Methodology: To successfully complete this project we used value-stream mapping

in conjunction with root-cause analysis, process improvement, and

the PDCA cycle.

Current Knowledge of Task: Root-cause analysis revealed that a lack of communication

and understanding between the Nursing and Pharmacy

departments seemed to cause most of the problems. To

correct the problem we observed and then mapped out the

current process.

We also:

- Looked at our current medication error rates and the

most common reasons and times that errors occurred.

- Interviewed Licensed nursing staff to ask when and how

they reorder medications to check for patterns and

consistency & interviewed pharmacy staff to check for

consistent issues on their end.

Best practices came from utilizing the knowledge of our

consultant pharmacist and Omnicare representatives.

Resources Used:

1. Aging Services of MN: Recommendations on Best

Practices to Prevent Drug Diversion

2. The Lewin Group: CMS Review of Current Standards of

Practice for Long-Term Care Pharmacy Services

3. DEA Narcotic regulations & recommendations

4. MN Board of Pharmacy recommendations

5. CMS & Federal/State Pharmacy & Medication

Regulations

6. ATTAX & AE Antipsychotic Medication Resources

Problem: It became apparent that our medication ordering process

as well as some other facets of the pharmacy-nursing

system had major gaps such as:

- Lack of Pharmacy policies

- Inconsistent ordering practices

- Little understanding of the pharmacies process

These process errors led to a gap in communication

between the two departments which ultimately led to high

stress & the opportunity for medication errors.

RN orders meds on floor Resident by resident 1.pull resident meds out 2.Med by med—put dose in cup 3.Count remaining pills -should be enough to get through next order day 4. check remaining meds 5. if refill is needed - pull label - Attach to sheet - Sheet -> bucket If label not pulled until later, sheet taken down separately (time?)

Rx “Hold” sheet returned 1. Collect “Hold” sheet from Dr. box 2. Scan in hold sheet 3. enter in computer that “hold” sheet is completed & returned 4. When refill comes up it will be ready

Summary of Success: This project became larger and more complicated as we peeled

back the layers of what all fed in to the Pharmacy and

Medication Ordering process.

Accomplishments:

- Increased quality improvement focus on pharmacy for the first

time at Saint Therese.

- 14 Policies identified as needing to be updated or created

- New Medication Error form & excel tracking system created

- Tighter auditing process implemented – consultant

pharmacist forms now show greater detail directly related to

factors tracked for F329. – *See results in graph

Barriers:

- Inadequate staffing within the Pharmacy led to difficulties in

staff time to attend weekly meetings.

- Industry changes took priority over this project causing delays

in starting this project

Calls coming in STAT orders—(10-15 every AM) Checking on orders - tab pulled & their not sure when - making sure they are ordered to come up *Staff has to go into computer and look up resident—check date of last fill, other reasons for new refill request — RN then comes down to collect refill to be told they can’t be filled/are already on the floor [All in Pharmacy Answer] Fill orders that were entered or called in

1. fill STAT calls first 2. 1W & 3rd floor requested earlier pickup times 3. Pull med/fill based on what computer says 4. Attach label securely 5. Put in correct bucket [Tech 1 Starts, Tech 2 helps after finishing label input]

Narcotic Orders 1. Label number is entered separately [RED] highlighted order means they are on hold - sheet was sent to Dr. to authorize refill 3. take off hold -> push through to refill 4. print new authorization hold sheet for Dr. to sign 5. Write “Hold” on it 6. put in Dr. box to get signed

Recommendations: 1. Continue to audit orders coming off the floor and number of

calls going to pharmacy for stat/inaccurate refill requests.

2. Educate nursing staff on new medication error form & tracking

system and on causes of common errors. Educate both nursing

and pharmacy on new medication order/fill process.

3. Update nursing orientation to ensure correct ordering system

is understood.

Surveyor Recommendations:

1. Ensure pharmacy does not put labels over expiration date on

bottles

2. Look into smeared labels – possibly from chemical reaction of

using hand sanitizer or lotion before touching label

By 4pm Buckets picked up by floor RN

1. RN initials med list to verify that they are all in the bucket 2. Takes basket to floor and puts meds in carts *Med list remains in bucket, goes back to Pharm, is saved for *3mo. No separate accountability for Narcotics? Pharmacy—Residence

Medication Order & Fill Initial Process Map

Acknowledgements: Sandra Delgehausen – QI ADON

Barb Hanle – RCC Project Director

Stacy Lind – Campus Clinical Director

Karen Vetter – Education Coordinator

Dr. Joe Sicora – Medical Director

Denise Johnson – Pharmacist Consultant

Al Brosseau – Pharmacist

Saint Therese Pharmacy Staff

Saint Therese Nurses

Processing Exceptions: 1. Refill too soon/on hold—includes date of last order & date new order can be filled 2. Prior authorization—needed from insurance or physician before med can be filled 3. Med out of Stock—can usually get following business day. If not, ordered from Omnicare

Medicare Refills—10 days Private Pay Refills—3 days

By 8/8:15am Tech enters label numbers into

computer @ Pharmacy [Tech 1. If any left @ 8 -> Tech 2] Pharmacy— Residence

7:30am Med Tech picks up buckets

- asks if there are any changes/updates [Tech 1]

8 total 1st, 2nd, 3rd floors of Care Center

Time Whom

Location

Pharmacy also fills for: - Residence - Oxbow - 2 outside facilities

6/20/13

Steps 1 & 2

•Create Pharmacy Adhoc QI Committee & hold preliminary meeting to do root-cause analysis to decide what would be included in this project

•Schedule weekly 30 minute meetings to work through action plan and policies

Steps 3 & 4

•Observe & document our current order and fill process in the form of a process map

•Policy development – update nursing/pharmacy policies and create pharmacy specific policies

Steps 5 & 6

•Review & update medication error forms and create & implement new medication error tracking system

•Review pharmacy consultant forms & developed internal auditing tools

Steps 7 & 8

•Review & update RSO & Ekit list and policies

•Adopt Aging Services Narcotic Diversion Plan

Steps 9 & 10

•Educate Pharmacy & Nursing staff on updated processes and policies

•Complete PDCA cycle by auditing for effectiveness

0

2

4

6

8

10

12

2013 Baseline Q4 2013

10.29 9.31

4.66

1.81

Prevalence of Antipsychotic Meds without a Dx*

MN Risk

Adjusted

State

Average

MN Risk

Adjusted

Facility