Medication Administration Errors Associated with Transitions of Care in Inpatients Receiving Dialysis in the

Setting of Partial Implementation of an Electronic Medical Record and Computerized Physician Order Entry

Erik Venos, Irfan Dhalla, Catherine YuDepartment of Medicine, St. Michael’s Hospital, Toronto, ON

CONTEXT

Patient transfers between and within facilities are associated with negative patient outcomes, with the administration of insulin being a problematic area

This project aimed to identify issues with transitions within the hospital on these outcomes

SETTING

General internal medicine (GIM) ward and a nephrology ward of a tertiary care centre, which operated a dialysis unit, serving out- and inpatients

Used computerized physician order entry (CPOE) along with an electronic medication administration record (eMAR), both being recently implemented on inpatient units in the hospital

PROBLEM/ISSUE

Focused on the medication administrations and transitions of care between a GIM ward and a dialysis unit for a patient with type 1 diabetes and end stage renal disease admitted to hospital

Her usual insulin regimen, a morning meal insulin injection and a basal insulin injection, was reinitiated

She was transferred to the dialysis unit at 0730 for her regular dialysis

Her blood sugar was normal at 0800, 17.8 mM at 1200 and 27 mM at 1500, requiring 10 units of supplemental insulin for correction

The eMAR did not report that the morning meal insulin or basal insulin was administered

INTERVENTION

Identifying processes that led to this error

Four steps were undertaken:

STAKEHOLDER IDENTIFICATION AND ENGAGEMENT

Face-to-face and by email

CREATION OF PROCESS FLOW MAPS

1. Physician ordering to nurse administration for patients admitted to the GIM ward (figure 2)

2. Patients admitted to GIM ward requiring dialysis, focusing on how insulin was given on dialysis days (figure 3)

3. Patients admitted to nephrology ward requiring dialysis, focusing on how insulin was given on dialysis days (figure 4)

MEASUREMENT AND ANALYSIS

Identified a more complex system for Map 1 compared to Map 2 (Figures 2 and 3)

Found issues with insulin administration

Nephrology GIM

Dialysis MDDialysis fellowRenal pharmacistDialysis RNs

GIM staffGIM residentEndocrinology staffGIM pharmacistGIM RNs

Figure 1: Considerations for designing a process flow map for hospitalized patients when leaving from and returning to their home unit from dialysis

Identification of the relevant stakeholders

Engagement of the relevant stakeholders

Description and analysis patient transfers using a process flow map

Utilizing this engagement and description to attempt to improve the process

Inpatient leaving ward for dialysis

What medications are given before the patient leaves the unit?What medications are deferred?What handover between RNs occurs?

Patient in dialysis unit for 4 hours

Where does the patient eat?Does the dialysis RN give insulin routinely?Will administered medications be charted on theeMAR or apaper chart?

Inpatient returns to home ward

Figure 3: A process flow map of medication administration for patients on a GIM ward receiving dialysis, on a dialysis day

Figure 2: A process-flow map of medication administration for patients on a GIM ward

RN (via barcode) confirms that the patient’s medications belong to patient

RN acknowledges patient receipt of medication in electronic record

Patient receives medication from RN as ordered (insulin is drawn up in syringe from floor supply vial)

Medications are entered into CPOE by physician

Pharmacist acknowledges order and approves medication

Medications are sent to floor where RN receives them

Patient, receiving dialysis, is admitted to hospital

Medications are entered into CPOE by physician

Pharmacist acknowledges order and approves medication

Medications are sent to floor where RN receives them

Patient goes off ward for dialysis

Dialysis RN should review patient’s medications from paper list

Dialysis RN notes insulin correction factor. Does not give standard insulin (assumes given on home unit?)

InsulinPerforms capillary blood glucose and assesses whether patient will eating. Meal is eaten in dialysis

Sliding scale insulin administered or physician called about concern (medication administration noted on paper MAR)

Floor RN notes medications given in dialysis unit

Floor RN gives scheduled medications post-dialysis

RN to enter medications into eMAR given in dialysis and after dialysis

No specific protocol existed as how insulin was noted

Dialysis RN looks at patient medication list and dialysis medication list to determine IV meds and antibiotics to give during dialysis

Medication given or physician called about concern

Floor RN holds medication scheduled during dialysis to be given after dialysis

Floor RN should print medi-cation list and eMAR prior to patient leaving ward

Floor RN gives patient medications pre-dialysis and charts this on eMAR

Other medications

Pt transported to GIM ward from dialysis

Patient, receiving dialysis, is admitted to hospital

Maps were distributed among the relevant stakeholders for feedback and information provision

GAPS IN CARE

1. The dialysis unit is an outpatient facility using paper medication orders and a paper MAR while the inpatient units use CPOE and an electronic MAR; outpatients supply and administer their own insulin and other medications

2. Patients were transferred between units with no specific protocol for nursing handover

3. The patient was transferred between units at 0730, a time when nursing handover occurs

4. Patients were off the ward in hemodialysis, not briefly, but for four or more hours, making the routine non-administration of medication until the patient returns to the unit problematic

5. Basal insulins were not routinely stocked in the dialysis unit

The practices on the nephrology ward (on the same floor as the dialysis unit) revealed an interesting workaround to the system (figure 4)

Floor RNs prepared CPOE-ordered insulin in syringes, administered in dialysis when the patient could be observed to be eating

CONTRIBUTION TO PATIENT SAFETY AND QUALITY IMPROVEMENT

Basal insulin to be supplied in the dialysis unit, so that insulin did not have to come from the home ward if it was not supplied by the home ward

Other measures were proposed for consideration to improve patient safety:

6. Development of the same workaround, as on the nephrology ward, for other units

7. Providing dialysis RNs training on CPOE and eMAR

3. The admission of patients with non-dialysis related chief complaints to the nephrology ward

4. Flagging the charts or medical record of all patients with type 1 diabetes

LESSONS LEARNED

5. The transition of care of patients between units, especially the dialysis unit, can lead to medication errors, particularly regarding insulin administration

6. CPOE and eMAR systems can have drawbacks that need to be noted during and after implementation

7. The engagement of relevant stakeholders is an important strategy to gain information about systems of care

8. The development of process flow maps are helpful tools to understand complex processes in the hospital

9. Understanding these processes can lead to problem identification and the creation of workable solutions

Figure 4: A process flow map for patients admitted to a nephrology ward receiving dialysis, on a dialysis day

Patient leaves ward for dialysis. Scheduled insulin is drawn up from floor stock by floor RN and goes with the patient to dialysis unit

Dialysis RN administers mealtime and basal insulins provided by floor RN

Dialysis RN performs capillary blood glucose and assess whether eating

Dialysis RN gives mealtime medications provided by floor RN

Patient returns to nephrology ward

Floor RN notes medica-tions given in dialysis unit

Floor RN gives scheduled medications post-dialysis

RN to enter medications into eMAR given in dialysis and after dialysis

Insulin charted as received in dialysis unit

Dialysis RN looks at patient medication list and dialysismedication list to determine IV meds and antibiotics to give during dialysis

Insulin

Other medications