheet MAR section.
• Telephone order?
  • If Yes:
    • Transcribe order to telephone order sheet, route copy to physician, place copy in chart.
    • Transcribe order onto MAR.
  • If No:
    • Transcribe order onto MAR.
    • Fax order to pharmacy.

Slide 8

Post eMAR Order Entry

Slide shows a decision tree with this sequence:

• New medication order received.
• Transcribe new order into eMAR.
• Compare new order to previous orders.
• Does order require clarification?
  • If Yes:
    • NH contacts physician to clarify order.
    • Enter any new order into eMAR.
    • Discontinue previous order.
    • Post order from eMAR; copy to chart and to physician.
  • If No:
    • Post order from eMAR; copy to chart and to physician.
• Telephone order?
  • If Yes:
    • Transcribe (handwrite) new order to physician order sheet.
    • Verify eMAR printed order matches handwritten order on physician order sheet.
  • If No:
    • Verify eMAR printed order matches handwritten order on physician order sheet.
    • Fax eMAR printed medication order to pharmacy.

Slide 9

Using Data to Improve Processes

• New order reports identify new orders from the past 24 hours:
  • Useful to stay current on resident condition and verify accuracy of new orders.
• High risk medication reports, such as anticoagulant and psychotropic agents, identify specific residents that may require careful monitoring and identify facility-wide trends of medication use.

Slide 10

Using Data to Improve Processes (continued)

• Late medications tracked via time stamping of actual medication administration times:
  • Useful to identify trends of high volume medication passes and systems issues that impede medication administration.
• 30 day look back provides a 30 day MAR for each resident.
• Medication exception report tracks documentation as to why medications were not administered:
  • Useful to identify systems impeding medication administration.

Slide 11

Moving from Paper to Touch Screen

• Quicker process.
• Legible MAR.
• Focused eMAR for current medication administration.
• More organized medication administration.
• More accessible MAR.
• More accessible related health information.
• Real time medication orders.

Slide 12

Technology Uptake Can Lead to Improvement

• Maximizing success with technology requires diligence and creating interfaces which lead to updated clinical processes.
• Data, data, data can drive how to maximize technology to improve resident safety and guide more directed and focused process improvement strategies.
• Workarounds are a reality and occur despite good process improvement or instead of good process improvement.

Slide 13

What is a Workaround?

• An informal temporary practice for handling exceptions to normal workflow.
• A workaround occurs as a worker perceives some disruption or block in the system that prevents the worker from completing a task as desired.

Slide 14

Workarounds when the process had been improved and integrated into technological updates

Slide 15

Workarounds when the process had not been improved and integrated into the technological updates.

Slide 16

How Facilities Defined Success

• Data from the eMAR systems results in good quality improvement (QI) information.
• Increased communication, increased focus on the work, and a heightened awareness of the potential for mistakes... "we cannot let our guard down, we always need to think about the potential for error."
• Recognizing that systems are underlying most errors; feel like "we are becoming better problem solvers."

Slide 17

What Have Been the Biggest Challenges?

• Working with state surveyors.
• Learning to maximize the use of data for real information.
• Underestimating the learning curve.
• Managing implementation with limited onsite resources.
• Recognizing that technology will not solve all the problems.